CABG and Heart Failure: When and how to
Reconstruct the LV during CABG?
Lorenzo A. Menicanti,
IRCCS Instituto Policlinico San Donato, Italy
NO CONFLICT OF INTEREST TO DECLARE
Significant LV dilatation occurred in
a relevant proportion (30%) of
patients with AMI successfully
treated with primary angioplasty
very close to 34% observed in
thrombolysed patients.
•
L.Bolognese et All. Circulation.2002 ;106:2351-2357
5-Year Mortality vs. ESVI
1
0.9
2 = 33.1
5-Year Mortality
0.8
p < 0.0001
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0
25
50
75
100
125
150
175
200
225
250
ESVI
Courtesy of Kerry Lee
275
Surgical LV Remodeling for Ischemic HF
Indications for SVR
• Previous Anterior or Inferolateral Myocardial Infarction as documented
by EKG or Cardiac MRI
• LV dysfunction (akinetic or diskynetic) with increased LV volume ( LVESVI>
60 ml/m2), NOT hypokinetic
• HF symptoms but also intractable ventricular arrhythmias and/or
angina needing for surgical revascularization if the previous conditions
are present
• Patients with enlarged
revascularisation
LV,
no
symptoms
of
HF,
needing
LEFT VENTRICLE RECONSTRUCTION
Suggested controindications
• Severe right ventricular dysfunction (biventricular dilated
cardiomyopathy) (absolute)
• Severe regional asynergy without LV dilatation (absolute)
• Severe pulmonary hypertension not associated with MR (relative)
•Restrictive diastolic pattern associated with high functional class
and MR (relative)
P.I. MALE 67 YEARS TRANSPLANT CANDIDATE
13-11-2011
26-11-2011
TRANSITIONAL ZONE
INFERIOR PLICATION
TRANSITIONAL
ZONE
ANTERIOR
PLICATION
TRANSITIONAL
ZONE
SEPTAL
DILATATION
SEPTAL PLICATION
Late Enhancement
Late Enhancement
EDVI 485 ml/m2
ESVI 435 ml/m2
EF 10%
SVI=50ml/m2
EDVI 57ml/m2
ESVI 26 ml/m2
EF 54%
SVI=31ml/m2
Cardiac MR
IRCCS Policlinico San Donato: Jan 2010 - Dec 2014
Total
MV surgery
MV Repair
53
50
MV Replac
3
Age 65±6
Pre-op
Post-op
Total
50
Ant
33
Post
14
DD (mm)
67
68
DS (mm)
55
EDVI(ml/m2)
An/Post
3
Total
46
Ant
30
Post
13
70
63
65
62
57
57
52
54
50
134
140
126
99
102
95
ESVI(ml/m2)
94
99
85
64
67
57
EF (%)
30
29
33
35
34
42
MR 3/4
100%
100%
100%
100%
7(15%)
6(20%)
1(7%)
NT-proBNP
3224
3478
1729
7491
1873
2228
858
Death
4(8%)
3(9%)
1(7%)
0(0%)
An/Post
RECOVER: REgistro Istituzionale sulla RiCOstruzione Chirurgica del VEntRicolo
Table 2. Preoperative and postoperative echocardiographic variables
Variable
Pre
Post
p-value*
Diastolic Diameter (mm)
63.8 (9.0)
61.3 (8.4)
<0.0001
Systolic Diameter (mm)
50.8 (10.2)
48.0 (10.3)
<0.0001
EDVI (mL/m )
116.0 (41.3)
89.1 (24.4)
<0.0001
ESVI (mL/m2)
80.8 (37.5)
54.2 (20.8)
<0.0001
EF (%)
32.3 (8.3)
40.2 (9.5)
<0.0001
SV (mL)
35.2 (9.4)
33.9 (9.8)
<0.08
TAPSE (mm)
19.9 (4.4)
16.2 ( (3.4)
<0.0001
PAPs (mmHg)
40.3 (14.7)
36.3 (11.8)
0.02
LVMI (g/m )
166.4 (41.6)
150.3 (38.9)
<0.0001
Sphericity Index, diastole
0.57 (0.1)
0.67 (0.1)
<0.0001
Sphericity Index, systole
0.49 (0.1)
0.58 (0.1)
<0.0001
Conicity Index, diastole
0.86 (0.17)
0.78 (0.12)
<0.0001
Conicity Index, systole
0.99 (0.30)
0.93 (0.16)
<0.0001
2
2
SURGICAL VENTRICULAR RECONSTRUCTION AND LONG-TERM
OUTCOME: RESULTS FROM 10-YEAR-SINGLE CENTER EXPERIENCE
SURGICAL VENTRICULAR RECONSTRUCTION AND LONG-TERM
OUTCOME: RESULTS FROM 10-YEAR-SINGLE CENTER EXPERIENCE
SURGICAL VENTRICULAR RECONSTRUCTION AND LONG-TERM
OUTCOME: RESULTS FROM 10-YEAR-SINGLE CENTER EXPERIENCE
Cumulative risk of all-causes mortality by post–operative ESVI classes (<60 mL/m2 and ≥60 mL/m2)
Log-rank = 7.06, p =
ESVI <60 vs ESVI ≥60
Gender (F vs.M)
Age
0.0079
HR
0.50
0.71
1.41
95% CI
0.29 0.88
0.36 1.41
1.07 1.86
P
0.015
0.330
0.016
Choosing to add SVR to CABG
should be based on a careful
evaluation of patients, including
symptoms (HF symptoms should
be predominant over angina),
measurements of LV volumes,
assessment of the transmural
extent of myocardial scar tissue,
and should be performed only in
centres with a high level of
surgical expertise.
• The clinical judgment of physicians and
surgeons responsible for care of STICH-eligible
patients determined the enrolment stratum
offered for patient consent under the
oversight of the ethics committee at each site.
The primary ethical concern guiding
equipoise for randomization was to offer
patients treatment combination judged to
have similar long term mortality
JACC 2010 Vol. 56, No. 6, 490–8
Conclusions: In patients undergoing coronary artery bypass
grafting plus surgical ventricular reconstruction,
a survival benefit was realized compared with bypass alone,
with the achievement of a postoperative endsystolic
volume index of 70 mL/m2 or less. Extensive ventricular
remodeling at baseline might limit the ability
of ventricular reconstruction to achieve a sufficient reduction
in volume and clinical benefit. (J Thorac Cardiovasc Surg 2013;146:1139-45)
(J Thorac Cardiovasc Surg 2013;146:1139-45)
Causes of Heart Failure
Non-Ischemic
Ischemic
32%
68%
Gheorghiade , 1998
OMT
CABG
Late Enhancement
RECOVER: REgistro Istituzionale sulla RiCOstruzione Chirurgica del VEntRicolo
N Engl J Med 2009;360.
La Chirurgia probabilmente è lo strumento più
efficace per combattere lo scompenso cardiaco ,
con le corrette indicazioni,
Sicuramente però nei pazienti a rischio
aumentato e quindi in coloro che ne
otterrebbero il massimo beneficio è fortemente
sotto utilizzata