SAUDI HEART ASSOCIATION

Transcription

1 SAUDI HEART ASSOCIATION LV aneurysm repair: reflections on the STICH trial John Pepper Royal Brompton Hospital Monday 21st February 2011 Riyaddh, Saudi Arabia.

2 Surgical Options in Advanced Heart Failure aue Lesion amenable to conventional surgery Stage C/D Potentially recoverable myocardium No target or recoverable myocardium Hibernation anterolateral Biological Lifetime scar replacement support CABG PCI Grade lll/lv MR Dor LVAD BIVAD Stem Tx cell LVAD BIVAD Valve repair Improvement No improvement

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4 Effect of cavity dilatation (remodelling) remodelling Cardiac output Endsystolic volume Wall tension Sarcomere shortening + SV

5 Advantages of patch plasty (Dor) Exclusion of scarred septum Reorientation of longitudinal ff of LV Reduces cavity size Additional bypass grafting to improve contractility and avoid arrhythmias

6 Surgical Anterior Ventricular Endocardial Restoration(SAVER) Jan.1998 July centres 439 patients Concomitant: t CABG 89% MV repair 22% Hospital mortality: 6.6% MV replacement 4%

7 SAVER in the remodelled ventricle after anterior MI Overall survival at 18 mts: 89.2% Incremental risk factors for death: lower postop EF (p<0.0003) 0003) older age (p=0.01) MV replacement (p<0.0001) Freedom from readmission at 18mts: 85%

8 SAVER: LVEF [Athansuleas CL JACC 2001;37:1199] SAVER Preop EF Postop EF

9 SAVER: LVESVI (ml/m 2 ) [Athanasuleas CL. JACC 2001;37:1199] preop postop

10 VOLUME REDUCTION SURGERY A geometrical repair is associated with improved results for the surgery of left ventricular aneurysm Load reduction improves extent t and orientation of intramyocardial lengthening V=4/3x r 3

11 Dor repair

12 Dor operation a c b d

13 Surgical anterior ventricular restoration [Athanasuleas CL. JACC 2001; 37: ]

14 SVR: aims Enhance myocardial contractility tilit Improve efficiency of LV contraction Restore LV to normal geometry

15 Surgery for hibernating myocardium How much asynergy exists? Is there sufficient compensatory muscle to restore function? What is the ventricular volume?

16 DOR procedure + CABG DAY POD 2 POD 10 LVEDD LVESD FS 23% 26%

17 The STICH Trial CAD EF< 0.35 Not YES NO NO SVR eligible? Medical eligibility SVR eligible? in trial NO YES YES Stratum Stratum Stratum A B C Medical CBG Medical CBG + SVR CBG CBG + SVR CBG

18 STUDY N Base EF (%) Athanasuleas 2001 (RESTORE) Di Donato 2001 Baseline LV size LVESVI 109 ml/m LVESVI 112 ml/m2 LV size reduction (% of baseline size) Hospital Mortality (%) Mickleborough LVESVI ml/m 2 O Neill LVESVI 120 ml/m Menicanti LVESV 145 ml Jones LVESVI (STICH) ml/m 2

19 STICH Well conducted d trial Long period of enrollment Less volume reduction than anticipated No difference in clinical outcome between groups: ventricular resection is a benign procedure? Lack of follow-up of LV volume and function: basic flaw in view of the mechanistic hypothesis The study did not specifically include patients with anterior hypokinesia and very large hearts Was the hypothesis h the correct one to test?

20 STICH: where do we go? A smaller RCT with more homogenous patient groups and physiological end- points Recruit surgeons s who exhibit equipoise regarding the efficacy of the Dor procedure. pocedue Randomise to different teams: Dor+ or Dor-

21 STICH: where do we go? Examine mechanisms: Pressure/anterior wall thickness loops Electromechanical LV resynchronisation In vivo analysis of lactate, glucose, MMP-2 and MMP-9 9b by microdialysis i

22 Impact of SVR on SV in ICM [DiDonato M. JTCS 2010; 140: 1325] EDVI<86 N=30 PRE POST EDVI>169 N=13 PRE POST EDVI ESVI SVI EF

23 Impact of SVR on SV in ICM [DiDonato M. JTCS 2010; 140: 1325] Stro oke volum me index ml/m baseline acute chronic

24 Unanswered Questions Does SVR work? Smaller STICH 2 with surrogate endpoints Why does SVR work? Effect of SVR on intraventricular conduction Effect of SVR on myocardial energy and ECM metabolism Effect on work and power production of LV

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26 Surgery for Heart Failure Treatment Current guidelines Level of evidence Revascularisation for ICM LM disease or equivalent l B No Randomised trial Revascularisation for ICM absent LM disease SVR Cardiac Transplant Destination LVAD MV repair lla B In progress llb C In progress L B No lla B Yes llb C In progress

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29 Volume reduction surgery 120 AU RESTORE DiDonato Mickleborough 0 Preop Postop Mortality 2yr survival LVESVI %

30 Slide 29 AU1 Authorised User, 2/20/2011

31 CARDIAC SURGERY A LIFE-LONG LONG APPRENTICESHIP Tuesday7 th February 2006

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33 Before and after CABG

34 Little change

35 Thank you