Review: Surgery for Heart Failure

1. British Heart Foundation Review:Surgery for Heart Failure Ian Ramnarine Cardiac Surgical Research Fellow

2. Background • End-stage Heart Failure • Deaths from CCF • Cardiac Rehabilitation • Pharmacotherapy • Percutaneous Intervention • Surgery

3. Heart transplants by year

4. PharmacotherapyNew & Old Drugs • ACE Inhibitors • Statins • Beta-blockers • Spironolactone

5. Percutaneous Intervention • PTCA • Balloon Angioplasty • Stents • Drug-eluting stents • Alcohol injection for HOCM • Trans-myocardial Revascularization

6. Surgery • Coronary Revascularization • Valvular Surgery • Ventricular Reconstruction for Ischaemic Cardiomyopathy • Mitral Repair for Regurgitation • LV Aneurysm Plication/Resection • Ventricular Remodelling • Post-infarct VSD repair

7. Ischaemic Cardiomyopathy

8. LV Aneurysm Plication/Resection

9. Batista Operation

10. Nair Operation

11. Cellular Mechanisms • Genetherapy • Cellular Cardiomyoplasty • Immunoregulation in Transplantation • Tissue Engineering (valves)

12. Cellular Cardiomyoplasty • HF when a critical number of cardiomyocytes irreversibly lost • Function improved with new cells • Islet cell implantation

13. Cellular Cardiomyoplasty • Optimal type of donor cells • Mechanism by which cell engraftment improves cardiac function • Optimization of cell survival • Potential benefits of cell transplantation in non-ischemic heart failure

14. Evidence • Grafted neonatal cardiomyocytes detectable in infarcted areas 6/12 post-transplantation • Sino-Atrial Fetal cells trigger pacemaker activity when conduction system damaged

15. Issues • Ethics • Availability • Antigenicity • Major risk • Tumor development • Arrhythmias

16. Skeletal myoblasts • Elastic properties • Direct contribution of grafted cells to improved systolic function • Paracrine effects • Modulates injury response

17. Bone marrow stem cells • Different cell populations • Pre-treated mesenchymal cells • CD34 and AC133

18. Clinical trail • 10 patients • vastus lateralis biopsy and cells prepared and cultured • Injection + CABG • postoperative arrhythmias

19. Surgery & Circulatory Support • Transplantation • Mechanical Assist • Biological Assist • Ventricular Containment

20. Surgery & Circulatory Support • Transplantation • Mechanical Assist • Cardiac Support • Implantable IABP • Ventricular Assist Devices • Total Artificial Heart • Axial Flow Pump • Biological Assist • Cardiomyoplasty • Skeletal Muscle Ventricle • Ventricular Containment

21. Ventricular containment • Cardiomyoplasty • ACORN net • Myosplint

22. Acorn Cardiac Support Device

23. CSD and Concommitant Proc

25. Myosplint Change in radius R1 R2

26. Myosplint Clinical trial • 4 patients with Myosplint • 4 patients with Myosplint + MVR • Symptomatic results unequivocal • No device related complications

27. Mechanical assist devices Principles: • Direct systolic augmentation of the heart, • Mechanical pumping to divert blood from the left atrium/ventricle directly into the aorta with sufficient force to maintain normal arterial pressure, • Diastolic augmentation

28. Mechanical assist devices • Pulsatile • Heartmate, LionHEART • Axial • Bearings • Jarvik 2000, Heartmate II • No Bearings • Heartmate III

29. Implantable IABP • The Kantrowitz CardioVADTM (KCV) • 60cc pumping chamber • Percutaneous access device (PAD), • External controller • Clinical trials • 5 men (age 59 to 73)

31. Results • Patient 1 died intra-operatively • 1 month • cardiac index increased (1.7 to 2.6 L/min/m2) • decreases in creatinine (2.6 to 1.5 mg/dL) • PCWP dec 32 to 14 mm Hg • RA dec 19 to 9 mm Hg • NYHA class improved (IV to II)

32. Ventricular Assist Devices • Timing of LVAD intervention • Bridge-to-transplant or to-recovery • REMATCH Trial

33. Indication for Use • Nov 2002 • FDA approved • Bridge-to-transplant • Destination therapy

34. REMATCH Trial • 129 patients • End-stage heartfailure • NOT eligible for transplantation • LVAD 68 patients • Optimal medicalmanagement (61).

35. Results • 48% dec in risk of death from any cause in LVAD group • Survival at oneyear 52% VS 25% (P=0.002) • Two years 23% VS 8% (P=0.09) • Adverse events risk in the device group was 2.35 times Infection, bleeding, and device malfunction

36. Conclusions • LVAD in advanced heart failure • clinically meaningfulsurvival benefit • improved quality of life • An acceptable alternative therapy in selectedpatients • Not in candidates for cardiac transplantation

37. Bridge-to-transplant

38. Abiomed

39. Heart Mate

40. Lionheart LVAS

41. Novocor LVAS

42. Novocor LVAS • 1461 worldwide • Porcine valved conduit • Solenoid coil • Pusher plates

44. Axial Flow Pump Jarvik 2000

46. DeBakey VAD axial pump • Eur J Cardiothorac Surg. 2002 Dec, Fabiani JN. • 1999 to 2002 9 patients • NYHA functional class IV • bridge to transplantation • LV apex to ascending aorta • Mean support was 81+/-62 (16-224 days). • Eight reoperations (three for bleeding or cardiac tamponade, one for haemoperitoneum • Hemolysis in two patients. • No device infection or dysfunction • Secondary recovery in six patients. • Five patients were transplanted

47. Rotary Blood Pump

48. Rotary pump as RVAD

50. Problems • Materials • Power supply • Drive line • Infection • Thrombosis • Haemorrhage • Cost • Availability