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S17-3 Development of Surgical Treatment for Ischemic and Non-Ischemic Dilated Cardiomyopathy (DCM)
Symposia Symposium 17. Cardiovascular Surgery 4: Surgical Treatment for Heart Failure
S29 S17-3 Development of Surgical Treatment for Ischemic and Non-Ischemic Dilated Cardiomyopathy (DCM) Tadashi Isomura. Hayama Heart Center, Japan
S17-1 Surgical Ventricular Restoration for Ischemic Heart Failure and STICH Trial Marisa di Donato, Lorenzo Menicanti. IRCCS Policlinico San Donato, Milano Italy Coronary artery disease is the most frequent cause of heart failure in the western societies and the HF can be the only mode of CAD presentation associated with increasing incidence and mortality. Pathophysiology of Postinfarction Remodeling: When after the occlusion of the Left Anterior Descending Coronary one third o more of ventricular perimeter is involved, left ventricular volume increases, the apical portion became rounded and subsequently involves also the basal portion. Pathophysiologic basis of Surgical Ventricle Restoration: The success of this surgical procedure is based on several points: a. Complete revascularization; b. Diminish Ventricular Volume; c. Restore the shape. Surgical procedure: the procedure is conducted on arrested heart. Anterior and septal wall scar is excluded. Patients: Between 1989 and 2006, 1400 pts with symptoms of angina and or heart failure have been operated. Results: A significant reduction of end diastolic and end systolic volumes and an increase in ejection fraction are observed. Conclusions: Surgical volume reduction, as obtained by SVR, is an effective treatment st for pts with ischemic failing ventricles following myocardial infarction. Our experience allowed us to validate the results although there is a need for a randomized trial which is ongoing (STICH trial or Surgical Treatment for Ischemic Heart failure). S17-2 Overlapping Ventriculoplasty Combined with Mitral Complex Reconstruction for Ischemic and Non-Ischemic Dilated Cardiomyopathy Yoshiro Matsui. Hokkaido University Hospital, Japan We performed overlapping ventriculoplasty (OLVP) and mitral complex reconstruction (MCA) to reduce LV volume, change LV shape, and control mitral regurgitation without resection of cardiac muscle on 100 end-stage dilated cardiomyopathy cases (55 ischemic (ICM), 45 non-ischemic(DCM)). Patients were 85 males and 15 females and age of 61±13 years old. Preoperative EF was 22±9%, LVEDVI was 170±54 mL/m2 , LVDd was 70±9 mm, and BNP was 1201±1149 pg/ml. Performed procedures were lone OLVP in 22, OLVP+MCR 46, and lone PMA in 32 cases. MCR consisted of ring annuloplasty, papillary muscles (PM) approximation, and PM suspension to posterior or anterior prosthetic mitral annulus. Only three emergent cases died of non-cardiac cause within 30 days (3%) in early series. Comparative pre and post-operative hemodynamics were as follows: EF 22±9 → 31±10%, LVEDVI 173±47 → 113±32 mL/m2 , LVDd 71±9 → 63±7 mm. Mitral regurgitation grade improved from 3.3±1.1 to 0.2±0.5. NYHA improved from 3.5±0.7 to 1.2±0.4. One and three years actuarial survival rate was 91% and 87% in ICM cases, and 77% and 61% in DCM cases. Our surgical approach for cardiomyopathy seems to be effective in terms of functional improvement, and early and late survival.
Background: Alternative treatment to heart transplantation for DCM has been developing. Left ventricular restoration (LVR) or valve surgery was conducted and evaluated. Patients and Methods: The non-transplant surgery was performed in 466 DCM patients. The etiology was ischemic (ICM) in 176 and non-ischemic (NI-DCM) in 290 patients. The mean age was 57 years and the preoperative NYHA was class 3 in 257 and class 4 in 209 including 86 emergent. Concomitant CABG was performed in 143 patients (2.7/patient) and mitral repair was performed in 355 patients. The kinesis of LV was examined by speckle tracking echo since 2004. The endoventricular circular patch plasty (EVCPP) newly developed septal anterior ventricular exclusion (SAVE) or Batista’s partial left ventriculectomy (PLV) with modification was selected. Results: The selected LVR were EVCPP in 98, SAVE in 120 or PLV in 126. Perioperative IABP was used in 80 and the hospital mortality was 6.3% (4% in ICM and 7.8% in NI-DCM) for elective operation, while 43% for emergent operation. After the site selection based on speckle tracking echo, no hospital death was in consecutive 31 patients with modified PLV. At follow-up, 81% in ICM and 61% in NI-DCM improved symptom. The 5-year-survival was 74.5% in ICM and 55.3% in NI-DCM. Conclusions: The site selection for LVR was very important and the modified Batista operation was useful for selected patients. The non-transplant surgery should be considered before end-stage and emergent situation. S17-4 Japanese Clinical Trial Results of Next Generation LVAS EVAHEART Kenji Yamazaki. Department of Cardiovascular Surgery, Tokyo Women’s Medical University, Japan The Japanese clinical trials (pilot and pivotal) of EVAHEART have been completed. We will report the summarized results, and consider the potential of the device for a feasible alternative to heart transplantation. Methods and Materials: 18 patients with advanced heart failure (NYHA Class IV, inotropes dependent, eligible for heart transplantation) were implanted with EVAHEART between May 2005 and February 2008. Results: The device provided pulsatile high flow circulatory support (5 9L/min) and significant improvement of cardiac index in all cases. The average support duration as of December 10, 2008 was 584 (61 1313) days. 16 patients were supported >6 months, 13 patients >1 year, 6 patients >2 years, and 3 patients >3 years, respectively. 14 patients improved to NYHA Class I. Three patients had heart transplantation after mean support duration of 1054 days. 10 patients remain on device. There were 5 deaths due to cerebral bleeding 3, stroke 1, RVF/MOF 1. The Kaplan-Meier survival rate for 6 months was 89%, 1 year was 83%, 2 and 3 year were 66%, respectively. 14 patients were discharged hospital and three patients returned to full-time work with the device. There was no critical device failure, no thrombus in any explanted pump. Conclusions: Next generation LVAS EVAHEART demonstrated improvement of patient’s prognosis, QOL, and significant potential for a feasible alternative to heart transplantation.
S29 S17-3 Development of Surgical Treatment for Ischemic and Non-Ischemic Dilated Cardiomyopathy (DCM) Tadashi Isomura. Hayama Heart Center, Japan
S17-1 Surgical Ventricular Restoration for Ischemic Heart Failure and STICH Trial Marisa di Donato, Lorenzo Menicanti. IRCCS Policlinico San Donato, Milano Italy Coronary artery disease is the most frequent cause of heart failure in the western societies and the HF can be the only mode of CAD presentation associated with increasing incidence and mortality. Pathophysiology of Postinfarction Remodeling: When after the occlusion of the Left Anterior Descending Coronary one third o more of ventricular perimeter is involved, left ventricular volume increases, the apical portion became rounded and subsequently involves also the basal portion. Pathophysiologic basis of Surgical Ventricle Restoration: The success of this surgical procedure is based on several points: a. Complete revascularization; b. Diminish Ventricular Volume; c. Restore the shape. Surgical procedure: the procedure is conducted on arrested heart. Anterior and septal wall scar is excluded. Patients: Between 1989 and 2006, 1400 pts with symptoms of angina and or heart failure have been operated. Results: A significant reduction of end diastolic and end systolic volumes and an increase in ejection fraction are observed. Conclusions: Surgical volume reduction, as obtained by SVR, is an effective treatment st for pts with ischemic failing ventricles following myocardial infarction. Our experience allowed us to validate the results although there is a need for a randomized trial which is ongoing (STICH trial or Surgical Treatment for Ischemic Heart failure). S17-2 Overlapping Ventriculoplasty Combined with Mitral Complex Reconstruction for Ischemic and Non-Ischemic Dilated Cardiomyopathy Yoshiro Matsui. Hokkaido University Hospital, Japan We performed overlapping ventriculoplasty (OLVP) and mitral complex reconstruction (MCA) to reduce LV volume, change LV shape, and control mitral regurgitation without resection of cardiac muscle on 100 end-stage dilated cardiomyopathy cases (55 ischemic (ICM), 45 non-ischemic(DCM)). Patients were 85 males and 15 females and age of 61±13 years old. Preoperative EF was 22±9%, LVEDVI was 170±54 mL/m2 , LVDd was 70±9 mm, and BNP was 1201±1149 pg/ml. Performed procedures were lone OLVP in 22, OLVP+MCR 46, and lone PMA in 32 cases. MCR consisted of ring annuloplasty, papillary muscles (PM) approximation, and PM suspension to posterior or anterior prosthetic mitral annulus. Only three emergent cases died of non-cardiac cause within 30 days (3%) in early series. Comparative pre and post-operative hemodynamics were as follows: EF 22±9 → 31±10%, LVEDVI 173±47 → 113±32 mL/m2 , LVDd 71±9 → 63±7 mm. Mitral regurgitation grade improved from 3.3±1.1 to 0.2±0.5. NYHA improved from 3.5±0.7 to 1.2±0.4. One and three years actuarial survival rate was 91% and 87% in ICM cases, and 77% and 61% in DCM cases. Our surgical approach for cardiomyopathy seems to be effective in terms of functional improvement, and early and late survival.
Background: Alternative treatment to heart transplantation for DCM has been developing. Left ventricular restoration (LVR) or valve surgery was conducted and evaluated. Patients and Methods: The non-transplant surgery was performed in 466 DCM patients. The etiology was ischemic (ICM) in 176 and non-ischemic (NI-DCM) in 290 patients. The mean age was 57 years and the preoperative NYHA was class 3 in 257 and class 4 in 209 including 86 emergent. Concomitant CABG was performed in 143 patients (2.7/patient) and mitral repair was performed in 355 patients. The kinesis of LV was examined by speckle tracking echo since 2004. The endoventricular circular patch plasty (EVCPP) newly developed septal anterior ventricular exclusion (SAVE) or Batista’s partial left ventriculectomy (PLV) with modification was selected. Results: The selected LVR were EVCPP in 98, SAVE in 120 or PLV in 126. Perioperative IABP was used in 80 and the hospital mortality was 6.3% (4% in ICM and 7.8% in NI-DCM) for elective operation, while 43% for emergent operation. After the site selection based on speckle tracking echo, no hospital death was in consecutive 31 patients with modified PLV. At follow-up, 81% in ICM and 61% in NI-DCM improved symptom. The 5-year-survival was 74.5% in ICM and 55.3% in NI-DCM. Conclusions: The site selection for LVR was very important and the modified Batista operation was useful for selected patients. The non-transplant surgery should be considered before end-stage and emergent situation. S17-4 Japanese Clinical Trial Results of Next Generation LVAS EVAHEART Kenji Yamazaki. Department of Cardiovascular Surgery, Tokyo Women’s Medical University, Japan The Japanese clinical trials (pilot and pivotal) of EVAHEART have been completed. We will report the summarized results, and consider the potential of the device for a feasible alternative to heart transplantation. Methods and Materials: 18 patients with advanced heart failure (NYHA Class IV, inotropes dependent, eligible for heart transplantation) were implanted with EVAHEART between May 2005 and February 2008. Results: The device provided pulsatile high flow circulatory support (5 9L/min) and significant improvement of cardiac index in all cases. The average support duration as of December 10, 2008 was 584 (61 1313) days. 16 patients were supported >6 months, 13 patients >1 year, 6 patients >2 years, and 3 patients >3 years, respectively. 14 patients improved to NYHA Class I. Three patients had heart transplantation after mean support duration of 1054 days. 10 patients remain on device. There were 5 deaths due to cerebral bleeding 3, stroke 1, RVF/MOF 1. The Kaplan-Meier survival rate for 6 months was 89%, 1 year was 83%, 2 and 3 year were 66%, respectively. 14 patients were discharged hospital and three patients returned to full-time work with the device. There was no critical device failure, no thrombus in any explanted pump. Conclusions: Next generation LVAS EVAHEART demonstrated improvement of patient’s prognosis, QOL, and significant potential for a feasible alternative to heart transplantation.