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Surgery for
Acquired Heart Disease
Sef de lucrari dr. Adrian MolnarCardiovascular Surgery Clinic
HEART INSTITUTE
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Cardiac Surgery the bad
Medical School
5 years General Surgery
2 years clinical/basic scienceresearch
2 years CT Fellowship
1 year advanced Fellowship Job opportunities
Stress/Work hours
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Cardiac Surgery the good
You operate on the heart
Huge impact on patients lives!
Potential to fix the sickest patients in thehospital.
Technically and intellectually challanging.
Worse ways to make a living
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Introduction
Cardiopulmonary Bypass
Coronary Artery Disease
Valvular Heart Disease
Transplant
Mechanical Assist Devices
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The Father of Bypass
(John H. Gibbon (1903-1973)
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CPB: Basic Principles
Full anticoagulation Heparin
Venous drainage
Right atrium SVC/IVC
Oxygenator
Pump
Arterial Inflow Aorta
Femoral artery
Axillary artery
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CPB: Cardiac Arrest
Cardiopledgia
K+ (hyperkalemic arrest)
Energy substrates
Free radical scavangers
Antegrade aortic root
Retrograde coronarysinus
Deep HypothermicCirculatory Arrest
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CPB: Myocardial Oxyge
nDema
ndUnloading the heart
Allen BS, Rosenkranz ER, Buckberg GD, et al: Studies of controlled reperfusion afterischemia, VII: high oxygen requirements of dyskinetic cardiac muscle. J Thorac
Cardiovasc Surg 1986; 92:543.)
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CPB: Myocardial Oxyge
nC
onsumptio
n
Influence of temperature
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CPB: Factor Activation
Bleeding
CoagulopathyFactor activation
doesnt help that we
have to heparinize!
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CPB: Inflammatory Activation
Reactive Oxygen Species Ischemia/Reperfusion
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CPB - Pros andCons
Hemolysis
Consumption
platelets
clottingfactors
Cytokineactivation
Embolism
Rest myocardium
Operate on still
heart Bloodless field
Allows opening ofchambers
Keeps patientstable
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nevertheless a cornerstone
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Coronary Artery Disease
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Anatomy: RightCoronary Artery
RCA
anterior on aorta
R A-V groove
nodal arteries
acute marginal
postero lateral posterior
descending
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Anatomy: Left Anterior Descending
LAD
branch of Left
main septal
diagonal
apex
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Anatomy: LeftCircumflex Artery
Left A-V groove
obtuse marginals
posteriordescending
postero lateral
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CAD: What is it?
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CAD: Why is it a problem?
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0 No angina
1 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 ofnormal activities)
3 Angi
na with walki
ng at a
normal pace less tha
n2
blocks orone flight of stairs (marked limitation)
4 Angina with even mild activity
Can
adian
C
ardiovascular SocietyAngina Classification
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CAD: Goals ofTherapy
IMPROVE BLOOD FLOW
Relief of symptoms
Prevention of complicationsMortality
MI
CHFArrhythmias
Prolong quality and quality of life
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CAD: Outcomes /Prognosis
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Coronary Artery Disease - Treatment
Medical Beta blockers, ASA, Nitrates
Risk factor modification Smoking, Lipid control, diet, activity
Interventional PTCA
Stents
Surgery CABG Coronary Artery Bypass Grafting
TMR Transmyocardial Revasc.
Transplant
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AHA/ACCGuidelines forCABG:
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
Class IIb
one or two vessel disease not involving proximal LAD
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
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AHA/ACCGuidelines forCABG:
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 moderateterritory at risk and demonstrable ischemia
ongoing ischemia despite medical therapy
Class IIa
proximal LAD stenosis and one or two vessel disease
Class IIb
one or two vessel disease not involving the LAD
ST segment elevation (Q-wave) MI Class I None
Class IIa Ongoing ischemia despite medical therapy
Class IIb
progressive heart failure with remote territory at risk
primary reperfusion within 612 hours
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CAD Treatment MovingTarget
Safer surgery
Myocardialprotection
Anesthesia
Better peri-operative care
Better
medications Statins
Beta-blockers
Sicker patients
Higherexpectations
Lifestylemodification
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Surgery CABG
CPB arrested heart
Off-pump (20%)
Conduits
IMA (L/R)
Aorto-Coronary
Vein (Saphenous)
Radial Artery
Other / Exotic NOT:
Prostetic
Non-autologous
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CABG: OnPump
Benefits Comfortable for the surgeon Bloodless field
Motionless field Myocardial protection Exposure to all vessels for total
revascularization
Risks
Aortic cannulation Cerebral Emboli Dissection
Negative effects of cardiopulmonary bypass
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CABG OffPump
OPCAB
Beating heart
No CPB
Lower heparin
Lower risk
Technically difficult
?outcome?
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CABG Durability: ConduitPatency
1967 1989(even better with modern meds!)
P
ercentPate
nt
P
ercentPate
nt
100100
8080
606011 22 33 44 55 66 77 88 99 1010 1111 1212
YearsYears
N= 5657N= 5657
N=24145N=24145
ITAITA
SVGSVG
1389138910541054
456456 402402 415415
343343338338 291291 222222
175175 167167405405
5796579647804780
17561756
13661366
15351535
15891589
1553155313451345
1183118310291029
738738 14751475
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CAD: CASS Registry Survival
Caracciolo, E., et Al., Circulation 1995; 91: 2325-2334.
100100
8080
6060
4040
2020
00
00 55 1010 1515
MedicalMedical
SurgicalSurgical
27%27%
37%37%
%%
YearsYears
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CAD Treatment
What about people who you cant doa CABG on?
Previous CABG Growing number of redo-CABGs
Poor targets
No conduitToo sick
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Transmyocardial Laser Revascularization
Create Reptilian Circulation
Patients deemed non
revascularizable Documented ischemia
Carbon dioxide / HolmiumYAG laser
30-40 holes drilled
Thoracotomy
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Transmyocardial Laser Revascularization
Outcomes
improved angina
increased exercise tolerance
increased quality of life scores
decreased medical regimen
higher rate of survival free of cardiacevents
NEJM vol. Sept 1999341:14
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Valve Disease
Tricuspid
Pulmonic
Mitral
Aortic
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Valve Surgery: Repair vs Replacement
No CoumadinLess durability
Re-operations
CoumadinMore durability
Bleeding
Emboliccomplications
Patient factors and preference the most important considerations
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Tissue Valves
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MechanicalValves
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Aortic Valve Disease
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Anatomy: Aortic Valve
The noncoronary leafletstraddles the central fibrous bodyoverlying the anterior leaflet ofthe mitral valve.
The conduction tissue traversesthe membranous septum betweenthe right coronary andnoncoronary leaflets.
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Aortic Valve Pathology
Stenosis
bileaflet
calcifications
Insufficiency
annulus
leaflet prolapse
Both
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Aortic Stenosis: Calcification
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Aortic Stenosis: The Problem
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AV R: Grading Aortic Stenosis
Mild aortic stenosis: area >1.5 cm2
Moderate aortic stenosis: area 1 to1.5 cm2
Severe aortic stenosis: area
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Aortic Stenosis: Disease Progression
not to mention the effects of CAD
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Aortic Regurgitation
Improper or inadequate coaptation of the valve leafletsduring diastole.
Allows previously ejected blood to flow retrograde into theleft 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 andsigns of left-sided failure as left ventricular end-diastolicvolume is exceeded.
Chronic volume/pressure overload allows forcompensatory changes in left ventricular volume, leadingto eccentric hypertrophy of the chamber.
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AVR: Surgery
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AVR: Cribier Edwards Perc. ValveThe Future?
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AVR: Tissue Valve Durability
Current Thoughts:
Young PatientsMechanical ValvesPregnancyRisk of re-opLifestyle
Middle AgeMechanicalRisk of re-opPatient preference
ElderlyTissue valvesRisk of coumadin
Influence of other comorbidities
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AVR: LongTerm Survival
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MitralValve Disease
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MitralValve: Anatomy
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MitralValve: Anatomy
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MitralValve: Anatomy
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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 inonly about 50% to 60% of patients; women are affectedmore often than men by a 2:1 to 3:1 ratio. Nearly alwaysacquired before age 20, rheumatic valvular diseasebecomes clinically evident one to three decades later.
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Mitral Regurgitation: EtiologyMuch larger problem
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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 intorestriction during diastole ("a") or systole ("b"). Type IIIb is
typically seen in patients with ischemic MR.
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Functional Mitral Regurgitation
Bolling: Sem. Thor. Card. Surg. 2002
CHFNormal
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MitralValve Surgery: Indications
Complications
Left atrialenlargement
PulmonaryHypertension
Atrial fib.
LV DysfxnSymptoms
Endocarditis
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Mitral Repair: Annuloplasty
Reduce annulardilatation
Reduce volumeoverload
Reduceventricular stressresponse
Reverseremodeling
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Mitral Repair: Leaflet Resection
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MitralValve Replacement
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Outcomes: Degenerative Mitral Disease
Mitral Valve Repair
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Outcome: Repair vs Replacement
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Survival After MVR
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Survival: Repair is Better!
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Mitral Repair: Sounds Great
But:
60% of Functional MR never gets addressed
>50% of all valve surgery is replacement most are mechanical
Why?
Technically difficult
Surgeon preference/bias Outcomes
?Not sure
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When Fixing the Heart Doesnt Work
REPLACE IT
Transplant
Mechanical Support
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Norman Shumway
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Cardiac Transplantation
> 5,000 patients listed for cardiactransplantation in the U.S.*
20-30% per year die waiting
< 2500 cardiac transplantsperformed per year in theU.S.*
unchanged since 1989 despite moremarginal donors utilized
* ISHLT database
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Cardiac Transplantation
2004ISHLT
189 318669
1185
2165
2720
31563380
40244186 4219
4382 4438 4356 4206 40873769
3436 3314 3219 3107
0
500
1000
1500
2000
2500
3000
3500
4000
4500
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
NumberofTran
splants
J Heart Lung Transplant 2004;23:796-803
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Long-Term Functional Status
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Transplant: Underlying Diagnosis
CAD 45%
Dilated CM 45%
Valvular 4%
Congenital 2%
Retransplant 2%
Misc. 2%
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Transplant: Donor selection
Age
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Transplant: Donor cardiectomy.
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Transplantation: Implant
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Transplant Rejection: A Worse Disease?
Symptoms:
AsymptomaticUnexplained arrhythmiasCongestive Heart Failure
Cardiogenic shock
vs
Infection/Sepsis
About 30% have somerejection in the first 6months
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Transplant: Survival
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Mechanical Assist Device
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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
Destination therapy non-transplant candidates
? chronic rejection in transplanted patients
? change age limitation for transplant listing
? can it be better than transplantation
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Selection criteria forVAD
Accepted as candidate for cardiac transplantation(relative)
Absence of coagulopathy or gastrointestinal hemorrhage
Heart failure (CI 25mmHg, systolic blood pressure
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Types of Mechanical Support
Short termsupport
Pulsatile
Continuous flow
Bridge totransplant
Pulsatile Continuous flow
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LeftVentricular Assist Device
Inflow from the LVapex
Outflow into theascending aorta
Percutaneousdriveline attached to
power source andcontroller
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Abiomed BVS 5000(i)
Easy implant/explant
Versatile
univentricular
biventriccular
Good patient support
Paracorporeal
Difficult to mobilize
patient
Aggressiveanticoagulation
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LongTerm LVAD: Thoratec
Easy implant/explant
Versatile
univentricular
biventricular Good patient support
Paracorporeal
Complex initial setup
Able to mobilize patient
Anticoagulation
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Total Artificial Heart: AbioCor
First Humanimplant July 2, 2001
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