Surgical management of heart failure

Coronary artery revascularisation
Valve surgery
Left ventricular reconstruction
Passive cardiac support devices
LV Assist devices
Cardiac transplantation

1. MSN PAVAN KUMAR,DM
NIMS,Hyderabad,India.
SURGICAL MANAGEMENT OF
HEART FAILURE

2. 1.Coronary artery revascularisation
2.Valve surgery
3.Left ventricular reconstruction
4.Passive cardiac support devices
5.LV Assist devices
6.Cardiac transplantation

3. Coronary Artery Revascularisation
Ischemic cardiomyopathy
Dysfunction arising d/t occlusion of coronary arteries.
Most common cause of heart failure in clinical trials.
3 inter related processes - stunning , hibernation, cell death.
Selection of patients.
Benefits – improvement in LVEF , symptomatic improvement ,
survival benefit.
Risks
Guidelines at present

4. Selection of patients :
Several clinical factors play a major role in the decision-making,
1.The presence of angina,
2.The severity of heart failure symptoms,
3.LV dimensions.
4.The adequacy of target vessels for revascularization and
5.The extent of jeopardized but still viable myocardium
Coronary Artery Revascularisation
Significant mortality and morbidity benefit occur after coronary
revascularisation when at least 25% of myocardium is viable
Arend F.L. Schinkel et al. JNM 2007

5. Benefits : Improvement in LVEF :
An average improvement in LVEF of 8 to 10 percent is likely to occur
following coronary artery revascularization.
Improvement is seen in pts with
1.>25% viable myocardium
2.< End systolic volume of 130ml
3.Normal LV geometry
Improvement continues 6 -12 months after surgery
Coronary Artery Revascularisation
Arend F.L. Schinkel et al. JNM 2007
De Bonis et alSurgery insight Nat Clin Pract Cardiovasc Med 2006

6. Benefits : improvement in symptoms:

Pagano D, Bonser RS, Camici PG: Myocardial revascularization for the
treatment of post-ischemic heart failure. Curr Opin Cardiol 1999
 Significant improvement in functional capacity following
revascularization, as reflected by a 34 % increase in exercise capacity
from 5.6 to 7.5 METs.
Coronary Artery Revascularisation
Symptom free1 year 5 year
Angina 98% 81%
Heart failure78% 47%

7. Benefits : improvement in survival:
No RCT was available untill recently
DUKEs database has compared CABG vs MEDICAL over 25 years
Coronary Artery Revascularisation
Years CABG MEDICAL
1 83% 74%
5 61% 37%
10 42% 13%
SURVIVAL OF PATIENTS(P<0.0001)
O'Connor CM et al: A 25-year experience from the Duke Cardiovascular
Disease Databank. Am J Cardiol 90:101, 2002

8. Benefits : Improvement in survival:
RCT – STICH ( Surgical Treatment of Ischemic Heart Failure).
Coronary Artery Revascularisation
Eric J. Velazquez et al Coronary-Artery Bypass Surgery in Patients
with Left Ventricular Dysfunction N Engl J Med 2011

9. Benefits : Improvement in survival:
RCT – STICH ( Surgical Treatment of Ischemic Heart Failure).
Coronary Artery Revascularisation

10. In patients randomized to STICH, there was no statistically significant
difference in all-cause mortality between medical therapy alone and
medical therapy with CABG
Medical therapy with CABG reduces cardiovascular mortality and
morbidity compared to medical therapy alone
When randomized to CABG, patients are exposed to an early risk
Benefits : Improvement in survival:
RCT – STICH ( Surgical Treatment of IsChemic Heart Failure).
Coronary Artery Revascularisation
Eric J. Velazquez et al Coronary-Artery Bypass Surgery in Patients
with Left Ventricular Dysfunction N Engl J Med 2011

11. Risks :
Perioperative risk in patients with severe LVD range from 2 to 10%.
Risk depends up on
1.Availability of targets
2.Viability
3.RV dysfunction
4.NYHA class
5.Increased LVEDP
6.Advanced age
7.Associated PAD/STROKE
8.COPD
Coronary Artery Revascularisation
Pocar et al.CABG for ischemic cardiomyopathy ATS 2007
Hillis et al.outcome of patients in low EF after CABG Circulation 2006

12. Guideline : (ACC/AHA) CABG in pts with poor LV function
CLASS 1 : LMCA or its equivalents
CLASS 2a : viable non contracting muscle
CLASS 3 : with out evidence of ischemia and viability
Coronary Artery Revascularisation
Hunt SA, et al: ACC/AHA 2009 : Circulation 2009 Rx for heart failure
Eagle KA, et al: ACC/AHA 1999: Circulation 1999 Rx by CABG

13. Valvular Surgery
1.Valvular heart disease that lead to LV dysfunction
2.Valvular dysfunction secondary to primary cardiomyopathy

14. Mitral valve :
MR is commonly observed in
pts with poor prognosis and
independent risk factor for poor
outcome
Ischemic / non ischemic MR
Benefits / risks
Current guidelines

Valvular Surgery
Valvular dysfunction– Mitral Valve Surgery.

15. Valvular Surgery
Valvular dysfunction– Mitral Valve Surgery .

16. Non ischemic MR :
Conventional teaching is surgical correction of MR is associated with
prohibitive operative mortality
Studies that proved against the tradition are BOLLING , MILLER ,
BISHAY , ACORN (ACKER et al.)
Ischemic MR:
BAX , FOTTOUCH , ACKER et al showed that mitral valve repair
showed significant benefit .
No randominized studies comparing mitral valve repair from medical
therapy is available
Valvular Surgery
Valvular dysfunction– Mitral Valve Surgery

17. ACORN TRIAL :
Non randominized ,30 centres , 193 pts , on medical therapy was done
to evaluate safety and efficacy of MVR + CorCop cardiac support
device.
Valvular Surgery
Valvular dysfunction– Mitral Valve Surgery – Benefits .
Acker MA, et al: Mitral valve surgery in heart failure: JTCS 2006
Change was
also noted in
MR , NYHA
class .

18. Mortality:
In non ischemic MR mortality from various studies ranged from
1.6%(ACORN trial) to 5%(Bolling study).
In Ischemic MR mortality was less than 5%
Recurrence :
Intial results showing recurrence were around 30-40%.later on
results showed to be recurrence of 10%.(recurrence rates can be
deceased by using non flexible and undersized rings).
Valvular Surgery
Valvular dysfunction– Mitral Valve Surgery – Risks/Disadvantages .
No current evidence of survival benefit after MR elimination

19. MVR for pts with LV dysfunction and ≥ moderate MR may be
appropriate for
1.Pts undergoing CABG
2.Pts with dilated cardiomyopathy who remain symptomatic
despite optimal medical therapy
ACC/AHA 2006 and ESC 2007 suggest that mitral annuloplasty with
an undersized rigid annuloplasty is beneficial.
Valvular Surgery
Valvular dysfunction– Mitral Valve Surgery – Guidelines.

20. Valvular Surgery
Valvular dysfunction– Aortic Valve Surgery – Aortic Stenosis.

21. Pereira JJ, et al: Survival after AVR for severe AS with low
transvalvular gradients and severe LVD. JACC 2002
Valvular Surgery
Valvular dysfunction– Aortic Valve Surgery – Aortic Stenosis.
82%
15%
78%
41%

22. Although operative mortality has been high in patients with AR and
LVD historically , cleveland clinic has indicated that patients with
pure AR oerative mortality has been same low since 1985.
In this series there was regresion in LV mass and improvement in
LV volume
Late survival has not been as good as pts with normal LV function
Valvular Surgery
Valvular dysfunction– Aortic Valve Surgery – Aortic Regurgitation.
Bhudia SK et al. improved outcomes after AVR in AR with LVD JACC 2007

23. ACC/AHA guidelines:
Aortic Stenosis :
AVR is indicated in pts with true severe aortic stenosis with LVD
with good contractile reserve(class I). With out good contractile
reserve???
Aortic Regurgitation:
AVR is indicated in pts with severe AR with LVD(class I).
Valvular Surgery
Valvular dysfunction– Aortic Valve Surgery – Guidelines .

24. LV Reconstruction
Drug Rx
LVR
LVR

25. LV Reconstruction
DOR procedureBATISTA procedureOverlapping-type
left ventriculoplasty
Yoshiro Matsui,et al. Left Ventricular Reconstruction for Severely Dilated
Heart Ann Thorac Cardiovasc Surg Vol. 14, No. 2 (2008)

26. The goal of the operation
is to reduce end systolic
volumes by at least 30%
while ensuing that the
ventricle in not too small
LV Reconstruction
RESTORE ( Reconstruction Endovascular Surgery Returning Torsion
Original Radius Elliptical Shape To LV)
STICH ( Surgical Treatment of Ischemic Heart Failure)

27. RESTORE ( Reconstruction Endovascular Surgery Returning Torsion
Original Radius Elliptical Shape To LV)
Multicentric registry with 1198 pts of post AMI with heart failure
operated between 1998 -2003.
Over all mortality was 5.3% with 1,3,5 year survival rates of 92%,90%
and 80%.
LV Reconstruction
Variable Preoperative Postoperative
LV ESVI 80% 56%
LVEF 29% 39%
NYHA 67%(III) 87%(I – II)

28. LV Reconstruction
STICH ( Surgical Treatment of Ischemic Heart Failure)
This study tested the hypothesis that adding SVR to CABG in ICMP.
Robert H. Jones et al. CABG with or without SVR NEJM 2009

29. LV Reconstruction
P=0.84
P=0.70
STICH ( Surgical Treatment of
Ischemic Heart Failure)
Robert H. Jones et al. CABG with or without SVR NEJM 2009

30. Limitations :
1.Average % reduction in end systolic volume after CABG and SVR was
19%
2.13% of pts in STICH trial didn’t have an infarct before the
development of LVD .
3.Selection bias so that the study didn’t include pts that clearly benefit
from SVR.
LV Reconstruction
STICH ( Surgical Treatment of Ischemic Heart Failure)
STICH trial didn’t prove or
disprove the original hypothesis

31. Current guidelines :
Class III
Partial left ventriculectomy is not recommended in patients with
nonischemic cardiomyopathy and refractory end-stage HF. (Level of
Evidence: C)
LV Reconstruction

32. Cardiac Support Devices
Cardiomyopastly
Limits ventricular dilation
Reduces LV stress ,with out
causing constriction
Prevents LV remodelling
Starling RC, Surgical treatment of chronic congestive heart failure. In: Mann D, ed.
Heart Failure: A Companion to Braunwald's Heart Disease, Philadelphia: WB
Saunders; 2003

33. Cor Cap device (ACORN TRIAL) Ann Thorac Surg 2007
Cardiac Support Devices
The CorCap CSD Rx group had a lower crude mortality rate (25.7%)
when compared to the control group (27.0%, risk reduction of 4.8%)
but this difference was not significant.

34. Current Guidelines:
As of now current guidelines doesn’t suggest cardiac support device
Cardiac Support Devices
US FDA doesn’t approve cardiac
support device as of now

35. Indications
Types of devices
Device selection
Evidence
Current guidelines
Ventricular Assist Device

36. Indications for VAD Support
Patient fails to wean from cardiopulmonary bypass.
Extremis with cardiogenic shock or with rapidly accelerating
multisystem organ failure due to acute cardiogenic shock
In chronic heart failure
LVEF < 25%
VO
2
< 14 cc/kg/min
NYHA class IV symptoms for 60 d
NYHA class III or higher symptoms for 28 d
1.IABP support for 14 d or
2.Two failed attempts to wean inotropes
Ventricular Assist Device
Rose EA,et al. Long-term mechanical left ventricular assistance
for end-stage heart failure. NEJM2001

37. Shot term devices (bridge to recovery)
Pulsatile devices (bridge to transplantation)
Axial flow devices (bridge to transplantation)
Total artificial heart (destination therapy)
Ventricular Assist Device
Types Of Devices:

38. Ventricular Assist Device
They are versatile and may be used
as a right ventricular assist device
(RVAD) (from right atrium or right
ventricle to pulmonary artery [PA]),
as an LVAD (from left atrium or LV
apex to aorta), or as part of an
ECMO.
Require systemic anticoagulation.
Types Of Devices:

39. The first-generation mechanical
circulatory devices used volume
displacement to invoke pulsatility.
Pulsatile volume displacement
pumps are large in profile, preload
dependent, and associated with
decreased durability
 The HeartMate XVE- textured
titanium - pseudo-neointima on
which thrombus formation is
greatly reduced, thereby decreasing
the need for anticoagulation.
Ventricular Assist Device
Types Of Devices:

40. First-generation pulsatile devices. The HeartMate VE/XVE (A) shown
here as the electric version and the Novacor LVAS (B) emerged as the
most successful implanted LVADs in the late 1980s and 1990s
Ventricular Assist Device
Types Of Devices:

41. Continuous-flow axial pumps
The continuous-flow pumps are smaller, capable of similar degrees of
pumping support (10 liters/min), more durable, and functionally
dependent on both preload and afterload.
Although axial flow pumps provide nonpulsatile flow, many patients
maintain some native cardiac function during axial pump support and
therefore continue to have pulsatile patterns of blood flow unlike with
many of the pumps previously described.
Ventricular Assist Device
Types Of Devices:

42. The second-generation HeartMate II device has an inlet cannula
of sintered titanium and a Dacron outflow cannula shown here
with bend relief to reduce kinking and injury at resternotomy
(A). The system provides mobility for the patient (B).
Ventricular Assist Device
Types Of Devices:

43. Ventricular Assist Device
Types Of Devices:
Eligible for transplantation as a
bride to transplantation with
NYHA class IV.
Pts not eligible for
transplantation and 30 mortality
of >70% -as destination therapy.
PVR > 640 dyne/s/cm
–5
,
Dialysis in previous 7 d , Serum
creatinine 5 mg/dL , Cirrhosis
with total bilirubin 5 mg/Dl,
Cytotoxic antibody 10%.
Copeland JG, Smith RG, Arabia FA, et al. Cardiac replacement with a total
artificial heart as a bridge to transplantation. N Engl J Med. 2004

44. Ventricular Assist Device

45. Survival rates in two trials of
LVADs as destination therapy.
The curves labeled 2009 are
those reported by Slaughter
and colleagues; those labeled
2001 were reported for the
REMATCH trial.
Fang J: Rise of the machines—left ventricular assist devices as permanent
therapy for advanced heart failure. NEJM , 2009
Ventricular Assist Device

46. Current guidelines:
ACC / AHA
Class IIa
Consideration of an LV assist device as permanent or “destination”
therapy is reasonable in highly selected patients with refractory end-
stage HF and an estimated 1-year mortality over 50% with medical
therapy. (Level of Evidence: B)
Ventricular Assist Device

47. Cardiac Transplantation
Indications
Contraindications
Donor selection criteria
Complications
Evidence /outcomes
Current guidelines

48. Cardiac Transplantation
Indications

49. Cardiac Transplantation
Contraindications

50. Cardiac Transplantation
Donor Selection Criteria

51. Cardiac Transplantation

52. Cardiac Transplantation

53. Rejection / immunosupression
Infection
Cardiac Transplantation
Hertz MI, et al: Registry of the International Society for Heart and Lung
Transplantation: A quarter century of thoracic transplantation. J Heart
Lung Transplant 27:937, 2008

54. Overall survival at 1 year of 87%
By the first year after transplantation surgery, 90% of surviving patients
report no functional limitations and approximately 35% return to work
Outcomes:
Cardiac Transplantation
Time Major cause of death
(%death)
< 30 daysNon specific graft
failure(41%)
1year Non CMV infection
1-5 yearsCMV infections
> 5 yearsCAV,late graft failure(31%)
Neoplasms(24%)
Non CMV infections(10%)
Hertz MI, Aurora P, Christie JD, et al: Registry of the International Society for Heart and Lung
Transplantation: A quarter century of thoracic transplantation. J Heart Lung Transplant 2008

55. Current guidelines: ACC/AHA
CLASS I
Referral for cardiac transplantation in potentially eligible patients is
recommended for patients with refractory end-stage HF. (Level of
Evidence: B)
Cardiac Transplantation

56. Lift is falling then…….?????
We never know when and where accidents will happen to us OR people around us. Read on
and hope this piece of information may help any of us when things do happen to yourself, our
friends and our loved ones.

One day, while in a lift, it suddenly broke down and it was falling from level 13 at a fast speed.
Fortunately, I remembered watching a TV program that taught you must quickly press all the
buttons for all the levels. Finally, the lift stopped at the 5th level.

When you are facing life and death situations, whatever decisions or actions you make
decides your survival. If you are caught in a lift breakdown, first thought in mind may be
'waiting to die'... But after reading below, things will definitely be different the next time you are
caught in a falling lift.

First - Quickly press all the different levels of buttons in the lift. When the emergency
electricity supply is being activated, it will stop the lift from falling further.

Second - Hold on tight to the handle (if there is any).. It is to support your position and prevent
you from falling or getting hurt when you lost your balance.

Third - Lean your back and head against the wall forming a straight line. Leaning against the
wall is to use it as a support for your back/spine as protection.

Fourth - Bend your knees. Ligament is a flexible, connective tissue. Thus, the impact of
fractured bones will be minimised during fall.

For everyone, kindly do share this piece of information with your near and dear ones !!

Thank You.