1. SURGERY FOR FAILING
HEART
Dr.Harilal.V.Nambiar MS, MCh(CTVS), FIACS
Sr. Consultant CT Surgeon
Baby Memorial Hospital
Calicut

2. 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.

3.  Incidence
 Heart 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 .

4. 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

5. 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.

6. Clinical Types
 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.

7. Causes
Acute Heart Failure
 Myocardial Infarction
 Pulmonary Embolism
 Myocarditis
 Post-partum
Cardiomyopathy
 Acute worsening of
CHF
 Acute HTx Rejection
 Trauma
Chronic Heart Failure
 Coronary artery disease
 Idiopathic cardiomyopathy
 Peripartum
cardiomyopathy
 Dilated cardiomyopathy
 Ischemic cardiomyopathy
 Valvular disease
 Congenital heart disease

8. 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.

9. 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 failure
NYHA 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 failure
NYHA 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
treatment
NYHA Class IV
Marked symptoms at rest despite
maximal medical therapy, with
recurrent hospitalizations

10. Acute Heart Failure – Rx
Options
 IABP
 ECMO
 TANDEM HEART
 IMPELLA

11. IABP
• Device placed via the femoral artery (in
the leg) to increase heart blood flow.

12. • 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

13. 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.

14. • 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

15. 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

17.  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

18. Levitronix Centrimag
• Newer generation
magnetic levitation
Centifugal pump rotates in
contact-free manner.
• Increased durability.
• Minimal thrombus and
hemolysis

19. 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

20. 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

22. Impella
 Axial flow pump
 Miniaturized impellar pump
in catheter
 Helical catheter tip placed
across aortic valve and left
ventricle
 Percutaneous or direct
placement
 Flow 4.5L/min
 Bridge to recovery

23. 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)

25.  Advantages
 Small pump
 Percutaneously placed
 Easy removal
 No need for trans septal puncture
 Disadvantages
 Hemolysis
 Difficulty of placement in PVD

26. CHF – Rx Options
 CABG
 VALVE SURGERY
 SURGICAL VENTRICULAR RESTORATION
 RESTRAINT DEVICES
 VENTRICULAR ASSIST DEVICES
 TOTAL ARTIFICIAL HEART
 HEART TRANSPLANT

27. CABG
 LVEF ≤ 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

28.  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)

29. Benefits
 Reduced mortality rates
 Improved NYHA classification
 Favorable alteration of LV geometry
 Increased LVEFs

30. Valve Surgery
AVR indicated in
 Symptomatic HF in
sev AS/AR
 Asymptomatic
patients with sev
AS/AR & EF <50%

31.  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

32. 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

33.  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%

35. 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

36. 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.

37.  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

38.  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

39. • 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

40. 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%.

41.  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

42. 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.

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

44. 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

45. 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

46. 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.

47. Relative contraindications
 Systolic pulmonary artery pressure >60 mmHg
 Severe right ventricular dysfunction
 Regional dyskinesis or akinesis without dilation of the
ventricle

48. Dor procedure for Ischemic
Cardiomyopathy

50. 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

51. SVR - Dor Procedure

52. 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.

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

54.  Symptomatic improvement occurred after
cardiomyoplasty
 Mechanism for improvement is unclear
 Pacemaker synchronization was critical for
obtaining optimal improvement.

55.  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

56. 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

57. 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

58.  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

59.  Myosplint
 Two epicardial pads and a tension wire
 Two pads on the surface of the heart
 Wire passes through
the ventricle
 Placed under tension to
to create a bi-lobular
shape

60.  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

61. Ventricular assist devices
 Pulsatile
 Heart mate XVE
 Abiomed 5000
 Thoratec VAD
 Non pulsatile
 Jarvik 2000
 Heart mate II
 Heart ware

62. Heart mate XVE
 Pneumatic or vented electric
plates
 Textured internal surfaces
 Only left-sided support
 Flows 10L/min
 Bridge to transplant
 First device to be approved for
destination therapy
 Need BSA>1.5
 Limited durability: half life 18
months
 Infection risk with
percutaneous drive line

63. Abiomed 5000
Extracorporeal
Pneumatic pulsatile
pumps
Uni- or biventricular
support
Bridge to transplant
Easy to insert and
operate so used in
community hospitals
Flows 6L/min

64. 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

66. 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)

67. Jarvik 2000 LVAD

68. 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

69. Heart Mate II…
 Pros:
 Excellent flow device
 Very durable
 Easily 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

70. 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

72. Device complications
 Early
 Bleeding
 Right sided heart failure
 Progressive multi organ system failure
 Arrhythmias
 Late
 Infection
 Thrombo embolism
 Failure of device

73. 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.

74. Indications
Bridge to Tx
 Patient at risk of imminent death from non reversible
bi-ventricular failure
 Post MI-VSR
 Intractable arrhythmias/ RV failure
Destination Rx
 Patients unfit for Tx-Malignancy, Systemic
disease(amylodosis)

75. Types of Artificial Heart
Jarvik 7
Robert 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.

76. Syncardia - Cradiowest TAH

77. Types of Artificial Heart
AbioCor
The 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

78. Types of Artificial Heart

79.  Advantage
 No External drive lines
 Trans cutaneous transmission of energy
 Reduced chance of infection
Disadvantage
 Large size
 Implantable only in 50% men and 20% women

81. Carmat Bioprosthetic TAH
– Carpentier, France 2013
 Made 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).

83. HEART TRANSPLANT
 Replacement of the failing
heart with a heart from a
suitable donor.

84.  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 guidelines
 Small number of available donor hearts
 Inapplicable in older pts or those with comorbid
conditions

85. 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.

86. • 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.

87. Contra Indication
 Active infection
 Active malignancy
 Active systemic disease
 PVR > 4Wood units
 On going drug abuse
 Mental instability
 Lack of compliance
 Age > 65 Years

88. Procedures
Orthotopic Tx
 Bi Atrial technique(Shum way)
 Bi caval Technique
Hetrotopic Tx

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

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

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

92.  Implantation of
allograft (continued). Left
atrial anastomosis.

93.  Right atrial
anastomosis.

94. •Aortic anastomosis.

95. • Completed
transplant
• Pacing wires
on donor
portion of
right atrium
and ventricle
• Pericardium
left open
*
Orthotopic HTx

96. Alternative Bicaval Approach
• Left atrial
anastomosis
performed
• Separate
inferior and
superior vena
caval
anastomosis
*

98. •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.

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

100. • Donor allograft preparation
for heterotopic heart
transplantation.

101. •Completed Hetrotopic
Tx.

102. Immuno suppression
 Cyclosporin
 Corticosteroids
 Mycophenolate mofetil
 FK-506 (tacrolimus):
 Antilymphocyte globulin
 Muromonab-CD3 (OKT3
 Rapamycin

103. Complications:
 Hyperacute Rejection
 Acute Cellular Rejection
 Vascular (humoral) Rejection
 Infection – CMV
 Toxoplasma gondii
 Pneumocystis carinii
 Aspergillus organisms
 Malignancy
 Hypertension
 Dyslipidemia
 Tricuspid Regurgitation

104. Outcome
 1 year survival rate 81.8%
 5 year survival rate 69.8%
 10 year survival rate 50%
 Functional status of the patient is excellent

105. Thank you…The Journey continues…