This document discusses various surgical options for treating heart failure, including: - Coronary artery revascularization to improve blood flow in ischemic cardiomyopathy. - Valve surgery like mitral valve repair to address functional mitral regurgitation and reduce ventricular volume overload. - Left ventricular reconstruction to remove scar tissue, restore a more elliptical chamber shape, and decrease wall stress. - Passive cardiac support devices like the CorCap that provide external diastolic support to facilitate reverse remodeling. - Mechanical circulatory support options for short-term support like IABP or long-term support like left ventricular assist devices as a bridge to transplant. - Cardiac transplantation as the gold

2. Definition
“a complex clinical syndrome that can
result from any structural or functional
cardiac disorder that impairs the ability
of the ventricle to fill with or eject blood‟‟

5. Surgery for heart failure?
It would appear so:
 by removing the primary ventricular
insult, so permitting recovery, or
 by amelioration of the damaged
ventricle with improvement of cardiac
output (so called „„reverse remodelling‟‟
or „„ventricular restoration surgery‟‟).


6. OPERATIONS TO REVERSE REMODEL THE
FAILING HEART
Intervention to improve CO by reducing ventricular
afterload:
– intra-aortic balloon pumping (IABP)
– resection of obstructed left ventricular outflow in
HCM
Surgical procedures to improve cardiac output by
reducing left ventricular size („„La Place surgery‟‟):
– myo-splint
– CorCap or Acorn device
– Batista operation
– left ventricular aneurysmectomy

7. Surgical strategies to re-power the failing heart:
Mechanical:
– cardiac resynchronisation therapy (CRT)
– ventricular assist devices (left (LVAS), right
(RVAS), bi- (BiVAS) and total artificial heart)
Biological:
– dynamic cardiac myoplasty
– heart transplantation
– cell transplantation
– gene therapy
– up-regulation of natural pathways

8. Surgical options
Coronary artery revascularization
 Valve surgery
 Left ventricular reconstruction
 Passive cardiac support devices
 Assist devices
 Cardiac transplantation


9. Coronary artery
revascularization
Ischemic cardiomyopathy:
 myocardial dysfunction that arises
secondary to occlusive or obstructive
coronary artery disease

10. Three inter-related pathophysiologic
process:
 Myocardial stunning
 Myocardial hibernation
 Myocyte cell death

11. 
Clinical factors for selection of suitable heart
failure patients
the presence of angina,
 severity of heart failure symptoms,
 LV dimensions,
 degree of hemodynamic compromise, and
 comorbidities.


Other major technical issues to be
considered are
adequacy of target vessels for
revascularization &
 adequate conduit strategy.


12. 
The most important determinant,
however, is the extent of jeopardized
but still viable myocardium.

Current studies have suggest at least
25% of the myocardium should be
viable

15. Risks of CABG

Studies have indicated that for patients
with clinical heart failure, perioperative
mortality rates will range from
approximately 2.6% to
8.7%, depending on age and presence
of one or more comorbid conditions

16. 
CABG Patch trial
– Angina - HF - : 1.3%
– Angina - mild HF (NYHA I/II): 4.8%
– Angina - severe HF(NYHA III/IV): 7.4%
SHOCK trial
 1-year mortality CABG : 42% to 56%
medical therapy - 56% to 75%
 IABP decreased in-hospital mortality but
had no effect on 1-year survival.


17. Benefits of Coronary Artery Bypass
Grafting

The beneficial effect of revascularization should,
theoretically, result from improved blood flow to
hypoperfused but viable myocardium, with a
subsequent improvement in LV function and clinical
outcomes.
 Alleviation of ischemia may also lessen the
tendency toward proarrhythmias, thereby reducing
the incidence of sudden cardiac death.
 Accordingly, coronary artery revascularization has
the potential to improve symptoms of heart failure,
LV function, and survival.

18. Improvement in LV function

19. Symptomatic improvement
In a study from Verona, 167 patients
with an average LVEF of 28%, with
angina and heart failure symptoms,
demonstrated
– Freedom from angina - 98% and 81% at 1
and 5 years.
– Freedom from heart failure - 78% and 47%
at 1 and 5 years.
– Both - 54% of patients

20. 
A blood flow–metabolism mismatch of
more than 18% was associated with a
sensitivity of 76% and a specificity of
78% for predicting a change in
functional status after revascularization.

Another study showed a 34% increase
in exercise capacity from 5.6 to 7.5
METs in the group of patients with
revascularization PET mismatch.

21. Survival benefit
SVD
DVD
TVD

22. 
DUKE data base: CABG > medical
therapy
– regardless of age, LVEF, NYHA class, or
presence of angina

Survival:
CABG
MEDICAL
THERAPY
1 YEAR
83%
74%
5 YEARS
61%
37%
10 YEARS
42%
13%

24. 
meta-analysis of 24 studies (3088 patients)
– revascularization decreased the risk of death by
79.6% in patients with evidence of viable
myocardium
– annual mortality of 3.2% compared with 16.0%
for patients without revascularization.

The type of viability study did not affect the
clinical outcomes.

In contrast, patients without viability showed
no survival benefit with revascularization.

25. 
A study of 908 CABG patients looking at
mid- and long-term results showed the
independent risk factors for short- and
long-term event-free survival are
– quality of coronary arteries,
– degree of myocardial viability,
– completeness of revascularization,
– number of grafts, and
– elective operation.

26. STICH TRIAL

27. (1) CABG combined with medical therapy
improves long-term survival compared
with medical therapy alone; and
(2) SVR provides additional long-term
survival benefit when it is combined with
CABG and medical therapy

28. 
Current ACC/AHA guidelines for CABG in
patients with poor LV function recommend
surgery
Class I - patients with left main or equivalent
disease,
Class IIa - patients with viable noncontracting
muscle,
Class III - without evidence of ischemia or viability.

29. Surgical options
Coronary artery revascularization
 Valve surgery
 Left ventricular reconstruction
 Passive cardiac support devices
 Assist devices
 Cardiac transplantation


30. VALVE SURGERY
MITRAL REGURGITATION:
 Progressive LV remodeling
progressive LV dilation
more spherical shape
Functional MR
• annular dilation,
• papillary muscle displaceme
• chordal tethering.

31. Consequences:
 increased preload,
 increased wall tension,
 increased LV workload,
Heart
failure
Significance:
 independent risk factor of poor
outcome, in both nonischemic and
ischemic causes

32. BOLLING hypothesis

there is an “annular solution for a
ventricular problem . . . such that
reconstruction of the mitral valve
annulus‟ geometric abnormality by an
undersized ring restores valvular
competency, alleviates excessive
ventricular workload, improves
ventricular geometry and improves
ventricular function.”

33. the reduction of the annulus by a small
ring reduces a radius of curvature of the
LV at the base equatorial and apical
levels
restore a more elliptical ventricular
shape
reverse remodelling

34. Acorn trial

35. 
Operative morality 2% – 5%

Recurrent MR – 30% - 40%

No survival benefit

36. Surgical options
Coronary artery revascularization
 Valve surgery
 Left ventricular reconstruction
 Passive cardiac support devices
 Assist devices
 Cardiac transplantation


37. Left ventricular reconstruction
The goals of ventricular reconstruction are
– to remove or to exclude the infarcted segment
– to restore an elliptical ventricular chamber
– to diminish remote wall stress
– to promote helical fiber orientation and
– to increase thickening of the akinetic or
dyskinetic portion of the chamber
– to reduce end-systolic volume
– to diminish mitral insufficiency, and
– to eliminate residual ischemia

39. The goal is to reduce ESV by at least 30% while
ensuring that the ventricle is not too small.

40. 



The RESTORE (Reconstructive Endoventricular
Surgery returning Torsion Original Radius Elliptical
shape to the left ventricle)
Concomitant procedures included CABG in 95%
and mitral valve repair in 22%.
The operative mortality - 5.3%.
At 5 years, the overall survival was 68% ± 2.8%,
and
freedom from hospital readmission for heart failure
was 78%.

41. 
Risk factors for death
– LVEF less than 30%
– LV end-systolic volume index ≥80 mL/m2
– advanced NYHA functional class, and
– age older than 75 years

Decrease in LV ESVI (from 80.0 ± 5.1 to 56.0 ± 34.3
mL/m2)

Increase in LVEF (from 29% ± 11.0% to 39% ± 12.3%).

30-day mortality of 1% and 1-, 3-, and 5-year survival of
92%, 90%, and 80%, respectively.

42. The SVR portion of the STICH
trial

Bypass surgery alone was done in 499
patients, and CABG plus SVR was
performed in 501 patients.

Median follow-up of 48 months.

There were no differences in deaths
from any cause or hospitalization for
cardiac causes during the 5 years of the
study.

44. Criticism:
 The average %reduction in ESV after
CABG plus SVR was only 19%.
 This is below the accepted criterion for
successful LV reconstruction of a
minimum of 30% reduction in ESV.
 In addition, the absolute end-systolic
volume index in the STICH patients
undergoing CABG plus SVR was
67mL/m2.

45. The results of Menicanti

46. Surgical options
Coronary artery revascularization
 Valve surgery
 Left ventricular reconstruction
 Passive cardiac support devices
 Assist devices
 Cardiac transplantation


47. Passive Cardiac Support
Devices

The CorCap cardiac support device
(CSD) is a fabric mesh sock that is
surgically implanted around the heart.

The CSD is designed to provide
circumferential diastolic support and to
reduce LV wall stress, thereby leading
to reverse cardiac remodeling.

50. 
The Acorn trial - CSD-treated patients
– fewer cardiac procedures
– improvement in NYHA class.
– decrease in LV EDV and ESV→ reverse
cardiac remodeling,
– increase in the LV sphericity index → indicative
of a more elliptically shaped ventricle
– improvement in quality of life scores.
Additive benefits with mitral valve surgery
 Continued benefits up to 5 years, with no
evidence of constrictive physiology
 Currently not approved by the FDA.


52. Surgical options
Coronary artery revascularization
 Valve surgery
 Left ventricular reconstruction
 Passive cardiac support devices
 Assist devices
 Cardiac transplantation


53. Cardiac transplantation

Christiaan Barnard performed the first clinical
human cardiac transplantation in 1967.

The most potent predictor of outcome in
ambulatory patients with heart failure is a test
of symptom-limited metabolic stress to
calculate peak oxygen consumption (V.o2)

A peak V.o2 of <12 mL/kg/min is indicative of
a poor prognosis, with a survival rate that is
lowerthan that for transplantation

54. 
Each patient undergoes immunological
evaluation, which is increasingly sophisticated, to
determine ABO blood type; antibody screening;
testing for panel reactive antibody (PRA); and
human leukocyte antigen (HLA) typing.
 The presence and levels of anti-HLA antibodies is
determined by cytotoxic testing in which the
recipient‟s serum is incubated with lymphocytes
from 30 to 60 individuals that represent a wide
range of HLA antigens.
 The PRA value is expressed as a percentage of
cell panel members that undergo cytolysis and is
considered positive if more than 10% of the cell
panel members undergo cytolysis.

55. The acceptable “cold ischemia” time for
cardiac transplantation is approximately
4 hours.
 The two most common surgical
approaches for the implantation of the
donor heart are the biatrial and bicaval
anastomoses.
 The biatrial anastomosis technique has
long had a reputation for being simple,
safe, and reproducible;
 four suture lines are made in the left
atrium, pulmonary artery, aorta, and


56. 
The bicaval anastomosis technique was
introduced in the early 1990s with the
intentions toreduce right atrial size, to
minimize distortion of the recipient heart, to
preserve atrial conduction pathways, and to
decrease tricuspid regurgitation.

This alternative procedure entails five
anastomoses: left atrium, pulmonary artery,
aorta, inferior vena cava, and superior vena
cava.

58. 
Although there has been no prospective
trial to establish th superiority of either
technique, the bicaval technique is now
performed more often in the United
States, primarily because it appears to
decreasethe need for permanent
pacemakers in transplant recipients.

59. 
The most common reason for failure to
wean a heart transplant recipient from
cardiopulmonary bypass is right-sided
heart failure, evidenced by a low cardiac
output despite a rising central venous
pressure.

Right ventricular function may be
enhanced with inotropic agents and
pulmonary vasodilators,

60. Most immunosuppressive regimens
begin with the simultaneous use of
three classes of drugs:
 Glucocorticoids,
 Calcineurin inhibitors, and
 Antiproliferative agents.


61. Outcomes
Survival:
 During the first year after
transplantation, early causes of death
are graft failure, infection, and rejection,
with an overall 1-year survival rate of
87%.
 Nonspecific graft failure accounted for
41% of deaths during the first 30 days
after transplantation, whereas
noncytomegalovirus infection was the
primary cause of death during the first

62. 
After 5 years, CAV and late graft failure
(31% together), malignancy (24%), and
noncytomegalovirus infection (10%)
were the most prominent causes of
death.
Functional Outcomes
 By the first year after transplantation
surgery, 90% of surviving patients
report no functional limitations, and
approximately 35% return to work

63. Surgical options
Coronary artery revascularization
 Valve surgery
 Left ventricular reconstruction
 Passive cardiac support devices
 Assist devices
 Cardiac transplantation


64. Mechanical Circulatory
support
Short – term:
1. Intra-aortic Balloon Pump
2. Abiomed Biventricular System 5000
3. Abiomed AB5000
4. Bio-Medicus Bio-Pump
5. Levitronix CentriMag
6. TandemHeart Percutaneous
Transseptal VAD
7. Impella Devices

70. Bridge to transplantation
1. Thoratec Percutaneous Ventricular
Assist Device System
2. CardioWest Total Artificial Heart
3. Novacor Ventricular Assist System
4. HeartMate XVE Left Ventricular Assist
Device
5. HeartMate II Left Ventricular Assist
Device

76. Future devices:
1. Jarvik 2000
2. MicroMed DeBakey VAD
3. HeartMate III
4. MVAD by HeartWare
5. Abiomed Total Artificial Heart