Ninth International Symposium
HEART FAILURE & Co.
Rozzano ,April 17, 2009
What Can the Surgeon Do to Avoid
Heart Replacement?
Paolo Ferrazzi
Dipartimento Cardiovascolare
Ospedali Riuniti Bergamo
Rozzano 17 aprile 2009
Paolo Ferrazzi
Valvular
Disease
Hypertension
DIABETES
Myocardial
Infarction
Cardiomyopathies
Delayed
Primary
PTCA
End Stage HF
(10%)
Rozzano 17 aprile 2009
SURGERY
Paolo Ferrazzi
Surgical Treatment of Heart
Failure in Italy
14%
15%
HTx
344/yrs
60%
11%
VAD 30/yrs
Conventional Surgery
n° ?
ISCHEMIC
VALVULAR
HYPERTENSIVE
25.000 End Stage
IDIOPATIC
250.000 Heart failure
Rozzano 17 aprile 2009
Paolo Ferrazzi
Heart Failure Surgical Options
 Heart Transplant
 VAD (recovery, continuous flow)
 Mitral annuloplasty
ICM worse results then DCM!!!
Rozzano 17 aprile 2009
Paolo Ferrazzi
Sugical Treatment of Heart Failure
 Substitutive Surgery
– Transplantation: shortage of donors
– VAD: cost, management, complications
 Reconstructive Surgery
– SVR + CABG (STICH Results)
– No basic research
Rozzano 17 aprile 2009
Paolo Ferrazzi
Rozzano 17 aprile 2009
Paolo Ferrazzi
STICH Results
Personal Opinions
 Comparison CABG vs SVR + CABG instead of
HTx vs SVR + CABG in a sub-class of patients
– VO2max and right catheterization not available
 In more experienced Centers: exclusion from
randomization of patients with a strong
indication to SVR
 Regional differences in surgical results
– SVR long tradition?
 Inadeguate mean ESV reduction (-19%) in
SVR patients
Rozzano 17 aprile 2009
Paolo Ferrazzi
Rozzano 17 aprile 2009
Paolo Ferrazzi
SVR & diastolic function
… presented for the first time in 2000!
Mathematical
model
Animal study
DIASTOLIC
FUNCTION
Post-op ECHO
study
Clinical follow-up
SYSTOLIC
FUNCTION
Systolic improvement is paid by some diastolic dysfunction
Rozzano 17 aprile 2009
Paolo Ferrazzi
Passive Diastolic Function ….a black
hole in echocardiography
Systolic Function
Early Diastole
Late Diastole
Fractional shortening
Vcf
E/A ratio
Stress-corrected Vcf
DT msec
Ejection fraction
IVRT msec
Tei index
 PV S/D ratio
Strain and strain rate
TDI-E/E’
TDI S-wave
Rozzano 17 aprile 2009
Paolo Ferrazzi
Clinical Research
SVR ….. thinking to diastolic function:
The “horseshoe repair”
Potential Advantages
Horseshoe repair
  Volume
  EqD
  Eccentricity index
  Stroke volume
 Late diastolic function 
Ferrazzi, et al JTCVS 2008
Rozzano 17 aprile 2009
Paolo Ferrazzi
SVR – “HORSESHOE REPAIR”
Apr 2005 - Dec 2008
n pts 34
Age (mean)
59.07±8.9
Mitral repair
21 pts (61%)
Follow-up (mean)
16±10.3 mo
Hosp. Mortality
2 pts (5.8%)
Fu mortality
2*
*1 pneumonia after 4 mo and 1 sudden death after 2 mo
NYHA
Preop
Follow-up
P-value
3.0±0.2
1.3±0.5
0.0001
96.8±29.3 (-44%)
50.3±7.7
84.1±11.6
0.0001
0.0001
40.0±8.2
0.0001
VTSV sn (ml)
174.0±56.3
Ø Equatoriale (mm)
64.2±5.5
Ø Longitudinale (mm) 99.5±13.4
FE (%)
Rozzano 17 aprile 2009
27.1±5.7
0.002
Paolo Ferrazzi
Experimental Research
The Endoventricular Elastic Devices
 Restore the elasticity of the
dilatated heart
 Reduce left ventricle volume
 Store wasted energy during
the diastolic phase
 Give the stored energy back
during the sistolic phase
Rozzano 17 aprile 2009
Ferrazzi, et al J Cardiovasc Med 2006
Paolo Ferrazzi
Rozzano 17 aprile 2009
Paolo Ferrazzi
Ischemic Heart Failure
COMPLEX PATHOPHYSIOLOGICAL
MECHANISM OF FUNCTIONAL MITRAL
INCOMPETENCE
 VALVE
 PAPILLARY MUSCLES
 LEFT VENTRICLE
Rozzano 17 aprile 2009
Paolo Ferrazzi
Rozzano 17 aprile 2009
Paolo Ferrazzi
Work in progress...
Rozzano 17 aprile 2009
Paolo Ferrazzi
Cardiac surgery
Surgical Trial
Personalized surgery
Current Practice:
One size fits all !
Rozzano 17 aprile 2009
Paolo Ferrazzi
Heart Failure: back to surgical research...
ANATOMY
&
GEOMETRY
GENOMICS
&
BIOLOGY
HEART
FAILURE
BIO
ENGINEERING
Rozzano 17 aprile 2009
PHYSIOLOGY
Paolo Ferrazzi