SURGERY FOR FAILING SURGERY FOR FAILING HEARTHEART

Dr.Harilal.V.Nambiar MS, MCh(CTVS), FIACS

Sr. Consultant CT Surgeon

Baby Memorial Hospital

Calicut

Introduction

Heart failure is a global term for the physiological state in which cardiac output is insufficient for the body's needs.

It is a condition in which there is problem with the structure or function of the heart and it impairs the ability to supply sufficient blood flow to meet the body's needs.

IncidenceHeart failure affects nearly 5.7 million people

Roughly 670,000 people are diagnosed with heart failure each year.

It is the leading cause of hospitalization in people older than 65.

1 in every 5 people will develop heart failure .

Incidence (per year)

Prevalence Hospitalization

Cost

• 550,000 new diagnoses

• 300,000 deaths

• 1-2% of population (5 million )

•6 days (average)

50% re -hospitalized within 6 months

•1-2% total health care

spending$ 35 billion

Mortality

80% of men and 70% of women with less than 65 years of age and HF will die within 8 years

Up to 42% of patients die of HF within 5 years of hospitalization of HF.

Sudden cardiac death is 6 to 9 times more likely in a HF patient as compared to the general population.

Acute heart failure:

A sudden change in heart function

related to some new event that has caused

damage to the heart.

Chronic heart failure:

A gradual decline of heart function over a period of

time. Often the body compensates slowly for the

loss of heart function.

Causes Acute Heart

FailureMyocardial InfarctionPulmonary EmbolismMyocarditis Post-partum

Cardiomyopathy Acute worsening of CHFAcute HTx RejectionTrauma

Chronic Heart Failure

Coronary artery disease Idiopathic cardiomyopathy Peripartum

cardiomyopathyDilated cardiomyopathyIschemic cardiomyopathyValvular diseaseCongenital heart disease

NYHA Functional Classification

Class Description

I No limitation of physical activity - ordinary physical activity doesn't cause tiredness, heart palpitations, or shortness of breath

II (Mild) Slight limitation of physical activity, comfortable at rest, but ordinary physical activity results in tiredness, heart palpitations, or shortness of breath

III (Moderate

)

Marked or noticeable limitations of physical activity, comfortable at rest, but less than ordinary physical activity causes tiredness, heart palpitations, or shortness of breath

IV (Severe)

Severe limitation of physical activity, unable to carry out any physical activity without discomfort. Symptoms also present at rest. If any physical activity is undertaken, discomfort increases.

AHA/ACC 2009 - Staging System of Heart

Stage Description Examples

A People at high risk for developing heart failure but without structural heart disease or symptoms of heart failure. Encompasses “pre heart failure” where intervention with management can overt Progression to symptoms

CAD (coronary artery disease), diabetes, hypertension, metabolic syndrome, obesity, using cardiotoxins or alcohol, family history of cardiomyopathy, cerebrovascular accident (CVA), personal history of rheumatic fever

B People with structural heart disease but without signs and symptoms of heart failureNYHA Class I

Left ventricular hypertrophy (LVH) or reduced left ventricular ejection fraction (LVEF), asymptomatic valvular heart disease, previous MI

C People with structural heart disease with prior or current symptoms of heart failureNYHA Class II and III

Known structural heart disease with dyspnea, fatigue, inability to exercise

D People who have advanced heart failure and severe symptoms difficult to manage with standard treatmentNYHA Class IV

Marked symptoms at rest despite maximal medical therapy, with recurrent hospitalizations

Acute Heart Failure – Rx Options

IABP

ECMO

TANDEM HEART

IMPELLA

IABP• Device placed via the femoral artery

(in the leg) to increase heart blood flow.

• Pros: – Can be placed and removed by a

catheter.– Will allow increased heart and brain blood

flow– Reduce the after load– Reduce myocardial O2 demand

• Cons: – Lack of active cardiac support– Need some residual LV function– Less effective in arrhythmias

ECMO• Blood is removed from the

venous system either peripherally via cannulation of a femoral vein or centrally via cannulation of the right atrium, – Oxygenate– Extract carbon dioxide

• Blood is then returned back to the body either peripherally via a femoral artery or centrally via the ascending aorta.

• Full cardiopulmonary bypass

• Provides body with oxygenated blood

• Provides body with full cardiac output

• Allows heart and lungs to rest as body recovers from injury and insult

Pros: Can be placed percutaneously anywhere

Provides full heart and lung support

Cons: Must be removed surgically

Need trained staff to monitor and adjust 24 hrs/day while on support Have increased bleeding and vascular complications

Centrifugal flow pump placed percutaneously

Designed to augment left ventricular output and rest left ventricle

Can augment cardiac output up to 5

LPM

Tandem Heart

• Newer generation

magnetic levitation

Centifugal pump rotates in

contact-free manner.

• Increased durability.

• Minimal thrombus and

hemolysis

No evidence to show superiority to conventional therapy.

•Theoretical advantage to allowing the left ventricle to rest and provide the body with support.

•No mechanism to deal with right ventricular failure.

•Trial starting now to determine efficacy versus other devices

Pros: - Can fully augment LV output.

- Placed & removed percutaneously

Cons: - Must have skilled person to place the cannula trans- septaly. - Cannula position is difficult to

control and can migrate

ImpellaAxial flow pumpMiniaturized impellar pump

in catheterHelical catheter tip placed

across aortic valve and left ventricle

Percutaneous or direct placement

Flow 4.5L/minBridge to recovery

Impella RP• Catheter-based

percutaneous VAD (22 Fr pump mounted on a 11 Fr catheter)

• Treatment: Right ventricular dysfunction

• Flow: > 4 L/min• Duration of support: up to

14 days• Pump Inflow: Inferior Vena

Cava (IVC) Pump Outflow: Pulmonary Artery (PA)

AdvantagesSmall pumpPercutaneously placedEasy removalNo need for trans septal punctureDisadvantages

Hemolysis Difficulty of placement in PVD

CHF – Rx OptionsCABGVALVE SURGERYSURGICAL VENTRICULAR RESTORATIONRESTRAINT DEVICESVENTRICULAR ASSIST DEVICESTOTAL ARTIFICIAL HEARTHEART TRANSPLANT

CABGLVEF ≤ 0.35

CAD suitable for CABG

anatomically.

Left main CAD ≥ 50% stenosis

Class III angina or greater

Viable(Hibernating)

myocardium(5/12 segments) –

Cardiac MRI/Dobutamine stress

echo

In patients with HF, LVD and CAD amenable

to surgical revascularization, CABG added to

intensive medical therapy (MED) will decrease

all-cause mortality compared to MED alone.

3% (CABG+Med) Vs 31%(Med alone)

Benefits

Reduced mortality rates

Improved NYHA classification

Favorable alteration of LV geometry

Increased LVEFs

Valve SurgeryAVR indicated in

Symptomatic HF in sev AS/AR

Asymptomatic patients with sev AS/AR & EF <50%

LV contractile reserve assessed by Dobutamine

stress echo.

Distinguish heart failure due to valvar disease or

cardiomyopathy – Ischemic / restrictive.

If contractile reserve present and a valvar

problem will benefit from Sx.

No contractile reserve / Cardiomyopathy treated

with

Aorto apical conduit/LVAD/Percutaneous valve/HTx

Mitral Valve Ischemic MR•Ischemic MR is a ventricular problem.•Papillary muscle rupture.•Stretching/tenting of mitral leaflet•Alteration in LV geometry, annular dilatation contributes to volume overload, ↑ wall tension, exacerbate failure

Ischemic MR• Sx will reverse the cycle of excess ventricular volume,

ventricular unloading and promoting myocardial remodeling.

Annuloplasty + CABG with chordal shortening/re location

Mitral valve replacement with chordal preservation. Isolated MVR not recommended.

Organic MR

Early Sx before LV dysfunction sets in(EF>50%)

Outcomes are poor with EF<30%

SURGICAL VENTRICULAR RESTORATION

History of procedures Ischemic- Batista- Left ventricular aneurysmectomy

Non ischemic - Cardiomyoplasty

Current LV Reconstructive procedures Ischemic

- Dor procedure Non-ischemic

- Acorn Mesh- Myosplint

SVR for Ischemic Cardiomyopathy

Systolic HF leads to an enlarged LV volume to maintain stroke volume

This leads to increase in wall stress due to Laplace's law stress = pressure x radius ÷ 2 x wall thickness

The ventricular geometry becomes less ellipsoid and more spherical leading to progression of left ventricular dysfunction and worsening heart failure.

LV size was a predictor of sudden cardiac death

In the 1990’s studies showed a relationship between LV size and Mortality

LV’s > 4 cm/m2 had a 2 year survival of 49% compared to 75% if < 4 cm/m2

Removing or excluding portions of the dysfunctional

myocardium returns the left ventricular cavity to a

smaller chamber with more normal geometry

This should improve cardiac work efficiency and

theoretically should improve heart failure

symptoms.

Ideally it would also translate into prolonged

survival

• Removal of a section of the left ventricular free wall, between both papillary muscles and extending from the apex to the mitral annulus

• Remaining free edges were re- -approximated and stitched together

• Mitral valve and subvalvular apparatus were either preserved, repaired, or replaced

Partial Left Ventriculectomy(Batista Operation)

Initial experience with the Batista procedure demonstrated an initial increase in LVEF, reduction in heart size, and improvement in clinical functional status

However, of 120 patients Batista reported a 22% operative mortality and 2 year survival of 55%.

Late fatal arrhythmias plagued this

procedure, forcing the use of

concomitant implantable defibrillators

Therefore the Batista procedure has

fallen out of favor and is no longer

considered to be an appropriate option

Left ventricular aneurysmectomy

The first successful surgical correction of an LV

aneurysm occurred in 1957 by Dr. Bailey

Done without off cardiac bypass by placing a

clamp on the base of an aneurysm and passing

suture beneath allowing excision of the

aneurysm.

Dr. Denton Cooley performed a resection of an LV aneurysm one year later on bypass which remained the standard for nearly 30 years

Left ventricular aneurysmectomy

A 2004 ACC/AHA task force concluded that it is

reasonable (class IIa recommendation) to

consider Aneurysmectomy +CABG, in patients

with a left ventricular aneurysm in the setting

of an acute MI who have intractable ventricular

arrhythmias and/or heart failure unresponsive

to medical and catheter-based therapy

LV Reconstruction for Ischemic Cardiomyopathy

Dor procedure also called endo ventricular

circular patch plasty (EVCPP), is an approach to

surgical reconstruction in the setting of post

infarction aneurysm formation first reported in

1985

Advantage to aneurysmectomy is in an attempt

to restore left ventricular geometry

Indications

Anteroseptal MI, with dilated left ventricle (end-

diastolic volume index >100 mL/m2)

Depressed LVEF (20%)

Left ventricular regional dyskinesis or akinesis

>30 % of the ventricular perimeter

Either symptoms of angina, heart failure, or

arrhythmias or inducible ischemia.

Relative contraindications

Systolic pulmonary artery pressure >60

mmHg

Severe right ventricular dysfunction

Regional dyskinesis or akinesis without

dilation of the ventricle

Dor procedure for Ischemic Cardiomyopathy

The operation shortens the long axis, but leaves the short axis length unchanged, producing an increase in ventricular diastolic sphericity while the systolic shape becomes more elliptical

SVR - Dor Procedure

SVR for non ischemic Cardiomyopathy

Cardiomyoplasty, also referred to as “Dynamic

cardiomyoplasty"

Surgical therapy for dilated cardiomyopathy in

which the latissimus dorsi muscle is wrapped

around the heart and paced during ventricular

systole.

Principle is based on the fact that skeletal muscle

can be trained to be fatigue resistant.

Carpentier and Chachques peformed the first successful surgery on a human in 1985

Symptomatic improvement occurred after

cardiomyoplasty

Mechanism for improvement is unclear

Pacemaker synchronization was critical for

obtaining optimal improvement.

Cardiomyoplasty experience has led to other novel approaches to heart failure.

Observations suggested that some patients benefited from the diastolic "girdling" effect of the muscle wrap

This observation led to the development of the Acorn device and Myosplint

SVR for Non-Ischemic Cardiomyopathy(new options)

Acorn device knitted polyester sock

that is drawn up and anchored over the ventricles in order to limit left ventricular dilation

Preliminary data suggest that the device produces an improvement in heart failure symptoms, LVEF, left ventricular end-diastolic dimension, and quality of life

CorCap Cardiac Support Device

The CorCap is designed to:

Provide end-diastolic ventricular support to reduce wall stress and myocardial stretch

Negate the stimuli for ventricular remodeling and promote myocardial reverse remodeling

Reverse progressive dilation and improve cardiac function and patient functional status

Study of 27 pt NYHA class went from mean

2.5 to 1.7

After one year, there is no evidence of

constriction and coronary blood flow reserve

remained normal

MyosplintTwo epicardial pads and a tension wireTwo pads on the surface of the heartWire passes through

the ventriclePlaced under tension to

to create a bi-lobularshape

NYHA functional class went from 3.0 +/- 0.3 at

baseline to 2.1 +/- 0.7 at 6 months (p = 0.001).

The LV ejection fraction significantly increased in

the Myosplint alone group (from 17.1 +/- 4.0% at

baseline to 23.1 +/- 7.2% at 6 months

No serious device-related adverse events or

device failures were observed

Ventricular assist devices

Pulsatile

Heart mate XVE

Abiomed 5000

Thoratec VAD

Non pulsatile

Jarvik 2000

Heart mate II

Heart ware

Heart mate XVE

Pneumatic or vented electric plates

Textured internal surfaces

Only left-sided supportFlows 10L/minBridge to transplantFirst device to be

approved for destination therapy

Need BSA>1.5Limited durability: half

life 18 monthsInfection risk with

percutaneous drive line

Abiomed 5000

ExtracorporealPneumatic pulsatile pumpsUni- or biventricular supportBridge to transplantEasy to insert and operate so used in community hospitalsFlows 6L/min

Thoratec VAD (pVAD/iVAD) Pneumatic, external(pVAD) or internal (iVAD), pulsatile

pump(s)

right-, left-, or bi-ventricular support (RVAD/LVAD/BiVAD)

up to ~7.2 lpm flow

Short- to medium-term use (up to ~1-2 years)

bridge to recovery

bridge to transplant

hospital discharge possible

iVAD pVAD

Jarvik 2000 LVAD Axial-flow (non-pulsatile)

pump

electric, intra-

ventricular

left heart support only

Speed: 8000-12000 rpm

flow: ~3-5 lpm Medium- to long-term therapy

(months to years)

bridge to transplant

(investigational)

Jarvik 2000 LVAD

Heart Mate II• Continuous axial flow pump• Connects LV apex to Aorta• Bypasses blood flow from the left

ventricle• Only has exteriorized driveline

connected to external monitor and power source

• Must be placed surgically• Can be used as bridge to transplant

or as destination therapy

Heart Mate II…Pros:

Excellent flow deviceVery durableEasily implantable Has excellent long term efficacy &

data

Cons:Difficult to explant Need chronic anticoagulation Device does have defined lifespan Patient must be of a certain size to

accommodate device

Heart ware• Continuous axial flow pump• Connects LV apex to Aorta• Bypasses blood flow from the left

ventricle• Only has exteriorized driveline

connected to external monitor and power source

• Must be placed surgically• Can be used as bridge to transplant

or as destination therapy• Small device can be placed in any

body habitus• Can be used for biventricular long-

term support• Currently on trial

Device complicationsEarly

BleedingRight sided heart failureProgressive multi organ system failureArrhythmias

LateInfectionThrombo embolismFailure of device

Total Artificial Heart

An artificial heart is a mechanical device

that replaces the heart. Artificial hearts are

typically used in order to bridge the time to

heart transplant, or to permanently replace

the heart in case transplantation is

impossible.

IndicationsBridge to TxPatient at risk of imminent death from non

reversible bi-ventricular failurePost MI-VSRIntractable arrhythmias/ RV failureDestination RxPatients unfit for Tx-Malignancy, Systemic

disease(amylodosis)

Types of Artificial Heart

Jarvik 7Robert Jarvik, MD is widely

known as the inventor of the first successful permanent artificial heart, the Jarvik 7.

In 1982, the first implantation of the Jarvik 7 in patient Barney Clark caught the attention of media around the world.

Syncardia - Cradiowest TAH

Types of Artificial Heart AbioCorThe AbioCor is the artificial heart is

developed by Abiomed .The AbioCor heart, which is composed of titanium and plastic, connects to four locations:

Right atrium Left atrium Aorta Pulmonary artery

Types of Artificial Heart

Advantage No External drive linesTrans cutaneous transmission of energyReduced chance of infectionDisadvantageLarge sizeImplantable only in 50% men and 20%

women

Carmat Bioprosthetic TAH – Carpentier, France 2013Made of biologic & Synthetic polymers.It has the shape & Volume of normal

heart.Weight - 900gms(3x of normal heart).Provided with multiple sensors for

optimizing CO in response to various demands.

Powered by lithium battery.Fits into 75% men & 25% women.Cost - $200,000(₹ 1,20,00000).

HEART TRANSPLANTReplacement of the

failing heart with a heart from a suitable donor.

Cardiac transplantation is currently the only established surgical approach (excluding AVR and CABG) for the treatment of refractory HF as listed in the 2005 ACC/AHA heart failure guidelinesSmall number of available donor heartsInapplicable in older pts or those with

comorbid conditions

Class I Indications for Cardiac Transplantation

Cardiogenic shock requiring mechanical assistance.Refractory heart failure with continuous inotropic infusion.NYHA functional class 3 and 4 with a poor 12 month

prognosis.Progressive symptoms with maximal therapy.Severe symptomatic hypertrophic or restrictive

cardiomyopathy.Medically refractory angina with unsuitable anatomy for

revascularization.Life-threatening ventricular arrhythmias despite aggressive

medical and device interventions.Cardiac tumors with low likelihood of metastasis.Hypoplastic left heart and complex congenital heart

disease.

• Patients should receive maximal medical therapy

before being considered for transplantation. They

should also be considered for alternative surgical

therapies including CABG, valve repair / replacement,

cardiac septalplasty, etc.

• VO2 has been used as a reproducible way to

evaluate potential transplant candidates and their long

term risk. peak VO2 <10 had the greatest survival

benefit.

Contra IndicationActive infectionActive malignancyActive systemic diseasePVR > 4Wood unitsOn going drug abuseMental instabilityLack of complianceAge > 65 Years

Procedures Orthotopic Tx

Bi Atrial technique(Shum way)

Bi caval Technique

Hetrotopic Tx

Donor Heart Procurement

Median sternotomy. Cold cardioplegia given one litre. Heart removed Kept in Cold University of Wiscosin solution. Cardiac ischemia time 180 min

Donor allograft preparation for orthotopic heart transplantation. Pulmonary vein orifices joined to form left atrial cuff.

First suture is placed at the level of the left superior pulmonary vein.

Implantation of

allograft (continued).

Left atrial anastomosis.

Right atrial anastomosis.

•Aortic anastomosis.

• Completed transplant• Pacing wires on donor portion of right atrium and ventricle• Pericardium left open

*

Orthotopic HTx

• Left atrial anastomosis performed• Separate inferior and superior vena caval anastomosis

*

•Bicaval is preferred one today.• described by Lower and colleagues.•Achieves more anatomic position, •Neutralizes potential for atrial enlargement•Less tricuspid regurge•Better hemodynamic performance.

• Heterotopic heart transplants are indicated in patients with - irreversible pulmonary hypertension or - significant donor-recipient size mismatch.

• Donor allograft preparation for heterotopic heart transplantation.

•Completed Hetrotopic Tx.

Immuno suppression CyclosporinCorticosteroidsMycophenolate mofetilFK-506 (tacrolimus):Antilymphocyte globulin

Muromonab-CD3 (OKT3Rapamycin

Complications:Hyperacute RejectionAcute Cellular RejectionVascular (humoral) RejectionInfection – CMVToxoplasma gondiiPneumocystis cariniiAspergillus organismsMalignancyHypertensionDyslipidemiaTricuspid Regurgitation

Outcome1 year survival rate 81.8%

5 year survival rate 69.8%

10 year survival rate 50%Functional status of the patient is excellent