TECHNIQUES OF OPTIMIZATION OF THE CLINICAL CONDITIONS OF PATIENTS IN

VIEW OF RECOVERY, TRANSPLANATION, AND/OR DESTINATION THERAPY

MARKO TURINA University Hospital Zurich, Switzerland

Copyright ©2001 The Society of Thoracic Surgeons

Beyersdorf, F.; Ann Thorac Surg 2001;71:192S-194S

Health Care Financing Administration (HCFA) expenditure on heart failure compared with that for cancer and myocardial infarction, according to Medicare in 1991

Optimization of the Patient’s Condition Some introductory statements

•  Surgeons are not the primary specialists treating a patient in profound heart failure (except in posto-perative low output syndrome): these are the cardiologist in their ICU.

•  Exact diagnosis (although sometimes difficult in cardiogenic shock) is the first, essential part of the decision-making process: insist on echocardio-graphy, coronary angiography, vascular and abdominal ultrasound.

•  Effectiveness of non-surgical stabilization (correc-tion of blood chemistry, catecholamines, optimi-zation of PVR, ventilation & oxygenation, haemo-filtration etc.) must be carefully assessed.

SEVERE HEART FAILURE IN NEED OF CIRCULATORY ASSISTANCE

Most common conditions encountered (postoperative LOS excluded)

•  Terminal myocardiopathy •  End-stage coronary artery disease •  Myocarditis •  End-stage valvular heart disease •  Late-stage congenital heart malformations •  Rare conditions: Arrhythmogenic dysplasia,

Uhl’s disease, amyloidosis

HEART TRANSPLANTATION Indications, Zurich 1985-1998

Other indications: •  Uhl’s disease •  Heart tumors •  Amyloidosis •  Endomyocardial

fibrosis •  Non-compaction

CMP46%

CAD37%

Congenital6%

Valvar6%

Other3%

Pulmonary1% Re-TX

1%

PULMONARY ARTERY CATHETER Obligatory when evaluating patients in heart failure

Full ICU monitoring before any surgical decision!

Checklist For Surgical Consultation In Patients With Profound Heart Failure

•  Pharmacologic stabilization (CO, PVR) with preload and afterload adjustment, catecholamines, beta-blockers, ACE and PDE inhibitors, NO, etc.

•  Heart rate and rhythm control in tachycardia and in atrial fibrillation.

•  Correction of blood chemistry: pH correction, continuous i-v insulin to achieve normoglycaemia, haematocrit elevation to ~ 35%, haemofiltration for control of blood volume and normalization of creatinin and urea.

•  Optimization of oxygen delivery (ventilator?) •  Resynchronization therapy in cardiomyopathy? •  PCI and stenting in coronary ischemia?

Recently elucidated mechanisms of heart failure: advent of molecular biology

Phosphodiesterase Inhibitor (“The Intelligent Drug”): mechanism of action

Reliable TEE, performed by an expert, with a modern machine, is an absolute must in preoperative evaluation

And it can show some previously unsuspected, essential details!

Apical thrombus

ASD

IABP should be used early, to facilitate the myocardial recovery

Diastolic Augmentation ↑ Coronary Perfusion

Assisted Aortic End- Diastolic Pressure ↓ MVO2 Demand

Assisted Systole

Unassisted Systole

Balloon Inflation

Unassisted Aortic End-Diastolic

Pressure

140

120

100

80

60

mm Hg

Arterial Waveform Variations During IABP Therapy: Insist On Optimal Timing!

© Datascope Corp.

Acute MI and Cardiogenic Shock

23%28%

68%

010203040506070

%

Group I Group II Group III

Survival Rates for AMI and Cardiogenic Shock

Stomel, R, et al; Chest 1994; 105(4):997-1002

PRESENT USE OF IABP

•  Unstable angina and acute coronary syndromes

•  Preoperative stabilization (heart failure and acute coronaries)

•  Postoperative low output syndrome Drawbacks: cannot be used with

incompetent aortic valve; in aorto-iliac disease; ineffective in children; poor efficiency in high-output failure with low PVR.

Resynchronization in heart failure: searching for reduction in QRS width and improvement of dyssynchrony of the LV

Overview of resynchronization trials

Biventricular Resynchronization Pacing In Severe Heart Failure

Caveats

•  Inefficient in many heart failure patients. •  Difficult placement and poor stability of LV

electrodes. •  Need for additional defibrillator (pro-

arrhythmogenic effect of synchronization) •  Both QRS width reduction and improvement of LV

dyssynchrony must be demonstrated in echocardiography.

•  Effect is not immediate: there can be a delay in clinical improvement.

Quiet revolution in ICU: continuous haemofiltration

SEVERE HEART FAILURE IN NEED OF CIRCULATORY ASSISTANCE

Which direction to take?

•  Recovery: very rare, possible in loose indications for LVAD, in acute viral myocarditis and in postop. LOS.

•  Destination therapy: contraindications for heart TX (age >70 y; low grade malignancy; chronic rejection; high antibody levels; etc.)

•  Bridge to TX: presently a large majority; all patients without heart recovery after 6 -8 weeks.

HEART TRANSPLANTATION Kaplan-Meier Survival (1/1982-6/2003)

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Years

Surv

ival

(%)

.

Half-life = 9.6 yearsConditional Half-life = 12 years

N=66,751

ISHLT 2005

N followed at longest time point: 25,908

J Heart Lung Transplant 2005;24: 945-982

NUMBER OF HEART TRANSPLANTS REPORTED BY YEAR

ISHLT 2005

NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as evidence that the number of hearts transplanted worldwide has declined in recent years.

J Heart Lung Transplant 2005;24: 945-982

ELECTRICALLY DRIVEN LVAD Novacor device

THE NASA DE BAKEY LVADTM

OUTFLOW GRAFT

LVAD

ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by VAD usage (Transplants: 1/1999-6/2003)

50

60

70

80

90

100

0 1 2 3 4 5

Years

Surv

ival

(%)

Heartmate/Novacor (N=1,055) No LVAD (N=7,000)

p = 0.022

ISHLT 2005

Note: Only 32 transplants involving continuous flow devices and 33 with ECMO; too few to analyze.

J Heart Lung Transplant 2005;24: 945-982

Prolonged assist with LVAD is essential for normalization of patient’s condition

MECHANICAL CIRCULATORY ASSISTANCE AS BRIDGE TO TRANSPLANTATION

Meta-analysis: odds ratio for non-survival

Heart Transplantation: Age of recipient as the determinant of survival

Heidelberg Databank, 2000 (Prof. Opelz)

ELECTRICALLY DRIVEN LVAD

MICROMED LVAD ACTION

Patient in massive heart failure When should one abstain from active surgical help?

•  Profound vasoplegia in spite of adequate

pharmacologic support and pH correction. •  Septic shock not responding to antibiotics. •  Cirrhosis Childs A or higher. •  Multiple organ failure •  Massive cerebrovascular incident or intracranial

bleeding (anticoagulation not possible). •  End stage malignancy. •  Established dementia (Alzheimer, cerebro-

vascular disorder). •  Known patient’s objection (“living will”).