SURGICAL OPTIONS FOR THE TREATMENT OF HEART FAILURE - PART 1 potx

Ray C-J Chiu McGill Uniiversity, Division of Cardiovascular and Thoracic Surgery, Montreal General Hospital, Montreal, Canada Umer Darr Yale University, Cardiothoracic Surgery, New Haven

SURGICAL OPTIONS FOR THE TREATMENT OF HEART FAILURE

Developments in

Cardiovascular Medicine

VOLUME 225

The titles published in this series are listed at the end of this volume

Surgical Options for the

Treatment of Heart Failure

edited by

ROY G MASTERS, MD FRCSC

Division of Cardiac Surgery;

University of Ottawa Heart Institute,

Ottawa, Ontario, Canada

KLUWER ACADEMIC PUBLISHERS

DORDRECHT / BOSTON I LONDON

A C.I.P Catalogue record for this book is available from the Library of Congress

ISBN 0-7923-61 30-X

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Table of Contents

List of Contributors

Introduction by Wilbert J Keon

vii

xi

1 Pathophysiology of Contractile Dysfunction in Heart Failure

2 Coronary Artery Bypass-.for Advanced Left Ventricular Dysfunction

John Elefleriades, Geroge Tellides, Habib Samady, Meher

3 Valve Surgery for Regurgitant Lesions of the Aortic or Mitral Valves

in Advanced Left Ventricular Dysfunction

4 Left Ventricular Aneurysm Repair for the Management of Left

Ventricular Dyshction

5 Selection and Management of the Potential Candidate for Cardiac

Transplanatation

6 The Registry of the International Society for Heart and Lung

Transplantation: Fifteenth Oficial Report - 1998

Jeffrey D Hosenpud, Leah E Bennett, Berkeley M Keck, Bennie

Fiol, MarkM Boucek, Richard J Novick

7 Mechanical Circulatory Support

Joe Helou and Robert L.Kormos

8 Dynamic Cardiomyoplasty

Vinay Badhwar, David Francischelli, and Ray C J Chiu

9 Partial Left Ventriculectomy

RichardJ KapIon andPatrickM McCarthy

10 Xenotransplantation

Furah N.K Bhatti np2d John Wallwork

11 Permanent Mechanical Circulatory Support

TofiMussivund, PmlJ Hewdiy, Roy G Masters,

and Wilbert J Keon

List of Contributors

Vinay Badhwar

McGill Uniiversity, Division of Cardiovascular and Thoracic Surgery, Montreal General Hospital, Montreal, Canada

Leah E Bennett

ISHLT Registry, Richmond, VA, U.S.A

Farah N.K Bhatti

Papworth Hospital, Papworth, Everard, Cambridge, United Kingdom

Robert O Bonow

Northwestern University Medical School, Division of Cardiology, Chicago, IL, U.S.A

Mark M Boucek

ISHLT Registry, Richmond, VA, U.S.A

Ray C-J Chiu

McGill Uniiversity, Division of Cardiovascular and Thoracic Surgery, Montreal General Hospital, Montreal, Canada

Umer Darr

Yale University, Cardiothoracic Surgery, New Haven, Connecticut, U.S.A Naranjan S Dhalla

University of Manitoba, Institute of Cardiovascular Sciences, St.Boniface General Hospital Research Center, Winnipeg, Canada

Joh A Elefteriades

Yale University, Cardiothoracic Surgery, New Haven, Connecticut, U.S.A Bennie Fiol

ISHLT Registry, Richmond, VA, U.S.A

David Francsichelli

Medtronic Inc., Minneapolis, Minnesota, U.S.A

Xiaobing Guo

University of Manitoba, Institute of Cardiovascular Sciences, St.Boniface General Hospital Research Center, Winnipeg, Canada

Joe Helou

University of Ottawa, Ottawa Heart Institute, Ottawa, Canada

VIII

Paul J Hendry

University of Ottawa, Ottawa Heart Institute, Ottawa, Canada

Jeiirey D Hosenpud

ISHLT Registry, Richmond, VA, U.S.A

Richard J Kaplon

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A

Berkeley M Keck

ISHLT Registry, Richmond, VA, U.S.A

Wilbert J Keon

University of Ottawa, Ottawa Heart Institute, Ottawa, Canada

Robert Kormos

University of Pittsburgh, Pittsburgh, Pennsylvania U.S.A

Roy G Masters

University of Ottawa, Ottawa Heart Institute, Ottawa, Canada

Patrick M McCarthy

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A

Toiy Mussivand

University of Ottawa, Ottawa Heart Institute, Ottawa, Canada

Richard Novick

ISHLT Registry, Richmond, VA, U.S.A

Habib Samady

Yale University, Cardiothoracic Surgery, New Haven, Connecticut, U S A Lloyd C Semelhago

McMaster University, McMaster Clinical Unit, Hamilton, Canada

Lynne Warner Stevenson

Harvard Medical School, Brigham and Women's Hospital, Boston, MA U.S.A

George Tellides

Yale University, Cardiothoracic Surgery, New Haven, Connecticut, U S A

John Wallwork

Papworth Hospital, Papworth, Everard, Cambridge, UK

Jingwei Wang

University of Manitoba, Institute of Cardiovascular Sciences, St.Boniface General Hospital Research Center, Winnipeg, Canada

Franz J Th Whackers

Yale University', Cardiothoracic Surgery, New Haven, Connecticut, U.S.A Mehcr Yepremyan

Yale University, Cardiothoracic Surgery, New Haven, Connecticut, U.S.A Bany Zaret

Yale University, Cardiothoracic Surgery, New Haven, Connecticut, U.S.A

Introduction

Despite the significant decline in heart disease mortaht>' rates over the last 25 years, heart failure has remained a significant problem We are now confronted with large numbers of terminally ill patients for whom conventional therapies for heart failure have been exhausted and for whom repeated hospital visits are necessary

There now is a major thrust towards a management strategy which embraces a comprehensive approach including vigorous preventive measures and earlier surgical interventions This book outlines the major surgical options for the treatment of heart failure and brings together a very broad base of opinions with contributions from several outstanding individuals

With the improved knowledge and techniques to control rejection, transplantation has become the central pillar in the surgical management of this group of patients Unfortunately, because of limited donor supply the teclmique cannot be applied to large numbers of patients A great deal of excitement, however, exists in the potential for xenotransplantation as a supplement to homotransplantation The use of cardiac assist devices has become a reality with several hundred LVADS and BiVADS implanted throughout the world and cardiac replacement with total artificial hearts continues to be used successfully as a bridge to transplantation We are on the thieshold of the broad application

of assist devices to provide prolonged relief of heart failure and restore patients to an ambulatoiy home environment and hopefully return to the work force in significant numbers The renewed interest in ventricular remodelling, early mitral valve repair, improved techniques for dealing with ventricular aneurysms and early revascularization during acute ischemic episodes has opened the doors to significant improvements in cardiac function in large numbers of heart failure patients This represents yet another opportunity to prolong the lives and relieve the suffering of heart failure patients and leave the door open for ultimate cardiac replacement with either transplantation or devices should this be necessary

This book is a timely and useful contribution to the overall knowledge of the

management of the heart failure patient and provides a useful and worthwhile read for every cardiac surgeon of the day

Wilbert J Keon

University of Ottawa Heart Institute

Ottawa, Canada

CORONARY ARTERY BYPASS FOR ADVANCED LEFT

VENTRICULAR DYSFUNCTION

John A Elefteriades, George Tellides Habib Samady, Mcher Yepremyan

Umer Darr, Franz J.Th Wackers and Barry Zarct

Introduction

Although courageous forays into the apphcation of coronaiy aitery' bypass grafting (CARCT)

to the patient with advanced lefl ventricular dystunction were made since the early days of open heart surgery, the opinion that the patient with advanced left ventricular dysfunction could not and should not be offered coronary artery bypass surgerv' prevailed well into the 1980's The reluctance centered around three concerns: (1) that the risk of operation would

be prohibitive, (2) that little symptomatic or longevity benefit would accme from CABCS, and (3) that CARG would merely punctuate an inevitable course of inexorable detentiration Cardiologists were therefore reluctant to refer such patients for coronary' revascularization and surgeons were reluctant to accept such patients In lerais of scientific evaluation, most large multicenter trials of coronar>' artery bypass grafling puqiosely excluded patients with

advanced left ventricular dysftjnction (Ejection fraction was >35% in the Coronaiy Aileiy

Surgerv- Study (CASS) and >50% for the European Coronary' Surgery Study (liCSS)) '•" Despite the substantial dangers anticipated in the application of CABCi to patients with advanced left ventricular dysfunction, the potential for recovery of function via grai\ing continued to add luster to the challenge The very definition of "hibernating muscle", coined originally by Rahimtoola, embodies the concept that non-fiinctioning, ischemic muscle can resume function upon provision of adequate blood supply The ultimate test of viabilil\' has always been, in fact, the restoration of function consequent upon revascularization fhe patient who poses the greatest potential for re-animation of hibernating muscle is the patient with coronary artery disease and advanced left ventricular dysfunction the patient with so-called "advanced ischemic cardiomyopathy'' It is not surprising that surgeons have attacked the problem of advanced ischemic cardiomyopathy, as the outlook with medical management alone is dismal Figure 1, from Franciosa and Cohn demonstrates vividly the desperate outlook for these patients In their study, these authors examined the survival of patients with cardiomyopathy according to etiology fhe pt)oresi outlook by far was for patients with coronarv' artery disease as the cause of tlieir iriyopalh\ who manifested 80% mortality over 3 years, '^ While cuncnt

Roy Masters (editor) Surgical Options for the Treatment of Heart Failure 15-31

16 J.A^ Kkfteriades el aL

100

Natural Historf of Adwanced L¥ Dysfunction

0 1 e 12 18 24 30 36

Figure 1 Survival in heart faibire The center line indicates the overall survival for patients with left

ventricular ftiiltire (ALL)^ The patients with idiopathic dilated cardiomyopathy cardiomyopathy (IDC), represented in the upper line, did somewhat better The poorest outlook by far was had by the patients wilk coronary artery disease (CAD) as the came of their myopathy, who manifested only 20% 3-year survival

From Reference !, with pemiisston

therapy with ACE^nhibition and P-blockade may have rendered some improvement m outlook, most authorities agree that the impact has been small and that this continues to be

a lethal disease, '•*

In the 1990's, a number of centers began to develop and pubhsh organized clinical expenence with coronary arten' bypass grafting in advanced left ventricular dysfunction These mvestigators and centers included Laks and colleagues at UCLA, Kron et al at the University of Virginia, Mickelborough al Toronto, Rose and colleagues at Columbia, Dreyfus in France, and our own group at Yale University, as well as others (Table 1), '"" The fmdmgs at these various centers witli a concentrated interest m this subject are largely consonant This chapter will review our own findings at Yale University in a relatively large group of patients undergoing CABG for advanced ischemic cardiomyopathy UTiere there

IS discordance m findings or recommendations betiveen our institution and the distinguished teams listed above, the data from the otlier centers will be emphasized specifically The questions to be addressed include:

What is the mortality risk of CABG in advanced left ventricular dysfunction?

-What technical principles underlie the safe peri-operative management of low

EF patient?

~-%Tiat, if any, improvements m symptomatic state can be achieved, for angina or for congestive heart failure (CHF)?

-\¥liat, if any, improvement m EF can be documented objectively?

-What is the long-terai survival after !ow-EF CABG?

Coronary Arteiy Bypass for Advanced Left Ventricular Dysfunction 1 7

Table I Secected studies of CABG in low EF from the present decade

Author (Dale)

Louie (1991)

Chrislakis<1992)

Lansman(l993)

Luciani (1993)

Milano(1993)

Langenbag

(1995)

Mickelbonjugh

(1995)

Shapira(1995)

K a u l ( l 9 9 6 )

Chan(1996)

HausmanTi(1997)

Radovanovic

(1998)

Elefleriades

(1998)

# o f

palicnls

22

-187

42

20

118

96

79

74

210

57

514

120

188

E F ( % ) (range)

<3Q%

<20%

< 2 0 %

<30%

< 2 5 %

< 2 5 %

< 2 0 %

<30%

< 2 0 %

S 3 5 %

< 30%

<20%

< 3 0 %

E F ( % ) (mean)

23%

-15.7%

22%

20%

18%

23.5%

28%

23.8%

-23.5%

Hospital Mortality

13.6%

9.8%

4.8%

20%

1 1 % 8%

3.8%

-10%

1.7%

7 1 %

7%

5.3%

Mean Followup

12

-34

-44

65

43

40

24

36

49

Post-Op

36%

-22.6%

42%

27%

-3 5 7 *

30%

39%

-33,2%

Survival

1 y r 3 yr 5 j r

72%

-88%

80%

77%

-94%

96

82%

86%

7

83%

86%

7 2 %

-68%

80%

-7 8 *

91

797c 80%

7

72%

75%

-57%

80%

57%

68%

86

73%

73%

7

58%

60%

Comments Prefer EF > 20;

L V E D D < 70mm

Poor distal largcLs are contraindication

O n l y hospital survivors tabulated

Many exclusion factors Thallium predicts EF improvement Only paticnLs with demonstrated Lschcmia operated

Extensive use o f coronary cndcrterectomy Laic EF at 5Y: 31.7%

- W h a t happens to EF long-term after CABG? Is it sustained or is there an

inexorable decrement?

What insights regarding pre-operative myocardial viability assessment can be

drawn from the surgical experience?

—What are appropriate guidelines for patient selection'.'

The Yale Experience

At Yale University, we have taken an aggressive approach by widely applying mvocardial levascularization for patients with advanced ischemic cardiomyopathy Our group at Yale University has carefully studied a series of patients undergoing surgical revascularization for advanced left ventricular dysfunction operated by one surgeon (JAE) ' "^ We used 30"/ii

as our upper limit for EF in this series Only patients who had a precise, objective, numerical determination of EF pre-operatively by ventriculographv or equilibrium radionuclide angiocardiography (ERNA) were included No "eyeball" estimates ofliF were accepted, so as to allow precise comparison of pre- and post-operative ventricular function Patients having concomitant valve replacement or left ventricular aneuiy smectomv were puiposcly excluded in order to evaluate a homogeneous patient group

There were 188 patients (156 M, 32 F) and the age ranged from 42 to 84 years, with

a mean of 67 75% of patients had angina and two-thirds had a)ngestive heait failure, with one quarter manifesting frank pulmonary- edema ()ne quarter had a prior histon^ of significant ventncular arrhythmia One quailer were already requiring ICU care at the time

of CARCi EF ranged from 10 to 30%, with a mean of 23.3% Two-thirds of the patients