Surgery for Acquired Heart Disease

Sef de lucrari dr. Adrian Molnar

Cardiovascular Surgery Clinic HEART INSTITUTE

Cardiac Surgery the bad

  

   

Medical School 5 years General Surgery 2 years clinical/basic science research 2 years CT Fellowship 1 year advanced Fellowship Job opportunities Stress/Work hours

Cardiac Surgery the good

 

You operate on the heart Huge impact on patients lives!



Potential to fix the sickest patients in the hospital.

Technically and intellectually challanging. Worse ways to make a living

Introduction
    

Cardiopulmonary Bypass Coronary Artery Disease Valvular Heart Disease Transplant Mechanical Assist Devices

The Father of Bypass

(John H. Gibbon (1903-1973)

CPB: Basic Principles



Full anticoagulation


Heparin Right atrium SVC/IVC

Venous drainage
 

  

Oxygenator Pump Arterial Inflow

  

Aorta Femoral artery Axillary artery

CPB: Cardiac Arrest



Cardiopledgia
  

K+ (hyperkalemic arrest) Energy substrates Free radical scavangers

 

Antegrade aortic root Retrograde coronary sinus Deep Hypothermic Circulatory Arrest

CPB: Myocardial Oxygen Demand

Unloading the heart

Allen BS, Rosenkranz ER, Buckberg GD, et al: Studies of controlled reperfusion after ischemia, VII: high oxygen requirements of dyskinetic cardiac muscle. J Thorac Cardiovasc Surg 1986; 92:543.)

CPB: Myocardial Oxygen Consumption

Influence of temperature

CPB: Factor Activation

Bleeding Coagulopathy Factor activation

doesnt help that we have to heparinize!

CPB: Inflammatory Activation

Reactive Oxygen Species Ischemia/Reperfusion

CPB - Pros and Cons

 

 

Rest myocardium Operate on still heart Bloodless field Allows opening of chambers Keeps patient stable

 

Hemolysis Consumption
 

platelets clotting factors

Cytokine activation Embolism

 nevertheless a cornerstone

Coronary Artery Disease

Anatomy: Right Coronary Artery

  

RCA anterior on aorta R A-V groove



nodal arteries

  

acute marginal postero lateral posterior descending

Anatomy: Left Anterior Descending

 

  

LAD branch of Left main septal diagonal apex

Anatomy: Left Circumflex Artery

  

Left A-V groove obtuse marginals posterior descending postero lateral

CAD: What is it?

CAD: Why is it a problem?

Canadian Cardiovascular Society

Angina Classification
0 1 No angina Angina only with strenuous or prolonged exertion

2 Angina with walking at a rapid pace on the level, on a grade, or up stairs (slight limitation of normal activities)

3 Angina with walking at a normal pace less than 2 blocks or one flight of stairs (marked limitation) 4 Angina with even mild activity

CAD: Goals of Therapy

IMPROVE BLOOD FLOW  Relief of symptoms  Prevention of complications
   


Mortality MI CHF Arrhythmias

Prolong quality and quality of life

CAD: Outcomes / Prognosis

Coronary Artery Disease - Treatment



Medical
 

Beta blockers, ASA, Nitrates Risk factor modification



Smoking, Lipid control, diet, activity

Interventional
 

PTCA Stents CABG Coronary Artery Bypass Grafting TMR Transmyocardial Revasc. Transplant

Surgery
  

AHA/ACC Guidelines for CABG:

Asymptomatic/mild/stable Angina
Asymptomatic/mild Angina


Class I
  

left main stenosis left main equivalent (proximal LAD and proximal circumflex) triple-vessel disease

Class IIa


proximal LAD stenosis and one or two vessel disease one or two vessel disease not involving proximal LAD

Class IIb


Stable angina


Class I
     

left main stenosis left main equivalent (proximal LAD and proximal circumflex) triple vessel disease two vessel disease with proximal LAD stenosis and EF <50% or demonstrable ischemia one or two vessel disease without proximal LAD stenosis but with a large territory at risk and high risk criteria on noninvasive testing disabling angina refractory to medical therapy proximal LAD stenosis with one vessel disease one or two vessel disease without proximal LAD stenosis, but with a moderate territory at risk and demonstrable ischemia

Class IIa
 

AHA/ACC Guidelines for CABG:

Unstable Angina / Acute MI
Unstable Angina


Class I
  

proximal LAD stenosis with one vessel disease one or two vessel disease without proximal LAD stenosis, but with a moderate territory at risk and demonstrable ischemia ongoing ischemia despite medical therapy

Class IIa


proximal LAD stenosis and one or two vessel disease one or two vessel disease not involving the LAD

Class IIb


ST segment elevation (Q-wave) MI

  

Class I Class IIa Class IIb

 

None Ongoing ischemia despite medical therapy

progressive heart failure with remote territory at risk primary reperfusion within 612 hours

CAD Treatment Moving Target



Safer surgery
 

 

Myocardial protection Anesthesia

Better perioperative care Better medications

 

Sicker patients Higher expectations Lifestyle modification

Statins Beta-blockers

Surgery CABG


CPB arrested heart



Off-pump (20%) IMA (L/R) Aorto-Coronary

  

Conduits
 

Vein (Saphenous) Radial Artery Other / Exotic Prostetic Non-autologous

NOT:
 

CABG: On Pump
Benefits
    

Comfortable for the surgeon Bloodless field Motionless field Myocardial protection Exposure to all vessels for total revascularization Aortic cannulation
 

Risks


Cerebral Emboli Dissection

Negative effects of cardiopulmonary bypass

CABG Off Pump

      

OPCAB Beating heart No CPB Lower heparin Lower risk Technically difficult ?outcome?

CABG Durability: Conduit Patency

100
1389 1054 456 343 402 415 338 291 175 222 167 405

Percent Patent

4780

1967 1989
1756 1366 1535 1589 1553 1345 1183 1029 738 1475

80

5796

(even better with modern meds!)

ITA N= 5657 SVG N=24145

60

10

11

12

Years

CAD: CASS Registry Survival

100 80 60 Surgical

37% 40 Medical 20 0 27%

5 Years

10

15

Caracciolo, E., et Al., Circulation 1995; 91: 2325-2334.

CAD Treatment


What about people who you cant do a CABG on?



Previous CABG


Growing number of redo-CABGs

  

Poor targets No conduit Too sick

Transmyocardial Laser Revascularization

 

 

Create Reptilian Circulation Patients deemed non revascularizable Documented ischemia Carbon dioxide / Holmium YAG laser


30-40 holes drilled

Thoracotomy

Transmyocardial Laser Revascularization



Outcomes
    

improved angina increased exercise tolerance increased quality of life scores decreased medical regimen higher rate of survival free of cardiac events
NEJM vol. Sept 1999 341:14

Valve Disease

 

Tricuspid Pulmonic

 

Mitral Aortic

Valve Surgery: Repair vs Replacement

No Coumadin Less durability Re-operations

Coumadin More durability Bleeding Embolic complications

Patient factors and preference the most important considerations

Tissue Valves

Mechanical Valves

Aortic Valve Disease

Anatomy: Aortic Valve

The noncoronary leaflet straddles the central fibrous body overlying the anterior leaflet of the mitral valve. The conduction tissue traverses the membranous septum between the right coronary and noncoronary leaflets.

Aortic Valve Pathology



Stenosis
 

bileaflet calcifications annulus leaflet prolapse

Insufficiency
 

Both

Aortic Stenosis: Calcification

Aortic Stenosis: The Problem

AVR: Grading Aortic Stenosis



Mild aortic stenosis: area >1.5 cm2 Moderate aortic stenosis: area 1 to 1.5 cm2 Severe aortic stenosis: area <1.0 cm2

Aortic Stenosis: Disease Progression

not to mention the effects of CAD

Aortic Regurgitation
   

Improper or inadequate coaptation of the valve leaflets during diastole. Allows previously ejected blood to flow retrograde into the left ventricle. Effective stroke volume is reduced. Unlike aortic stenosis, both volume and pressure overload of the left ventricular chamber occurs.
 

Volume overload secondary to regurgitant flow Pressure overload is due to the increased wall stress


Law of Laplace.

Acute overload leads to immediate decompensation and signs of left-sided failure as left ventricular end-diastolic volume is exceeded. Chronic volume/pressure overload allows for compensatory changes in left ventricular volume, leading to eccentric hypertrophy of the chamber.

AVR: Surgery

AVR: Cribier Edwards Perc. Valve

The Future?

AVR: Tissue Valve Durability

Current Thoughts:
Young Patients Mechanical Valves Pregnancy Risk of re-op Lifestyle Middle Age Mechanical Risk of re-op Patient preference Elderly Tissue valves Risk of coumadin Influence of other comorbidities

AVR: Long Term Survival

Mitral Valve Disease

Mitral Valve: Anatomy

Mitral Valve: Anatomy

Mitral Valve: Anatomy

Mitral Stenosis


Generally the result of rheumatic heart disease.



Very rare in the U.S. (and modern countries)

      

Nonrheumatic causes Severe mitral annular and/or leaflet calcification Congenital mitral valve deformities Malignant carcinoid syndrome Neoplasm Left atrial thrombus Endocarditic vegetations A definite history of rheumatic fever can be obtained in only about 50% to 60% of patients; women are affected more often than men by a 2:1 to 3:1 ratio. Nearly always acquired before age 20, rheumatic valvular disease becomes clinically evident one to three decades later.

Mitral Regurgitation: Etiology

Much larger problem

Etiology: Mitral Regurgitation

Carpentier's functional classification

  

Type I: Leaflet motion is normal. Type II: Due to leaflet prolapse or excessive motion. Type III: (restricted leaflet motion) is subdivided into restriction during diastole ("a") or systole ("b"). Type IIIb is typically seen in patients with ischemic MR.

Functional Mitral Regurgitation

Normal

CHF
Bolling: Sem. Thor. Card. Surg. 2002

Mitral Valve Surgery: Indications



Complications


   

Left atrial enlargement Pulmonary Hypertension Atrial fib. LV Dysfxn Symptoms Endocarditis

Mitral Repair: Annuloplasty



Reduce annular dilatation Reduce volume overload



Reduce ventricular stress response

Reverse remodeling

Mitral Repair: Leaflet Resection

Mitral Valve Replacement

Outcomes: Degenerative Mitral Disease Mitral Valve Repair

Outcome: Repair vs Replacement

Survival After MVR

Survival: Repair is Better!

Mitral Repair: Sounds Great



But:
 

60% of Functional MR never gets addressed >50% of all valve surgery is replacement most are mechanical Technically difficult Surgeon preference/bias Outcomes ?Not sure

Why?
   

When Fixing the Heart Doesnt Work

REPLACE IT


Transplant Mechanical Support

Norman Shumway

Cardiac Transplantation
> 5,000 patients listed for cardiac transplantation in the U.S.*



20-30% per year die waiting

< 2500 cardiac transplants performed per year in the U.S.*



unchanged since 1989 despite more marginal donors utilized

* ISHLT database

Cardiac Transplantation
4500 4000

Number of Transplants

3500 3000 2500 2000 1500 1000 500 0

189 318 1185 669 2165 3156 2720 3380 4024 4186 4219 4382 4438 4356 4206 4087 3769 3436 3314 3219 3107

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

ISHLT

2004

J Heart Lung Transplant 2004; 23: 796-803

2002

Long-Term Functional Status

Transplant: Underlying Diagnosis

     

CAD Dilated CM Valvular Congenital Retransplant Misc.

45% 45% 4% 2% 2% 2%

Transplant: Donor selection

 

Age <55 Absence of the following:

       

Prolonged cardiac arrest Prolonged severe hypotension Preexisting cardiac disease Severe chest trauma with evidence of cardiac injury Septicemia Extracerebral malignancy Positive serologies for HIV, hepatitis B, or hepatitis C Hemodynamic stability without high-dose inotropic support (<20 g/kg/min dopamine) Past medical history and physical examination Electrocardiogram Chest roentgenogram Arterial blood gases Laboratory tests (ABO, HIV, HBV, HCV) Cardiology consultation (echocardiogram & cath)

Cardiac donor evaluation

     

Transplant: Donor cardiectomy.

Transplantation: Implant

Transplant Rejection: A Worse Disease?

Symptoms: Asymptomatic Unexplained arrhythmias Congestive Heart Failure Cardiogenic shock vs Infection/Sepsis About 30% have some rejection in the first 6 months

Transplant: Survival

Mechanical Assist Device

The Last Hope: Mechanical Support



Bridge to myocardial recovery

 

Short term Long term



?recovery / healing

Bridge to transplantation
  

Save the sickest patients Make a bad candidate into a good one ? making the problem worse non-transplant candidates ? chronic rejection in transplanted patients ? change age limitation for transplant listing ? can it be better than transplantation

Destination therapy
   

Selection criteria for VAD



 

  

Accepted as candidate for cardiac transplantation (relative) Absence of coagulopathy or gastrointestinal hemorrhage Heart failure (CI <1.8 L/min/m2, left atrial pressure >25 mmHg, systolic blood pressure <90 mmHg), despite: Corrected metabolism (temperature, acid-base, electrolytes) Adequate preload, appropriate afterload reduction Maximal inotropic support Intra-aortic balloon pump assistance Reality: what kind of mood we are in on any given day.

Types of Mechanical Support



Short term support

 

Pulsatile Continuous flow

Bridge to transplant
 

Pulsatile Continuous flow

Left Ventricular Assist Device

Inflow from the LV apex Outflow into the ascending aorta Percutaneous driveline attached to power source and controller

Abiomed BVS 5000(i)

 

Easy implant/explant Versatile

 

univentricular biventriccular

  

Good patient support Paracorporeal Difficult to mobilize patient Aggressive anticoagulation

Long Term LVAD: Thoratec

 

Easy implant/explant Versatile

 

univentricular biventricular

    

Good patient support Paracorporeal Complex initial setup Able to mobilize patient Anticoagulation

Total Artificial Heart: AbioCor



First Human implant July 2, 2001