> 30 > 0.2 IMR RV (ml) > 60 ERO (cm 2 ) >
0.4ORGANIC ECHO CRITERIA OF SEVERE MR M. Enriquez-Sarano
Slide 5
Restrictive Mitral Annuloplasty: two sizes under
Slide 6
Slide 7
Postoperative echo result
Slide 8
Restrictive Annuloplasty for Ischaemic Mitral Regurgitation
results in Reverse Left Ventricular Remodeling J. Braun, J.J. Bax,
M.I.M. Versteegh, P.G. Voigt, E.R. Holman, R.J.M. Klautz, R.A.E.
Dion Departments of Cardiothoracic Surgery and Cardiology, Leids
Universitair Medisch Centrum
Slide 9
Patient characteristics EACTS 15/09/04 Jan 2000 March 2004 87
patients age 66 10 yrs NYHA 3.0 0.9 III / IV: 82 % log
EuroSCORE11.0 10.8 previous CABG7 %
RESULTS PRE-MVPPOST-MVP LVEDD65 mm53 mm LVESD49 mm32 mm LA43
mm35 mm MVA2.2 cm 2 Mean gradient2.8 mmHg
Slide 22
11 patients MRI pre-surgery and follow-up MRI 7 men / 4 women
mean age SD: 53 14 years mean follow-up period SD: 42 7 months
Long-Term Durability after restrictive MVP
Slide 23
PRE POST (note: MI jet)(note: restrictive ring) Long-Term
Durability after restrictive MVP
Conclusions RMA + CABG yield reverse remodeling Preoperative LV
dimensions limit extent of reverse remodeling Additional techniques
may be needed when LVEDD > 65 EACTS 15/09/04
Slide 26
Restrictive Mitral Annuloplasty in Non-ischemic Dilating
Cardiomyopathy Non-ischemic Dilating Cardiomyopathy J. Braun, J.J.
Bax, M.I.M. Versteegh, P.G. Voigt, E.R. Holman, R.J.M. Klautz,
R.A.E. Dion Departments of Cardiothoracic Surgery and Cardiology,
Leids Universitair Medisch Centrum
Slide 27
Patient Characteristics 02/02/05 July 2000 March 2004 29
patients6 RMA + CorCap 23 RMA
Left ventricular restoration in ischemic congestive heart
failure: The Leiden Experience Klein P. 1, Versteegh M.I.M. 1,
Klautz R.J.M. 1, de Weger A. 1, Tavilla G. 1, Holman E.R. 2, Bax
J.J. 2, Dion R.A.E. 1 1 Department of Cardiothoracic Surgery, 2
Department of Cardiology Leids Universitair Medisch Centrum
Slide 39
Study population (I) 39 patients with ICHF 30 males, mean age
62 11 years NYHA-class 3.1 0.5 LVEF 20.5 6.4% median interval after
infarction 36 months (1-240) EuroSCORE 14 13 5 patients were
operated in emergency (13%) 2 pre-op IABP 1 pre-op ventilation 1
acute infarction
Slide 40
Surgical procedure according to DOR Fontan stitch sizing of
residual LV using a saline-filled balloon (55 ml / m 2 BSA)
elliptical shape !
Slide 41
Dor / SVR
Slide 42
Concomitant procedures CABG in 28 patients (72%) Mean number of
distal anastomoses 2.4 1.2 Restrictive mitral annuloplasty in 25
patients (64%) Mean ring size 26 2 Tricuspid annuloplasty 10 (26%)
VT-ablation 1 (3%) VSR-repair 1 (3%)
Reversible cause? No Correction Recovery Follow Up NON-ISCHEMIC
(medication+ lifestyle) No complete recovery RESYNCHRONIZATION?
Significant Valve disease? Indication SVR? Valve surgery + SVR
Valve surgery CorCap Yes No Indication SVR? Yes No INVASIVE
SURGERYREVASCULARISATION/SURGERY No ISCHEMIC Ischemia and/or
viability? AP and significant CAD? CABG + valve-surgery Significant
Valve disease? CABG + SVR/Dor + valve surgery Indication LV-
reconstruction? SVR/Dor Indication LV- reconstruction? Valve
surgery + SVR/Dor Indication SVR/Dor? Significant Valve disease?
CABG + SVR/Dor PCI or CABG Yes No Yes No Valve surgery ( CorCap) No
Yes Indication SVR? Yes No FOLLOW UP Yes MISSION! HF
Slide 55
INVASIVE MISSION! HF REVASCULARISATION/SURGERY ISCHEMIC
Ischemia and/or viability? AP and significant CAD? CABG +
valve-surgery Significant Valve disease? CABG + SVR/Dor + valve
surgery Indication LV- reconstruction? SVR/Dor Indication LV-
reconstruction? Valve surgery + SVR/Dor Indication SVR/Dor?
Significant Valve disease? CABG + SVR/Dor PCI or CABG Yes No Yes No
Valve surgery ( CorCap) No Yes Indication SVR? Yes No FOLLOW UP Yes
RESYNCHRONIZATION?
Slide 56
Reversible cause? No CorrectionRecovery Follow Up NON-ISCHEMIC
(medication+ lifestyle) No complete recovery RESYNCHRONIZATION?
Significant Valve disease? Indication SVR? Valve surgery + SVR
Valve surgery CorCap Yes No Indication SVR? Yes No INVASIVE SURGERY
No FOLLOW UP MISSION! HF
Slide 57
SCREENING & ETIOLOGY History NYHA class Examination LAB ECG
X-ray Chest TTE Further analysis Chronic heart failure? No LVEF
< 40% NYHA III or IV Exercise testing with VO2 max Myoview
stress and rest, FDG CAG (left & right) 24 hour Holter
monitoring additional LAB QOL score + 6 min. walk test Old
myocardial infarction and/or 1 coronair with > 50% stenosis? Yes
ISCHEMIC causeNON-ISCHEMIC cause No LAB NT-proBNP Complete blood
count ESR, CRP Electrolytes, Creat, BUN Liver panel Lipid profile
TSH, fT4 Glucose Yes No Yes THERAPY Further analysis
Slide 58
MISSION! HF BASIS NYHA I Continue medication(!), lower dosis
diuretics NYHA II Atrial fibrillation VR > 100: Digoxine
Diuretics ACE-inhibitor eta blocker + + Thiazide 1 dd when mild HF
and clearance > 30 - start ATB in case of ACE-intolerance -
c.i.: potassium > 5.5, dubbelsided renal arterystenosis - raise
every 2 weeks untill (individual) maximum Persisting low potassium:
start spironolacton 1 dd 12.5 mg or Inspra 1 dd 12.5 mg
Loopdiuretics 1 dd Loopdiuretics 2 dd - start when no signs of
decompensation - raise every 2 weeks until (individual) maximum
Loopdiuretics 2 dd + Thiazide Nitrate in case of orthopnoea
Consider Nitrate i.c.w. Hydralazine in case of ACE-intolerance
Spironolacton 1dd 25 mg - in case of gynaecomasty: eplerenone 1 dd
25-50 mg - c.i.: potassium > 5.0, Creat > 250 - if needed,
consider ATB in stead of spironolacton NYHA III or IV NYHA IV
Digoxin (sinusrhythm) NYHA III MEDICATION
Slide 59
MISSION! HF RESYNCHRONIZATION? Biventricular ICD FOLLOW UP EF
< 30% VF or haemodynamic unstable VT ICD EF 30 - 40 % + VT/NSVT
EFO Indication HTx? Stemcell therapy? ICD When pre-operative: LVEF
40 or QRS > 120ms: - epicardial LV-lead peri- operative -
post-operative biventricular ICD When pre-operative: - LVEF <
30%: ICD post-operative - LVEF > 30% + (NS)VT: EFO + ICD When
surgery waitinglist is long and (biv) ICD indication: consider
(biv) ICD implantation pre- operatively SL delay > 40 ms (EF
< 30% + NYHA III or IV) Yes No SCD RISK ASSESSMENT
Slide 60
MISSION! HF FOLLOW UP and RE-EVALUATION Month 3 + Month 9 Week
2-3 AFTER INVASIVE PROCEDURE DOCTOR + HF nurse History, NYHA class
Examination LAB ECG TTE (only Month 3 visit) HF nurse History, NYHA
class Examination LAB (incl. NT-proBNP) ECG REGULAR FOLLOW UP Month
6 + Month 12 DOCTOR + HF nurse HF nurse History, NYHA class
Examination LAB (incl. NT-proBNP) ECG QOL + 6 min. walk test
Exercise + VO2max TTE Only month 12 visit: 24 hour holter
RE-EVALUATION Every year or worsening NYHA When appropriate,
re-evaluate indication for: - revascularisation - valve / LV
surgery - resynchronization therapy - ICD - HTx - stemcell therapy
every 3 months DOCTOR + HF nurse History, NYHA class Examination
LAB (incl. NT-proBNP) ECG Exercise + VO2max TTE LUMC every year OWN
CARDIOLOGIS T NYHA class III / IV NYHA class I / II History, NYHA
class Examination LAB ECG DOCTOR + HF nurse History, NYHA class
Examination LAB (incl. NT-proBNP) ECG TTE Exercise + VO2max QOL + 6
min. walk test Holter (CAG) ( Myoview) PRE-OP 2 weeks before
surgery HF nurse History, NYHA class Examination LAB ECG
RE-EVALUATION DOCTOR every 6 months History, NYHA class Examination
LAB ECG
Slide 61
Acute hemodynamic effects of restrictive mitral annuloplasty in
patients with end-stage heart failure S.A.F. Tulner, P. Steendijk,
R.J.M. Klautz, J.J. Bax, M.I.M. Versteegh, E.E. van der Wall,
R.A.E. Dion J Thorac Cardiovascular Surgery (in press) Departments
of Cardio-Thoracic Surgery and Cardiology Leiden University Medical
Center
Slide 62
Results: typical example of RMA
Slide 63
Control group Unchanged systolic function Improved active
relaxation, increased diastolic chamber stiffness Restrictive
Mitral Annuloplasty No significant acute effects on global, and
intrinsic systolic function Alterations in diastolic function
appear similar to the control group Conclusions