surgical treatment for chf...ccf due to chf, ascites and a fib .h/o of ephedrine-related drug abuse...

G. Economopoulos MD FACSG. Economopoulos MD FACS

SURGICAL TREATMENT FOR CHF"Where we are today"


Major Issues in the Surgical Tx for CHF

. SVR + CABG

. Mitral Valve Regurgitation

. Assist Devices


CABG in patients with low EF , graftable vessels and recruitable myocardium is the better option today in terms of long lasting benefits

SVR+ GABG?


S V R (Surgical Ventricular Restoration)

FACTS : CHF increase due to: aged population

. more efficacious myocardial infarction treatment

Post MI LV remodeling: chamber dialatation

abnormal LV shape

Systolic+Diastolic dysfunction Progressive CHF

SVRRelieve Ischemia (GABG)

Diminish LV Volume

Reshape LV geometry

Further diminish LLV by MV repair if appropriate


SVR Surgical Ventricular Restoration


STICH trial (Surgical Treatment for IschemiC Heart failure)

Multicenter International study (including many pat strata .)

In the C stratum 1000 pats with EF<30% divided between CABG alone and CABG+ SVR

Analysis of the results : No survival benefit associating ventricular remodeling with CABG in pats with anterior LV akinesis and Low EF

Even a sub analysis in pats with larger LV volumes found no benefit

R Jones: " This study suggests that there is no need to add this refined operation to CABG" NEJM 2009


H O W EV E R !

ESC congress 2010

An analysis of the STICH trial found the following flaws

- LV volume criteria for inclusion not always met

- LV volumes were inadequately measured

- viability was not assessed

- only 50% of pats were in NYHA III / IV

- more than half of SVR pats did not achieve adequate volume reduction

IT MAYBE PREMATURE TO CONCLUDE THAT SVR ADDED TO CABG HAS NO VALUE!

It is possible that the only pats that could benefit from an SVR added to CABG

are those with large hearts ,anterior wall akinesia without viability


MITRAL VALVE REGURGITATION (role of MV repair) ( 1 )

FACTS : - Mitral regurgitation has an adverse impact on survival

MAJOR QUESTION: Which pats benefit from surgical repair? (undersized rings)

Definite Contraindications : - RV dysfunction

- absence of contractile reserve

- heavy co- morbidities

Recurrence of MV regurgitation : up to 30% in pats with:

- LVESD> 51 mm

- long duration of CHF


MITRAL VALVE REGURGITATION ( 2)

Mitral Valve replacement with preservation of sub-valvular apparatus

WHEN : - multiple ,complex jets

- absence annular dialatation

- severe tethering (> 4cm tented area )

- posterior leaflet-annular plane >45degrees

- advanced LV adverse remodeling

PM repositioning, section of secondary chordae, sling around the PMs are other procedures used ( small series)

CONSIDER: AF ablation, resynchronization, TV repair for associated TV regurgitation


VENTRICULAR ASSIST DEVICES

What we know so far :

- Major breakthroughs with : -size reduction

- changes in technology

Large Small Pulsatile Continuous


V A Ds

Based on : - improved survival

- reduced complications

- Implantation of the new centrifugal pumps should be considered on a predictive probability of survival around 25% (Seattle Heart failure model)

- The new generation VADs allow long term support to an eventual OHT

- They provide relief of symptoms, satisfactory exercise capacityand thus can be considered to a more than a BTT


CASE 1

• 44 y old male, an active body builder ( BMI >35Kg/m2),admitted at CCF due to CHF, ascites and A fib .H/o of ephedrine-related drug abuse stimulants. ECHO : Biventricular failure with est LVEF 5-10%, PAWP 30mmHg, CVP 28, LVEDD 80mm. Elevated BUN-Creatinine( 2,4/ 76) . Declinining rapidly despite inotropes, vasopressors, and O2. ( Acidosis, rising Lactic levels, hypoxemia, widening QRS, Ventricular ectopy in salvos of 4-5).

• Inability to insert IABP, (even a simple AL).• HFS Team Urgent Consultation called at 01.00 hrs.

• 44 y old male, an active body builder ( BMI >35Kg/m2),admitted at CCF due to CHF, ascites and A fib .H/o of ephedrine-related drug abuse stimulants. ECHO : Biventricular failure with est LVEF 5-10%, PAWP 30mmHg, CVP 28, LVEDD 80mm. Elevated BUN-Creatinine( 2,4/ 76) . Declinining rapidly despite inotropes, vasopressors, and O2. ( Acidosis, rising Lactic levels, hypoxemia, widening QRS, Ventricular ectopy in salvos of 4-5).

• Inability to insert IABP, (even a simple AL).• HFS Team Urgent Consultation called at 01.00 hrs.

George C Economopoulos, MD FACS


INTERMACSLevel Short Name Condition Site of

careInotropes Time Frame

1 Crash & Burn Unstable, Uncontrolled

ICU YES Hours

2 Sliding on inotropes

Unstable, Uncontrolled

ICU YES DAYS

3 Depedent stability

Unstable , controlled

ICU/Tele NO/YES Weeks

4 Frequent Flyer Stable,Controlled

Tele/Home No/Yes Variable

5 HouseBound Stable, Self controlled

Home No/Yes Variable

6 Walking wounded

Stable, self controlled

Home No Variable

7 Stable Self controlled

Home No ReassessGeorge C Economopoulos, MD FACS


Immediate action Required !

Immediate action Immediate action Required !Required !



DECISIONS ABOUT MCSWHAT IS THE END POINT OF THE MCS?



Action takenAction takenAction taken

Insertion of A-V ECMO via Femoral cut downFlows at 3.5 Lts

RESULTSImproved Hemodynamics,Improved PO2, PH, Lactic levels

POD 3: Pat stable, Neurologically intact,Normalization of Renal, Pulmonary ,Hepatic functionMinimal inotropes and reduced flow to allow ejectionAPTT= 45-50 (heparin drip)

Insertion of A-V ECMO via Femoral cut downFlows at 3.5 Lts

RESULTSImproved Hemodynamics,Improved PO2, PH, Lactic levels

POD 3: Pat stable, Neurologically intact,Normalization of Renal, Pulmonary ,Hepatic functionMinimal inotropes and reduced flow to allow ejectionAPTT= 45-50 (heparin drip)



ECMO CircuitECMO CircuitECMO Circuit



ECMO SUPPORT FOR 7 DAYSECECMO SUPPORT FOR 7 DAYSMO SUPPORT FOR 7 DAYS

Awake, alert fully orientedTEE wean trial : no improvement in RV or LV function with decrease of ECMO flow and addition of inotropes, (ECMO flow gradually down to 500ml and iv inotropes)

Awake, alert fully orientedAwake, alert fully orientedTEE wean trial : no improvement in RV or LV function with TEE wean trial : no improvement in RV or LV function with decrease of ECMO flow and addition of inotropes, (ECMO decrease of ECMO flow and addition of inotropes, (ECMO flow gradually down to 500ml and iv inotropes)flow gradually down to 500ml and iv inotropes)



Next Step?Next Step?Next Step?



Decision making Decision making

Choice AChoice AChoice A

� List pat as Stage 1A for immediate OHT while on ECMO

�� List pat as Stage 1A for List pat as Stage 1A for immediate OHT while on immediate OHT while on ECMOECMO

ConsConsCons

� Overweight, issues about conformity unknown waiting period

� High PAP pressures (> 5 wood units) most likely reversible

� Uncertain family support

� Big individual, donor pool limited

� Pros� Definite, uncomplicated ( virgin

mediastinum) entry, one shot treatment

�� Overweight, issues about conformity Overweight, issues about conformity unknown waiting periodunknown waiting period

�� High PAP pressures (> 5 wood units) High PAP pressures (> 5 wood units) most likely reversiblemost likely reversible

�� Uncertain family supportUncertain family support

�� Big individual, donor pool limitedBig individual, donor pool limited

�� ProsPros�� Definite, uncomplicated ( virgin Definite, uncomplicated ( virgin

mediastinum) entry, one shot mediastinum) entry, one shot treatmenttreatment



Decision MakingDecision MakingDecision Making

Choice BChoice BChoice B

� MCS with Bi VAD system�� MCS with Bi VAD systemMCS with Bi VAD systemProsProsPros

� Time for : ( if BTT)� -Normalizing organ function� - Need for long waiting because

of 1. BMI>40Kg/M2� 2. Blood Type 0+

� Time for: ( if BTR)� - Recovery of native

myocardium ( has been reported)

� Cons� Prolonged LOS , 2 VADs, assoc

morbitidity

�� Time for : ( if BTT)Time for : ( if BTT)�� --Normalizing organ functionNormalizing organ function�� -- Need for long waiting because Need for long waiting because

of 1. BMI>40Kg/M2of 1. BMI>40Kg/M2�� 2. Blood Type 0+ 2. Blood Type 0+

�� Time for: ( if BTR)Time for: ( if BTR)�� -- Recovery of native Recovery of native

myocardium ( has been reported)myocardium ( has been reported)

�� ConsCons�� Prolonged LOS , 2 VADs, assoc Prolonged LOS , 2 VADs, assoc

morbitiditymorbitidity



MCS as BTTMCS as BTTMCS as BTT

� MCS as BTT� Need a paracorp or implantable Bi VAD� Major deciding factor: prolonged waiting period due to : � 1. BMI (> 40Kgm2)� 2. Blood type O+� 3. High PAPs ( expected to normalize with BiVAD)

� - Thoratec p Bi VAD

� - Thoratec i Bi VAD

� - TAH

�� MCS as BTTMCS as BTT�� Need a Need a pparacorp or aracorp or iimplantable Bi VADmplantable Bi VAD�� Major deciding factor: Major deciding factor: prolonged waiting period prolonged waiting period due to : due to :

�� 1. BMI (> 40Kgm2)1. BMI (> 40Kgm2)�� 2. Blood type O+2. Blood type O+�� 3. High PAPs ( expected to normalize with BiVAD)3. High PAPs ( expected to normalize with BiVAD)

�� -- Thoratec p Bi VAD Thoratec p Bi VAD

�� -- Thoratec i Bi VADThoratec i Bi VAD

�� -- TAHTAH



MCS for BTRMCS for BTRMCS for BTR

� Need for BIVAD support , since there is RVF with the following benefits:

� 1. Native heart remains in place, since recovery is expected/anticipated

� 2. Capability to support both ventricles for a long period, till recovery is beyond doubt

� 3. Pat Friendly: allows hospital D/C home, mobility, almost every day common tasks, easy to self manage.

�� Need for BIVAD support , since there is RVF with the Need for BIVAD support , since there is RVF with the following benefits:following benefits:

�� 1. Native heart remains in place, since recovery is 1. Native heart remains in place, since recovery is expected/anticipatedexpected/anticipated

�� 2. Capability to support both ventricles for a long 2. Capability to support both ventricles for a long period, till recovery is beyond doubtperiod, till recovery is beyond doubt

�� 3. Pat Friendly: allows hospital D/C home, 3. Pat Friendly: allows hospital D/C home, mobility, almost every day common tasks, easy to self mobility, almost every day common tasks, easy to self manage.manage.



Thoratec p BiVAD SystemThoratec p BiVAD SystemThoratec p BiVAD System



Thoratec i Bi VAD SystemThoratec i Bi VAD SystemThoratec i Bi VAD System



Total Artificial Heart :TAH Total Artificial Heart :TAH Total Artificial Heart :TAH


G. Economopoulos MD FACSG. Economopoulos MD FACSGeorge C Economopoulos, MD FACS


TAH CONSOLE(S)


"BIG BLUE" Console Driver


Predictions for the future ?

surgical treatment for chf...ccf due to chf, ascites and a fib .h/o of ephedrine-related drug abuse...

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