Professor of Cardiac Surgery Director, Department of Adult Cardiac Surgery Prince. Sultan Cardiac Center Riyadh Kingdom of Saudi Arabia
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1 Results of surgical ventricular restoration An ntonio Maria CALAFIORE Professor of Cardiac Surgery Director, Department of Adult Cardiac Surgery Prince Sultan Cardiac Center Riyadh Kingdom of Saudi Arabia
2 STICH trial: conclusions The STICH trial definitively shows that adding SVR to CABG provides no clinical benefit be yond that of CABG alone in the study population.
3 STICH trial: conclusions The STICH trial definitively shows that adding SVR to CABG provides no clinical benefit be yond that of CABG alone in the study population. Both operative str rategies provided d similar short- and long-term relief of angina and HF and improvement in 6-minute walk te est performance.
4 Criticisms The eligibility criteria were changed during the study and in 2003 the heart failure symptoms were abolished.
5 Criticisms The eligibility criteria were changed during the study and in 2003 the heart failure symptoms were abolished. The LV volume was not anymore an eligibility criterion. Only the EF 35% was kept. The study then switched from heart fail lure patients to ischemicc patients.
6 Chronic dyssynergy per se is sufficient to induce ischemic LV remodeling in patients. Carluccio E et al. Patients with hibernating myocardium show altered left ventricular volumes and shape, which revert after revas cularization: evidence that dyssynergy might directly induce cardiac remodeling g. J Am Coll Cardiol 2006;47:
7 preop Chronic dyssynergy per se is end diastole sufficient to induce ischemic LV remodeling in patients. end systole Carluccio E et al. Patients with hibernating myocardium show altered left ventricular volumes and shape, which revert after revas cularization: evidence that dyssynergy might directly induce cardiac remodeling g. J Am Coll Cardiol 2006;47:
8 preop postop Chronic CABG dyssynergy per se is sufficient to end diastole end diastole induce ischemic LV remodeling in patients. end systole end systole Carluccio E et al. Patients with hibernating myocardium show altered left ventricular volumes and shape, which revert after revas cularization: evidence that dyssynergy might directly induce cardiac remodeling g. J Am Coll Cardiol 2006;47:
9 EDVI 160 ml/m² ESVI 148 ml/m² EF 7% Ogawa M et al. Reverse-remodeling after coronary artery bypass grafting in ischemic cardiomyopathy: assessment of myocardial viability by delayedenhanced magnetic resonance imaging can help cardiac surgeons. Interact CardioVasc Thorac Surg 2007;6:673-5
10 EDVI 160 ml/m² ESVI 148 ml/m² EF 7% <25% <25% Ogawa M et al. Reverse-remodeling after coronary artery bypass grafting in ischemic cardiomyopathy: assessment of myocardial viability by delayedenhanced magnetic resonance imaging can help cardiac surgeons. Interact CardioVasc Thorac Surg 2007;6:673-5
11 EDVI 160 ml/m² ESVI 148 ml/m² EF 7% EDVI 127 ml/m² ESVI 83 ml/m² <25% <25% EF 36% Ogawa M et al. Reverse-remodeling after coronary artery bypass grafting in ischemic cardiomyopathy: assessment of myocardial viability by delayedenhanced magnetic resonance imaging can help cardiac surgeons. Interact CardioVasc Thorac Surg 2007;6:673-5
12 The dilemma of surgery for left ventricu ular scars is still not solved.
13 The dilemma of surgery for left ventricu ular scars is still not solved. What is more important, the vo olume or the sh hape?
14 The STICH trial had, as basic surgical technique, the Dor procedure, volume-related and not shape- related.
15 Surgical technique: Dor operation The STICH trial had, as basic surgical technique, the Dor procedure, volume-related and not shape- related. Eisen HJ. Surgical ventricular reconstruction for heart failure. N Eng J Med 2009;360:1781-4
16 When the purse string and the patch insertion are limited to the scar rim, the result is surely a smaller cavity, bu ut the heart can become more spherical than th he baseline.
17 When the purse string and the patch insertion are limited to the scar rim, the result is surely a smaller cavity, bu ut pre HR (b/min) 66 EDV (ml) 175 ESV (ml) 148 EF (%) 15 CO (l/min) 1.78 the heart can become more spherical than th he baseline. Doenst T et al. Fluid-dynamic dynamic modeling of the human left ventricle: methodology and application to surgical ventricular restoration. Ann Thorac Surg 2009;87:
18 When the purse string and the patch insertion are limited to the scar rim, the result is surely a smaller cavity, bu ut pre post HR (b/min) EDV (ml) ESV (ml) EF (%) CO (l/min) the heart can become more spherical than th he baseline. Doenst T et al. Fluid-dynamic dynamic modeling of the human left ventricle: methodology and application to surgical ventricular restoration. Ann Thorac Surg 2009;87:
19 Aspect Ratio = Short/Long Axis = Sphericity Index courtesy of dr Lorenzo Menicanti Sallin EA. Fiber orientation and ejectio on fraction in the human left ventricle. Biophys J 1969;9:
20 In the most recent years morpholo ogy of fth the anterose ptal scars changed dinmany patie ents.
21 In the most recent years morpholo ogy of fth the anterose ptal scars changed dinmany patie ents. In the past dilation was predomi inant and surgical re emodeling was relativ vely easier.
22
23 This anatomic as pect prevents the involved region ntobedyskinetic and to collaps se after cardiac decompress ion in the OR.
24 This anatomic as pect prevents the involved region ntobedyskinetic and to collaps se after cardiac decompress ion in the OR. Akinesia is the most diffuse morpholog gical aspect.
25 This anatomic as pect prevents the involved region ntobedyskinetic and to collaps se after cardiac decompress ion in the OR. Akinesia is the most diffuse morpholog gical aspect.
26 As a cons sequence, nowadays volumes are not as large as bef fore.
27 As a cons sequence, nowadays volumes are not as large as bef fore.
28 The septum is oft ten more involved than the free wall and bulges toward the right ventricle, minimizing the external dilation.
29 The septum is oft ten more involved than the free wall and bulges toward the right ventricle, minimizing the external dilation.
30 In such cases pu rpose of surgery is to address the correction mainly to the septum, thatis rebuilt and mo oved anteriorly.
31 In such cases pu rpose of surgery is to address the correction mainly to the septum, thatis rebuilt and mo oved anteriorly. The longitud dinal axis is maintained similar to the preoperative o ne, to avoid any change in sph hericity, even if some apical scar has to be included in th he correction.
32 The longitud dinal axis is maintained similar to the preoperative o ne, to avoid any change in sph hericity, even if some apical scar has to be included in th he correction.
33 Calafio ore et al Left ventricula ar restoration for anteros septal scars: s volume ver rsus shape J Thorac Cardiovasc Surg 2010;139:
34 popul lation January 1988 to February patients underwent LVR for anteroseptal scars
35 popul lation January 1988 to February patients underwent LVR for anteroseptal scars Dor procedure n=107 (34.7%)
36 popul lation January 1988 to February patients underwent LVR for anteroseptal scars Guilmet procedure n=32 (10.4%) Dor procedure n=107 (34.7%)
37 popul lation January 1988 to February patients underwent LVR for anteroseptal scars Guilmet procedure septal reshaping n=32 (10.4%) n=140 (45.6%) Dor procedure n=107 (34.7%)
38 popul lation January 1988 to February patients underwent LVR for anteroseptal scars Guilmet procedure septal reshaping n=32 (10.4%) n=140 (45.6%) Dor procedure n=107 (34.7%) septoapical Dor procedure n=29 (9.3%)
39 popul lation January 1988 to February patients underwent LVR for anteroseptal scars Target of the procedure was: LV volume n= =107 (34.7%) LV shape n= =201 (65.3%)
40 current surgical indica ation to septoapical Dor procedure , 2008, n=29
41 current surgical indica ation to septal reshaping , 2008, n=140 S A
42
43 The patch is as long as necessary (m median 6 cm). Its height varie es according to the ED volumes.
44 The patch is as long as necessary (m median 6 cm). Its height varie es according to the ED volumes. If <80 ml/m m², the ratio length/he eight is 2:1
45 The patch is as long as necessary (m median 6 cm). Its height varie es according to the ED volumes. If <80 ml/m m², the ratio length/he eight is 2:1 If 80 ml/m², t he ratio is 3:1
46 The patch is as long as necessary (m median 6 cm). Its height varie es according to the ED volumes. If <80 ml/m m², the ratio length/he eight is 2:1 If 80 ml/m², t he ratio is 3:1 In case of sev vere diastolic dysfunction n, the ratio is alway ys 2:1
47 late re esults Mean follo ow up was 77±50 months
48 Su urvival pro obability (%) ±2.5 Freedom from death any cause 66.7± Number at risk months
49 ity (%) Survival probabil ± Freedom from cardiac death Freedom from death any cause 73.2± Number at risk Group: Group: months
50 Surviv val probab bility (%) ±2.8 Freedom from cardiac death Freedom from death any cause Freedom from cardiac event Number at risk Group: Group: Group: months 54.3±
51 Sur rvival prob bability (% %) ±2.8 Freedom from cardiac death Freedom from death any cause Freedom from cardiac event Freedom from any event Number at risk Group: Group: Group: Group: ± months
52 late re esults Curves were cut at 5y years to allow groups comparison.
53 freedom from cardiac death Su urvival prob bability (%) Group S 86.6±2.6 Group V 76.3± Number at risk Group: S Group: V months
54 freedom from cardiac death Su urvival prob bability (%) p= =0.032 Group S 86.6±2.6 Group V 76.3± Number at risk Group: S Group: V months
55 freedom from cardiac death Su urvival prob bability (%) HR=2.4 95CI= p=0.011 p= =0.032 Group S 86.6±2.6 Group V 76.3± Number at risk Group: S Group: V months
56 freedom from cardiac events Survival pro obability (% %) Group S 77.9±3.3 Group V 63.9± Number at risk Group: S Group: V months
57 freedom from cardiac events Survival pro obability (% %) p= =0.011 Group S 77.9±3.3 Group V 63.9± Number at risk Group: S Group: V months
58 freedom from cardiac events Survival pro obability (% %) HR=2.4 95CI= p= Number at risk Group: S Group: V p= =0.011 months Group S 77.9±3.3 Group V 63.9±
59 freedom from cardiac events (1 st month excluded) 100 Survival pro obability (% %) Group S 81.1±3.3 Group V 71.2± Number at risk Group: S Group: V months
60 freedom from cardiac events (1 st month excluded) Survival pro obability (% %) p= =0.039 Group S 81.1±3.3 Group V 71.2± Number at risk Group: S Group: V months
61 freedom from cardiac events (1 st month excluded) Survival pro obability (% %) HR=2.2 95CI= p= Number at risk Group: S Group: V p= =0.039 months Group S 81.1±3.3 Group V 71.2±
62 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling
63 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling septal reshaping n=30
64 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling septal reshaping n=30 septoapical Dor n=15
65 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling septal reshaping n=30 septoapical Dor n=15 lateral resection n=8
66 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling septal reshaping n=30 septoapical Dor n=15 in nferior resection n=3 lateral resection n=8
67 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling mitral valve surgery yes n=41, 73.2% no n=15, 27.8%
68 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling mitral valve surgery yes n=41, 73.2% mitral valve procedure repair n=41, 73.2% no n=15, 27.8% prosthesis insertion n=15, 27.8%
69 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling mitral valve surgery yes n=41, 73.2% mitral valve procedure repair n=41, 73.2% tricuspid valve surgery no n=15, 27.8% yes n=24 4, 42.8% prosthesis insertion n=15, 27.8% no n=32, 57.2%
70 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling No patient die ed during the first 30 days 3 to 6 months after surgery 3 patients (5.3 3%) died due to septi icemia i (dyalisis catheter, d efibrillator wire and pacema aker wire)
71 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling EF modification before surgery and at discharge
72 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling EF modification before surgery and at discharge % 27±9
73 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling EF modification before surgery and at discharge % 27±9 p< < ±8
74 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge
75 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge 113±3131 end diastole ml/m²
76 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge 113±3131 end diastole ml/m² 85±44
77 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge 113±3131 end diastole ml/m² p<00 < ±44
78 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge 113±3131 end diastole ml/m² 83±3131 p<00 < end systole 85±44
79 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge 113±3131 end diastole ml/m² 83±3131 p<00 < end systole 85±44 57±36
80 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge 113±3131 end diastole ml/m² 83±3131 p<00 < end systole 85±44 p < ±36
81 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge %
82 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge % -26.5
83 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling volumes modification befor re surgery and at discharge %
84 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling After a median follow up of 10 months, we wer re able to contact only 31 of the 53 survivors (60%).
85 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling After a median follow up of 10 months, we wer re able to contact only 31 of the 53 survivors (60%). One patient (3.2%) was unchanged and the remain ning 30 (96.8%) improved of at lea ast 1 NYHA Class.
86 Department of Adult Cardiac Surgery Prince Sultan Cardiac Cen nter, Riyadh, Saudi Arabia June 2009 to December elective or urgent patients underwent LV surgical remod deling After a median follow up of 10 months, we wer re able to contact only 31 of the 53 survivors (60%). One patient (3.2%) was unchanged and the remain ning 30 (96.8%) improved of at lea ast 1 NYHA Class. One patient had a late CVA, but fully recov vered.
87 conclu usions Long term outc come after left ventricular ti surg gical remodeling is good.
88 conclu usions Long term outc come after left ventricular ti surg gical remodeling is good. In our experience e better results, in particular freed dom from cardiac events, are achieved when purpose of surg gery is to recover a conica al shape.
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