surgical restoration of ventricular function
TRANSCRIPT
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SURGICAL RESTORATION OFVENTRICULAR FUNCTION
DR. REZWANUL HOQUE BULBULMBBS, MS, FCPS, FRCS(GLASGOW), FRCS(EDINBURGH)
ASSOCIATE PROFESSOR, CARDIAC SURGERY
BSMMU, DHAKA, BANGLADESH
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DILATED CARDIOMYOPATHY-
PATHOPHYSIOLOGY
Dilated cardiomyopathy is characterized by ventricular chamberenlargement and systolic dysfunction with greater LV cavity size withlittle or no wall hypertrophy. Hypertrophy is judged as the ratio of LVmass to cavity size; this ratio is decreased in persons with dilatedcardiomyopathies.
Dilated cardiomyopathies are associated with both systolic anddiastolic dysfunction. The decrease in systolic function is by far theprimary abnormality. This leads to an increase in the end-diastolicand end-systolic volumes.
Associated with activation of RAAS, increased arginine-vasopressin,
ANP,BNP and CNP, increased catecholamine with down regulation ofreceptors, volume overload and increased workload of the heart.
Elevation of TNF-alpha, IL-1b, IL-2R, IL-6 may mediate myocardialcell injury.
http://emedicine.medscape.com/article/152696-overview#a0104
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DCM- INCIDENCE, PREVALENCE & ETIOLOGY
The reported incidence is 400,000-550,000 cases per year, with a prevalence of 4-5 million people.
Causes of dilated cardiomyopathy include the following- ( Ischemic, non-ischemic, valvular)
Genetics
Secondary to other cardiovascular disease: ischemia, hypertension, valvular disease, tachycardia induced
Infectious: viral, rickettsial, bacterial, fungal, metazoal, protozoal
Probable infectious: Whipple disease, Lyme disease
Metabolic: endocrine diseases (e.g., hyperthyroidism, hypothyroidism, acromegaly, myxoedema,hypoparathyroidism, hyperparathyroidism), diabetes mellitus, electrolyte imbalance (e.g., potassium,phosphate, magnesium)
Nutritional: thiamine deficiency (beriberi), protein deficiency, starvation, carnitine deficiency
Toxic: drugs, poisons, foods, anaesthetic gases, heavy metals, ethanol
Collagen vascular disease
Infiltrative: hemochromatosis, amyloidosis, glycogen storage disease, Granulomatous (sarcoidosis)
Physical agents: extreme temperatures, ionizing radiation, electric shock, nonpenetrating thoracic injury
Neuromuscular disorders: muscular dystrophy (limb-girdle [Erb dystrophy], Duchenne dystrophy,fascioscapulohumeral [Landouzy-Dejerine dystrophy]), Friedreich disease, myotonic dystrophy
Primary cardiac tumour (myxoma), Senile, Peripartum
Immunologic: postvaccination, serum sickness, transplant rejection
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DEFINITION OF SURGICAL
VENTRICULAR RESTORATION
Surgical ventricular restoration (SVR) is a procedure designed to restore orremodel the left ventricle to its normal, spherical shape and size in patientswith akinetic segments of the heart, secondary to either dilatedcardiomyopathy or post infarction left ventricular aneurysm.
The SVR procedure is usually performed after coronary artery bypass
grafting (CABG) and may proceed or be followed by mitral valve repair orreplacement and other procedures such as endocardectomy and cryoablationfor treatment of ventricular tachycardia.
A key difference between surgical ventricular restoration and ventriculectomy(i.e., for aneurysm removal) is that in SVR the ventricle is reconstructed usingpatches of autologous or artificial material that are placed to close the defect
while maintaining the desired ventricular volume and contour.Additionally, SVR is distinct from partial left ventriculectomy (i.e., the Batistaprocedure) which does not attempt to specifically resect akinetic segmentsand restore ventricular contour.
BlueCross BlueShield Association Medical Policy Reference Manual "Surgical Ventricular Restoration." Policy No. 7.01.103
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RELATIONSHIP BETWEEN
STRUCTURE & FUNCTION
The central theme of cardiac surgery is that alteration of structure improvesfunction, and this concept is fundamental during surgical restoration of dilatedhearts in cardiac failure.
The conical pattern of normal cardiac size and shape is well known and theunderlying spatial arrangements are closely linked to the helical ventricular
myocardial band and comprised of a surrounding wrap of the basal loop withtransverse fibres and an apical loop of reciprocal oblique fibres forming a spiralvortex at the apex.
The spherical configuration of the enlarged global ventricle widens the apical loopby making the oblique apical loop fibres develop a transverse orientation that moreclosely resembles the horizontal fibre orientation of the basal loop.
Configuration of muscle fibers at the apex: figure of 8, produce 60% E.F. with only 15%
muscle fiber shortening .Transverse fiber direction: - E.F.= 30% increases to 60%with oblique direction
The bioengineering infrastructure for this mechanical change in size and shapereduces ejection fraction, which is 60% with oblique fibre direction and lowered to30% when fibre orientation is transverse.
Buckberg GD: Form versus disease: optimizing geometry during ventricular restoration. Eur J Cardiothorac Surg 2006;29
Suppl 1:S238S244
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LAPLACE LAWT = ( P * R ) / M Where T is the tension in the walls,
P is the pressure difference acrossthe wall, R is the radius of thecylinder, and M is the thickness ofthe wall. An example of Laplace Lawis Dilated cardiomyopathy. In thiscondition heart becomes greatlydistended and the radius (R) of
ventricle increases. Therefore tocreate the same pressure (P) duringejection of the blood much largerwall tension (T) has be developed bythe cardiac muscle. Thus dilatedheart requires more energy to pumpthe same amount of blood ascompared to the heart of normalsize. The new surgical procedure,
called ventricular remodelling, usesLaplace principle to improve thefunction of dilated, failing hearts.
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A- OBLIQUE APICAL LOOP FIBRE IN NORMAL HEART
B- TRANSVERSE APICAL LOOP FIBRE IN DILATED
HEART
Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007
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ISCHEMIC DCM
White emphasized on ESVI rather than E.F. as the prognostic
barometerLV Volume: a sensitive prognostic parameter for both late and earlyevents after a MI
Prior to early reperfusion: transmural infarction classic thinned,dyskinetic (paradoxical wall motion) LV aneurysm
With early reperfusion epi- and mid-myocardium spared withendocardial necrosis segmental akinesis (lack of contractility)Endocardium and mid-myocardium damage >50% of the LV wallincapable of functional recovery
Progressive heart dilatation follows asynergy of >50% (30%) LVcircumference after anterior MI
GUSTO (1997): ESVI>
40 ml/m2
a high incidence of CHF & poorlong-term survival
HF developed by progressive decrease of compensatory contractionof remote muscle.
Overview: Ventricular restoration a surgical approach to reverse ventricular remodeling, Heart Failure Reviews, 9, 233-239 2004
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RATIONALE FOR SVR
Because of the shortage of donors for heart transplantation, surgicalventricular reconstruction (SVR) has been under development totreat end-stage heart failure due to a dilated left ventricle.
The operative procedures have been developed and modified based
on the clinical results and preoperative findings of severalexaminations.
SVR is performed to reduce the size and volume of the ventricle aswell as to reshape it.
The procedures, which differ based on the particular left ventricularlesion, are endoventricular patch plasty or septal anterior ventricularrestoration for anteroseptal exclusion and partial left ventriculectomyor a posterior restoration procedure for posterolateral exclusion.
In the indicated patients, SVR has been emerging as an alternativeto heart transplantation.
The New England Journal of Medicine (2009) Volume: 361, Issue: 5, Pages: 529;
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INDICATION FOR SVR
Indication
Anteroseptal MI with dilated LV: LVESVI >60ml/m2, LVEDVI>100ml/m2
Left ventricular asynergy( akinesia or dyskinesia) > 35% of LVanterior wall
Relative contraindication
Diffusely diseased RCA or LCX not amenable to CABG withinferior wall asynergy or aneurysm
Absolute contraindication Idiopathic pulmonary HTN with PASP>60 mm Hg
Severe RV dysfunction
Surgical Ventricular Restoration, ntuh.sicu.org.tw/upload/.../Surgical%20Ventricular%20Restoration.p...
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CONCEPT OF SURGICAL
CORRECTION
Based upon Laplace's law
Reduces the size of the ventricle
Restores the elliptical shape of the heart
Return the left ventricular volume/mass ratiotoward normal
Significantly improves the pumping action of theheart
Improves clinical statusUsually done with CABG, often done with valverepair
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COOLEY, 1959, THE FIRST SURGICAL TREATMENT OF LARGE DYSKINETIC, LV ANEURYSM ON CPB
LINEAR CLOSURE, DOES NOT ADDRESS SEPTAL ANEURYSM, DISTORTION OF LV GEOMETRY AND
PERSISTENCE OF THIS DAMAGED AREA LEADS TO RECURRENT HF MANY YEARS LATER.
V Rao et al. Asian Cardiovasc Thorac Ann 2008;16:401-406
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SEPTAL PLASTY OPERATION OF
STONEY, 1978
Ventricularaneurysmectomy
Emphasis on
anteroseptal repair byusing a flap of scarredtissue
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JATENE, 1984
Imbricated the scar and reformed the elliptical scar
Ventricular structure and Surgical history, Heart Failure Reviews, 9, 255-268 2004
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SCHEMA OF SURGICAL
PROCEDURESSchemata of the Dor procedure, Batistaprocedure, and Overlapping-type leftventriculoplasty (OLVP).
a: Dor procedure: LV volume reduction isaccomplished by an endoventricular patch in theanterior and septal portions. The basic
concept is the same as Cooleys method and the
septal anterior ventricular exclusion (SAVE)procedure.
b: Batista procedure: LV lateral wall is broadlyresected and closed with direct suture.
c: OLVP: This procedure performs ventriculotomyof the anterior wall without ventriculectomy, anddoubles in part the LV anterior wall by
overlapping the incised wall around the apex.Papillary muscles approximation (PMA) is alsoperformed as an adjunct to OLVP, depending onthe situation of the case.
Yoshiro Matsui Shigeyuki Sasaki. Ann Thorac Cardiovasc Surg Vol. 14, No. 2 (2008)
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PROCEDURES OF CHOICE
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CIRCULAR PATCH REPAIR
Circular patch repair. The aneurysm wall is incised. Aninferior aneurysm is shown.
Circular patch repair. The aneurysmal wall is excised,leaving a 2-cm rim of fibrous aneurysmal wall attachedto healthy muscle.
Circular patch repair. The aneurysmal defect is closedwith a Dacron patch using interrupted 2-0 monofilamenthorizontal mattress sutures with reinforcing pledgets.
Glower D Di , Lowe J Ei . Left Ventricular Aneurysm. Cohn Lh, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2008:803-822
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ENDOVENTRICULAR PATCH REPAIR
Endocardial patch. Without excising theaneurysm wall, the ventricular defect is closedwith a Teflon felt patch using 3-0polypropylene suture secured at three or fourpoints along the suture line. Additional 3-0pledgeted horizontal mattress sutures may beused to achieve haemostasis.
Endocardial patch. The aneurysm wall isclosed over a Teflon patch after resectingexcess aneurysm tissue. A double row ofrunning vertical 2-0 polypropylene sutures isused.
Glower D Di , Lowe J Ei . Left Ventricular Aneurysm. Cohn Lh, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2008:803-822
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ENDOVENTRICULAR CIRCULAR PATCH PLASTY
Both akinetic and dyskinetic scarred portion of the ventricle isexcluded
Avoids pericardial adhesion as it does not contain externalprosthetic material
Relieve ischemia by complete coronary revascularization:
grafting the LAD providing upper septal perfusionVentricular sizing: 60 mL/m2 (EDV150 mL/m2) Diminish ventricular volume diminish wallstress, reduce myocardial oxygen consumption
Ventricular geometry is better maintained resulting indiminished wall stress, improved wall compliance, reducedfilling pressure, enhanced diastolic coronary flow, decreasedmyocardial O2 consumption, improved systolic contraction.
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STEPS TO DOR PROCEDURE
Fontan, 1989
Placed a circumferential suture around the borderof ischemic and normal tissue to create an ovalneck for patch placement after securing thissuture .Patch: oval with a long diameter of 2 2.5cm in situmade 2.5 3 cm to compensatespace taken up by suture line.
Cooley, 1992
Excluding septal aneurysm wall by placing anendoventricular patch placed between the scarredand viable areas
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DOR PROCEDURE- STEPS
a. Open left ventricle during
restoration showing palpation
to define the contracting and non-contracting muscle.
b. Shows Fontan suture in place
and interrupted sutures through
neck and into suture holders,
quite similar to valve procedures.
Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007
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STEPS-CONTINUED
a. Sizing the oval from Fontansuture,
b. shows placement of
prericardial patch with inner ringon surgical neck
c.shows oblique pericardialpatch in final intraventricularposition.
Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007
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STEPS- CONTINUED
Finding the left ventricular apex, either from theoutside where it is adjacent to right ventricularapex, or from the inside with use of a conical
intraventricular balloon.
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STEPS- CONTINUED
a. Wrap around anteriorinfarction and scar,
b. shows open leftventricle with inferiorscar. Imbrication of theinferior wall frommattress sutures eitherthe outside in
c or the inside in d.
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STEPS
Creation of LV apex by securingthe imbricating inferior sutures
and using the tip b as the apexin a.
Placement of oblique patch torebuild a conical shape in b.
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STEPS
a. Demonstration of the normal
width between papillary muscles inb,
Widening from distance betweenpapillary muscle bases is shown inc.
c
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STEPS
Narrowing of the widened
dimension between bases
of papillary muscles is shown in a.
Placement of mattress sutures
between the bases of the papillary
muscles and the ventricular
muscle between the bases in
shown in b,
and securing these sutures to restore the
normal dimension between the papillarymuscle bases in c.
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STEPS
The normal annulardimensions are compared to
the widened annulus withcentral functional mitralregurgitation ,and downsizingthe annulus with a posteriorlyplaced mitral ring shownbelow.
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TRIANGULAR PATCH VENTRICULOPLASTY
Scar involving the base,
septum and lateral wallfollowing inferior infarction in
a.
Site of inferior wall incisionparallel to posteriordescending coronary
artery in b and exposure of
intraventricular cavityfollowing incision in c.
Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007
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CONTINUED
Triangular patch that conforms to thebase of the infarct region shown inupper left.
Insertion of double arm imbricating
sutures in base, septum and lateral
wall in upper right.Securing the imbricating suture
to make a smaller triangle(retriangulation) in lower left.
Patch placement with sewing
the patch rim for haemostasis
(centre) and ventricular closure
on lower right.
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SAVER
Surgical anterior ventricular endocardial restoration
Utilize Dors principle with some technical modification
SAVER in the dilated remodeled ventricle after anterior myocardial infarction, Journal of the American Collegeof Cardiology 37(5) 2001 1199-1209
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SAVER
Pacopexy or SAVER procedurewith open left ventricle andinterrupted mattress sutures in
septum and LV free wall A,insertion of oblique patch fromapex to high septum, usingTeflon strip in (B),
and closure to
rebuild a conical chamber in (c).
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SAVER/SAVE PROCEDURE
Left ventricular restoration
in dilated cardiomyopathy in
ischemic disease without discretescar.
The SAVER or Pacopexyprocedure is used to make thespherical chamber becomeelliptical. A patch is placedbetween the apex and septum
to reconstruct a conical chamber.
Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007
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UNIFIED CONCEPTS
Unified concept with the
dilated spherical left ventricular
shape in either ischemic,nonischemic
or valvular cardiomyopathy
Geometrically changing shapeto create a conical
of elliptical chamber in either
ischemic, non-ischemic orvalvular disease to alterstructure toward normal asshown here.
Buckberg GD. Scandinavian Journal of Surgery 96: 164176, 2007
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VENTRICULAR REMODELLING OPERATION (BATISTA
PROCEDURE): 1994
The ventricular remodelling operation (also known as the Batista procedure,partial left ventriculectomy, heart reduction surgery, and wedge resection ofthe heart) has been proposed as a surgical procedure to replace or postponeheart transplantation in patients with dilated non-ischemic cardiomyopathy. Itinvolves removing a viable portion of the enlarged left ventricle and repair ofthe resultant mitral regurgitation with a valve ring. It attempts to augmentsystemic blood flow through improvement in the mechanical function of the
left ventricle by restoring its chamber to optimal size. In most cases, partialleft ventriculectomy is accompanied by mitral valve repair.
Although initial reports on the Batista procedure lacked significant informationon its safety and effectiveness, overall clinical impression was that theoperation may serve as a bridge to heart transplantation especially in patientswith idiopathic dilated cardiomyopathy.
In a prospective evaluation of the Batista procedure, Weston et al (2000)reported that at 3, 6, and 12 months post-surgery the ejection fractions ofpatients who had undergone the operation were not significantly better thanprior to surgery. Moreover, there was no survival benefit with 60% of thepatients expiring within 6 months after the Batista procedure.
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LIMITATION & OUTCOME OF BATISTA
http://www.aetna.com/cpb/medical/data/100_199/0182.htmlhttp://www.aetna.com/cpb/medical/data/100_199/0182.html -
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LIMITATION & OUTCOME OF BATISTA
PROCEDURE
Remove LV lateral wall irrespective ofregional dysfunction used less forischemic etiologies
Reduce systolic wall stress and improveE.F.
A deleterious effect on diastoliccompliance: reduce recruitable strokework (Starling law), magnitude of shapechange or pumping capacity
SVR: resection of non-functionalmyocardium resection of akineticportion with normal thickness in dilated,poorly functioning heart
Long-term effectiveness for primarilyIDCM: despite impressive improvement
in acute LVEF (1631%), disappointinglylow event-free survival rates at 1 year(49%) and 3 years (26%)
ACC/AHA: class III procedure
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The CorCap Cardiac Support Device,manufactured by Acorn Cardiovascular, Inc.,resembles a net that is placed around and
attached to the heart to support the damagedheart muscle and limit further enlargement.
It provides passive support that reduces thestress on the ventricular wall.
http://www.columbiasurgery.org/pat/cardiac/acorn.htm
ACORN CORCAP CARDIAC
SUPPORT DEVICE
http://www.columbiasurgery.org/pat/cardiac/acorn.htmhttp://www.columbiasurgery.org/pat/cardiac/acorn.htm -
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MYOSPLINT, 2002
Reshape the spherical LV into two elliptical LV
Surgical left ventricular remodeling in heart failure, The European Journal of Heart Failure 7 (2005) 704-709
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OTHER BRIDGE TO TRANSPLANTATION PROCEDURE
May be used as bridge or destination therapy
Cardiac resynchronization/ biventricular pacing
AICD
VAD TAH
Heart transplantation is the procedure by which the failingheart is replaced with another heart from a suitable donor.[1] Itis generally reserved for patients with end-stage
congestive heart failure(CHF) who are estimated to have lessthan 1 year to live without the transplant and who are notcandidates for or have not been helped by conventionalmedical therapy.
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