PERIOPERATIVE VENTRICULAR

DYSFUNCTION:

CURRENT STRATEGIES FOR MANAGING

SERIES 2000

copyright Sanofi-Synthelabo, and Ventiv

Healthcare
CURRENT CONCEPTS IN CARDIAC SURGERY

 Changing demographics and increasing use

of angioplasty, stenting, and platelet inhibitors
 Older patients with greater myocardial
dysfunction and increased comorbidities

Estafanous FG, et al. Ann Thorac Surg. 1998;65:383-389.

Fontana GP. Chest Surg Clin N Am. 1998;8:871-890.
Verrier ED. J Am Coll Surg. 1999;188:104-110.
CURRENT CONCEPTS IN
CARDIAC SURGERY (CONTD)

 Expanding use of beating heart and minimally

invasive cardiac surgical techniques
 Alternative surgical therapies for treating
congestive heart failure (CHF)

Estafanous FG, et al. Ann Thorac Surg. 1998;65:383-389.

Fontana GP. Chest Surg Clin N Am. 1998;8:871-890.
Verrier ED. J Am Coll Surg. 1999;188:104-110.
NEW YORK HEART ASSOCIATION (NYHA)
FUNCTIONAL CLASSIFICATION

Class I No symptoms or limitations on

ordinary activity

Class II Slight limitation of physical activity.

Ordinary activity results in fatigue,
dyspnea, or angina

Goldman L, et al. Circulation. 1981;64:1227-1234.

NYHA FUNCTIONAL
CLASSIFICATION (CONTD)

Class III Marked limitation of physical activity.

Patients are asymptomatic at rest and can
carry out only very limited physical activity

Class IV Inability to perform any physical activity

without developing symptoms. Some
symptoms are present even at rest

Goldman L, et al. Circulation. 1981;64:1227-1234.

MEDICAL THERAPY OF HEART FAILURE

 Diuretics
 Angiotensin-converting enzyme inhibitors
 -Adrenergic–receptor blockers
(mild to moderate heart failure)
 Digoxin
 Vasodilators—oral/intravenous (IV)
 IV inotropic/inodilator agents (acute decompensation)
 - AND  -ADRENERGIC RECEPTOR
1 2
SUBPOPULATIONS IN HUMAN
VENTRICULAR MYOCARDIUM

100
*
Receptor density (fmol/mg)

*
75

50 1- and 2-receptor

densities in ventricular
myocardial membranes
25 prepared from
nonfailing (n = 27) and
failing (n = 28) human hearts
0 *P<.05
Total 1 2

Bristow MR, et al. Circ Res. 1986;59:297-309.

ANALYSIS OF -ADRENERGIC RECEPTOR
LEVELS IN HUMAN VENTRICULAR BIOPSY
SPECIMENS

Progressive reduction of 1-adrenergic receptors

in heart failure
NYHA Class II 7%

NYHA Class III 26%

NYHA Class IV >50%

Reduction in 1 Receptor Levels (%)

Engelhardt S, et al. J Am Coll Cardiol. 1996;27:146-154.
DIRECT EVIDENCE OF ACUTE CARDIAC
-RECEPTOR DESENSITIZATION DURING
CARDIOPULMONARY BYPASS (CPB) IN HUMANS

 Acute 1-receptor desensitization—20%

 Proposed etiology
 Uncoupling of G-protein from 1-receptor complex
 Impaired adenylate cyclase activity

 2-receptor density unchanged

Abraham WT, et al. In: Poole-Wilson PA, et al, eds. Heart Failure. 1997:127-141.
Booth JV, et al. Anesthesiology. 1998;89:602-611.
Landolfo K, et al. Anesth Analg. 1997;84:SCA 6. Abstract.
Schwinn DA, et al. Circulation. 1991;84:2559-2567.
Smiley R, et al. Anesth Analg. 1992;74:212-218.
SYMPATHETIC DOWN-REGULATION
IN HEART FAILURE*

Normal
NE 1 +++ AC +++ cAMP
Down-regulated
E 1 +++ Contractility
NE + AC +cAMP
NE 1
NE
E + Contractility
*NE indicates norepinephrine; E, epinephrine;
AC, adenylate cyclase; cAMP, cyclic adenosine monophosphate.
Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine. 1992:393-443.
-BLOCKADE IN CHRONIC HEART FAILURE

 Previous thinking: contraindicated

 Short-term adverse effects
 Current thinking: indicated in stable
mild to moderate heart failure

Australia/New Zealand Heart Failure Research Collaborative Group. Lancet. 1997;349:375-380.

Colucci WS, et al. Circulation. 1996;94:2800-2806.
Packer M, et al. Circulation. 1996;94:2793-2799.
Packer M, et al. N Engl J Med. 1996;334:1349-1355.
EFFECTS OF -BLOCKADE
IN CHRONIC HEART FAILURE

 Improves cardiac function

  ejection fraction (EF)
  left ventricular (LV) end-diastolic volume
  LV end-systolic volume

Australia/New Zealand Heart Failure Research Collaborative Group. Lancet. 1997;349:375-380.

CIBIS-II Investigators and Committees. Lancet. 1999;353:9-13.
Colucci WS, et al. Circulation. 1996;94:2800-2806.
Merit HF Study Group. Lancet. 1999;353:2001-2007.
Packer M, et al. Circulation. 1996;94:2793-2799.
Packer M, et al. N Engl J Med. 1996;334:1349-1355.
EFFECTS OF -BLOCKADE
IN CHRONIC HEART FAILURE (CONTD)

 Reduces symptoms and improves functional class

 Slows disease progression
 Reduces risk of hospitalization
 Improves survival

Australia/New Zealand Heart Failure Research Collaborative Group. Lancet. 1997;349:375-380.

CIBIS-II Investigators and Committees. Lancet. 1999;353:9-13.
Colucci WS, et al. Circulation. 1996;94:2800-2806.
Merit HF Study Group. Lancet. 1999;353:2001-2007.
Packer M, et al. Circulation. 1996;94:2793-2799.
Packer M, et al. N Engl J Med. 1996;334:1349-1355.
CARDIAC SURGERY IN PATIENTS
WITH DIABETES

 Diffuse multivessel coronary artery disease

 Increased preoperative and perioperative
myocardial infarction rate
 Less distensible ventricle due to
interstitial glycoprotein
 Potential for autonomic dysfunction

Factor SM, et al. N Engl J Med. 1980;302:384-388.

Hiramatsu K, et al. Am J Cardiol. 1992;70:1185-1189.
CARDIAC SURGERY IN PATIENTS
WITH DIABETES (CONTD)

 Catecholamines worsen hyperglycemia

 Increased renal insufficiency, sternotomy
complications, and sepsis
 Increased peripheral vascular disease and
intra-aortic balloon pump complications
 Increased hospital stay and costs

Factor SM, et al. N Engl J Med. 1980;302:384-388.

Hiramatsu K, et al. Am J Cardiol. 1992;70:1185-1189.
IMPLICATIONS OF
BEATING-HEART SURGERY
 Beating heart with controlled myocardial ischemia
 Hemodynamic instability produced by mechanical
stabilizers and manipulation
 Vasoactive and inotropic support may be required
during acute periods of surgical revascularization
ACUTE MYOCARDIAL DYSFUNCTION
AND RECOVERY AFTER CORONARY SURGERY

60

50

40
Percentage

LVEF = left ventricular

ejection fraction
30
RVEF = right ventricular
ejection fraction
20
Preop
10 Immed postop
Nadir (~4 h)
0 Recovery (6-7 h)

RVEF LVEF
Breisblatt WM, et al. J Am Coll Cardiol. 1990;15:1261-1269.
RISK FACTORS FOR LOW CARDIAC
OUTPUT AFTER CPB

 Preoperative LV dysfunction
 Long aortic cross-clamp time and total CPB time
 Incomplete cardiac surgical revascularization
 Emergency surgery
 Persistent ischemia
 Reperfusion injury and inflammatory changes

Hardy JF, et al. J Cardiothorac Vasc Anesth. 1993;7:33-39.

RISK FACTORS FOR LOW CARDIAC
OUTPUT AFTER CPB (CONTD)

 Dysrhythmias
 Pulmonary hypertension and right
ventricular (RV) failure

Hardy JF, et al. J Cardiothorac Vasc Anesth. 1993;7:33-39.

PREOPERATIVE AND INTRAOPERATIVE PREDIC-
TORS OF INOTROPIC SUPPORT AND LONG-
TERM OUTCOME IN PATIENTS HAVING CABG

 Lower preoperative EF
 Older age
 Cardiac enlargement on chest x-ray
 Female sex
 Higher baseline and postcontrast
LV end-diastolic pressure
 Prolonged bypass or ischemic time
Royster RL, et al. Anesth Analg. 1991;72:729-736.
FACTORS THAT PREDICT THE NEED FOR
INOTROPIC DRUG SUPPORT DURING
CARDIAC VALVE SURGERY

 Increased age
 History of CHF
 Increased length of CPB
 Decreased LVEF
 Pulmonary hypertension
 Concurrent coronary artery bypass graft (CABG)

Butterworth JF, et al. Anesth Analg. 1998;86:461-467.

CONSEQUENCES OF “FAILED WEAN”
FROM CPB

 Ventricular distention  ischemia 

 contractility
 Added pump time
 Increased risk of coagulopathy, pulmonary
dysfunction, and neurological injury
 Greater risk of atrial and ventricular
dysrhythmias

Lewis KP. J Cardiothorac Vasc Anesth. 1993;7:40-45.

Parr GVS, et al. Circulation. 1975;51:867-874.
CONSEQUENCES OF “FAILED WEAN”
FROM CPB (CONTD)

 Systemic hypotension and organ injury

 Subsequent need for mechanical support
 Additional operating room time and costs

Lewis KP. J Cardiothorac Vasc Anesth. 1993;7:40-45.

Parr GVS, et al. Circulation. 1975;51:867-874.
POTENTIAL ROLE OF EARLY INOTROPIC
THERAPY FOR WEANING FROM CPB

 Reduced incidence of
 Ventricular distention
 Need for mechanical assist devices
 Multiorgan dysfunction
 Decreased time on CPB
 Decreased cost

Doolan LA, et al. J Cardiothorac Vasc Anesth. 1997;11:37-41.

ADVANTAGES OF INTRAOPERATIVE
ECHOCARDIOGRAPHY

 Systolic and diastolic function

 LV volume
 Regional wall motion
 Direct valve assessment
 Assessment of the aorta
PERIOPERATIVE ECHOCARDIOGRAPHY:
DIAGNOSTIC INDICATIONS

 Hemodynamic instability of uncertain etiology

 Valve anatomy and function
 Aortic assessment
 Valve repair or replacement
 Congenital heart surgery
 Aortic dissection or aneurysm
 High-risk myocardial revascularization
PERIOPERATIVE ECHOCARDIOGRAPHY:
DIAGNOSTIC INDICATIONS (CONTD)

 Ventricular assist devices

 Endocarditis
 Intracardiac air or mass
 Assessment of myocardial infarction complications
 Assessment during beating-heart and minimally
invasive cardiac surgery
ADVANTAGES OF INTRAOPERATIVE
ECHOCARDIOGRAPHY

 Transesophageal echocardiography (TEE)

can measure cardiac output and indicate
why it is low
 Global LV and RV dysfunction
 Regional LV dysfunction (ischemia)
 LV volume
 Valvular dysfunction
INTRAOPERATIVE ECHOCARDIOGRAPHIC
ASSESSMENT OF AORTA

 TEE
 Dissection
 Type I, II, or III, AR, hemopericardium
 Aneurysm
 Location, size, thrombus

 Epiaortic echo
 Identifies atherosclerosis of the ascending aorta
 Risk factor for perioperative CNS injury
Wareing TH, et al. Ann Thorac Surg. 1993;55:1400-1407.
INTRAOPERATIVE ECHOCARDIOGRAPHY:
HIGH-RISK CORONARY BYPASS

 Major management alteration

 Surgical (33%)
 Pharmacologic therapy (51%)

 Reduced morbidity and mortality (retrospective)

 Myocardial infarction (1.2% vs 3.8%)
 In-hospital CNS morbidity (1.2% vs 3.3%)
 Hospital mortality (1.2% vs 3.8%)

Savage RM, et al. Ann Thorac Surg. 1997;64:368-373.

SYSTOLIC AND DIASTOLIC FAILURE

Normal

CHF (systolic failure)

Pressure

Compliance (diastolic failure)

Normal

Volume
USE OF IV POSITIVE INOTROPIC DRUGS
IN CARDIAC SURGERY

 Incidence of drug usage varies widely

 Administered in response to ventricular
dysfunction during weaning from bypass
 Therapy usually continued to the ICU
 Additional therapy may be required in ICU;
however, consider other reversible causes
Clinical Process Improvement Program. Clinical Process Improvement: Coronary Artery Bypass Graft (CABG) Clinical
Benchmarking Database. Report #2, 1996.
Royster RL. J Cardiothorac Vasc Anesth. 1993;7:19-25.
COMPLICATIONS OF
SYMPATHOMIMETIC THERAPY

 Dysrhythmias
 Altered systemic and pulmonary
vascular resistance
 Myocardial ischemia
 Electrolyte disturbances
 Hyperglycemia
USE OF INOTROPIC AGENTS
AND DYSRHYTHMIAS

 Any inotropic agent may exert proarrhythmic

effects by increasing intracellular cAMP
 Patients with LV dysfunction may be more prone
to nonsustained ventricular tachycardia with any
inotropic therapy
 The incidence of dysrhythmias attributable to all
inotropic agents is similar and relatively low

Naccarelli GV, et al. Am J Cardiol. 1989;63:35A-40A.

GOALS OF THERAPY

 Maintain organ perfusion pressure

 Maintain myocardial O2 supply
 Optimize O2 delivery
 Optimize ventricular loading conditions
 Optimize pulmonary and systemic arterial
afterload conditions
PHARMACOLOGIC APPROACHES FOR
PERIOPERATIVE BIVENTRICULAR DYSFUNCTION

 Vasodilator therapy  Pulmonary vasodilators

 Phosphodiesterase
 Inotropic agents
 Catecholamines inhibitors
 Inhaled nitric oxide
 Phosphodiesterase
 Prostaglandins
inhibitors
 Digoxin, calcium, T3  New agents

Not within product labeling currently approved by the USFDA.

Not currently approved by the FDA for use in the United States.
Bailey JM, et al. Adult Cardiac Surgery. 1997:225-254. Levy JH. J Cardiothorac Vasc Anesth. 1993;7(suppl):46-51.
Bennett-Guerrero E, et al, for the Duke T 3 Study Group. Royster RL, et al. Cardiovasc Anesth. 1992;74:3-13.
JAMA.1996;275:687-692.
VASODILATOR THERAPY

 Arterial vasodilation decreases ventricular

wall stress
 Venodilation decreases venous return and preload
 Multiple mechanisms for improving systolic and
diastolic dysfunction
 Nitrate tolerance (chronic use)
 Therapy may be limited by hypotension
Kikura M, et al. Curr Opin Anesth. 1994;7:42-52. Munzel T, et al. Am J Cardiol. 1996;77:24C-30C.
Levy JH, et al. Calcium Antagonists in Clinical Medicine. 1997. Munzel T, et al. J Am Coll Cardiol. 1996;27:297-303.
Levy JH. J Cardiothorac Vasc Anesth. 1993;7(suppl):46-51.
CATECHOLAMINES: SELECTIVITY OF
SYMPATHOMIMETIC DRUGS

Alpha
Phenylephrine
Norepinephrine
Epinephrine
Dopamine
Dobutamine
Dopexamine
Not currently approved by the FDA
Isoproterenol


for use in the United States.

Beta Bailey JM, et al. Adult Cardiac Surgery. 1997:225-254.

Levy JH. J Cardiothorac Vasc Anesth. 1993;7(suppl):46-51.
PARENTERAL PHOSPHODIESTERASE
INHIBITORS

 Methylxanthines (aminophylline)
 Bipyridines (milrinone and amrinone)
 Imidazolones (enoximone)
 Benzylisoquinolines (papaverine)

Not currently approved by the FDA for use in the United States.

Bailey JM, et al. Adult Cardiac Surgery. 1997:225-254.

Levy JH. J Cardiothorac Anesth. 1993;7(suppl):46-51.
INOTROPIC EFFECTS OF
PHOSPHODIESTERASE INHIBITORS*

-adrenergic agonists
Calcium Extracellular
channel Adenylyl cyclase Cell membrane
Ca++ ATP
Phosphodiesterase
cAMP 5' AMP
Ca++ Phosphorylated
Mg++

PDE inhibitors
active kinase Inactive protein kinase
++
Ca Ca++
Ca++ Intracellular
Increased contractility *ATP indicates adenosine
triphosphate; AMP, adenosine
Colucci WS, et al. N Engl J Med. 1986;314:290-299. monophosphate; PDE, phosphodiesterase.
PERIOPERATIVE DOSING AND
ADMINISTRATION OF MILRINONE

 Loading dose of 50 mcg/kg over 10 min

followed by an infusion of 0.5 mcg/kg/min
 Titrate (0.25-0.75 mcg/kg/min) depending
on effect
 Weaning protocols vary
 Half-life may increase with renal and
prolonged administration
BENEFITS OF EARLY PHOSPHODIESTERASE
INHIBITOR ADMINISTRATION

 Increased inotropy (LV and RV)

 Pulmonary vasodilation
 Possible avoidance of mechanical pumps
 Dilation of internal mammary artery (IMA)
 Possible prevention of a “failed wean”

Doolan LA, et al. J Cardiothorac Vasc Anesth. 1997;11:37-41. Hardy JF, et al. J Cardiothorac Vasc Anesth. 1993;7:33-39.
Doyle AR, et al. Ann Thorac Surg. 1995;59:S3-S11. Lobato EB, et al. Br J Anaesth. 1998;81:782-784.
 MILRINONE EFFECTS ON LV
END-DIASTOLIC PRESSURE AND DP/DT
ECG

dP/dt

100
mm Hg

LV

50

0
Baseline Milrinone
Baim DS, et al. N Engl J Med. 1983;309:748-756.
MILRINONE CONCENTRATION
AND CARDIAC INDEX (CI) IN
CARDIAC SURGICAL PATIENTS

120

100
% Change in CI

80

60

40

20

0
0 100 200 300 400 500

Milrinone Concentration (ng/mL)

Bailey JM, et al. Anesthesiology. 1994;81:616-622.
THE EFFECT OF MILRINONE ON CI
AFTER EMERGENCE FROM CPB

Changes in CI (mean ± SD)

5.0 *† MIL 50
*† *†
* * *† MIL 50 + 0.5
*† *†
4.0
CI (L/min/m2)

* MIL 75 + 0.75

Control
3.0

2.0

1.0
0 3 5 10
Time (min)


Not within product labeling currently approved by the USFDA.
Kikura M, et al. Anesth Analg. 1997;85:16-22.
THE EFFECT OF MILRINONE ON LV
FUNCTION AFTER EMERGENCE FROM CPB

Changes in velocity of circumferential fiber shortening corrected for heart rate (Vcfc) (mean ± SD)
2.0

*†
1.6 *†
*† *† MIL 50
Vcfc (circ/sec)

*†
*† MIL 50 + 0.5
1.2 MIL 75 + 0.75
Control
0.8

0.4

0.0
0 3 5 10
Time (min)

Not within product labeling currently approved by the USFDA.
Kikura M, et al. Anesth Analg. 1997;85:16-22.
THE EFFECT OF MILRINONE ON CI AND
VCFC AFTER EMERGENCE FROM CPB

 CI and Vcfc significantly increased from baseline

at 5 and 10 min in all milrinone groups
 CI and Vcfc were significantly higher at
5 and 10 min than in control group
 No significant changes in CI and Vcfc
were observed in control group

Kikura M, et al. Anesth Analg. 1997;85:16-22.

CAVEATS OF MILRINONE THERAPY

 Milrinone is a potent venodilator, therefore

give cautiously in the hypovolemic patient
 If patient has LV outflow tract obstruction
and mitral regurgitation due to systolic anterior
motion of the mitral valve, milrinone should
not be administered
 Hypotension can be attenuated with slower
administration, volume administration,
and/or concomitant catecholamines
A COMPARISON OF MILRINONE LOADING
DOSES IN PATIENTS UNDERGOING
CARDIAC SURGERY
4.5

4.0
CI (L/min/m2)

3.5

3.0

2.5
25 mcg/kg
50 mcg/kg
2.0
75 mcg/kg
1.5
B1 B2 2.5 5 7.5 10 20 30 45 60
Elapsed Time (min)

Not within product labeling currently approved by the USFDA.
Butterworth J, et al. Anesth Analg. 1995;81:783-792.
IN VITRO EFFECTS OF PHOSPHODIESTERASE
INHIBITORS ON HUMAN IMA RELAXATION

20
% Relaxation

40

60
A = amrinone
E = enoximone E
80 M = milrinone A
P = papaverine P
M
100
0.1 1 10 100 1000
Concentration (mcmol)

Not currently approved by the FDA for use in the United States.
Salmenpera M, Levy, JH. Anesth Analg. 1996;82:954-957.
IMA FLOW AFTER
MILRINONE AND EPINEPHRINE

60 *P<.05 compared with pretreatment

* Values are mean ± SD
50 M = milrinone 50 mcg/kg
IMA Flow (mL/min)

E = epinephrine 0.03 mcg/kg/min

40

30

20

10

0
Before M After M Before E After E

Lobato EB, et al. J Cardiothorac Vasc Anesth. In press.

MILRINONE IN THE CARDIAC
TRANSPLANT SETTING

 Use to test reversibility of elevated pulmonary

vascular resistance
 Continuation depends on predrug and postdrug
hemodynamics
 List as status Ia or lb and continue agent(s)
until transplant
 Minimal problems with thrombocytopenia

Not within product labeling currently approved by the USFDA.
Givertz MM, et al. J Am Coll Cardiol. 1996;28:1775-1780.
Skoyles JR, et al. J Cardiothorac Vasc Anesth. 1993;6:222-225.
MILRINONE IN THE CARDIAC
TRANSPLANT SETTING (CONTD)

 Continue agent(s) as a “tune-up”

for days to weeks
 Optimize oral agents and send
home as status II
 Intraoperative and postoperative use
to prevent or treat RV failure

Givertz MM, et al. J Am Coll Cardiol. 1996;28:1775-1780.

Skoyles JR, et al. J Cardiothorac Vasc Anesth. 1993;6:222-225.
PERIOPERATIVE VENTRICULAR
DYSFUNCTION IN PEDIATRIC PATIENTS

 Incomplete repair
 Prolonged CPB and ischemic time
 Immature myocardium (very calcium-dependent)
 Afterload sensitivity
 Pulmonary hypertension
HEMODYNAMIC EFFECTS
OF MILRINONE IN NEONATES

 Increased cardiac output (47%)

 Decreased systemic vascular resistance (36%)
 Decreased pulmonary vascular resistance (30%)
 Decreased right and left atrial pressure


Not within product labeling currently approved by the USFDA.
Chang AC, et al. Crit Care Med. 1995;23:1907-1914.
HEMODYNAMIC EFFECTS OF A LOADING
DOSE (50 MCG/KG) OF MILRINONE IN
INFANTS AND CHILDREN

 Increased cardiac output (18%)

 Decreased blood pressure (12%)
 Decreased systemic vascular resistance (25%)


Not within product labeling currently approved by the USFDA.
Bailey JM, et al. Anesthesiology. 1999;90:1012-1018.
PHARMACOKINETICS AND DOSING OF
MILRINONE IN PEDIATRIC PATIENTS

 Larger volume of distribution and clearance

than adults
 Clearance is lower in infants than children
 A 50 mcg/kg loading dose is therapeutic—
an additional loading dose may be needed
to maintain therapeutic levels


Not within product labeling currently approved by the USFDA.
Bailey JM, et al. Anesthesiology. 1999;90:1012-1018.
Ramamoorthy C, et al. Anesth Analg. 1998;86:283-289.
PHARMACOKINETICS AND DOSING OF
MILRINONE IN PEDIATRIC PATIENTS (CONTD)

 A 0.5 mcg • kg-1 • min-1 infusion will

maintain therapeutic levels


Not within product labeling currently approved by the USFDA.
Bailey JM, et al. Anesthesiology. 1999;90:1012-1018.
Ramamoorthy C, et al. Anesth Analg. 1998;86:283-289.
COMPARISON OF MILRINONE
VERSUS AMRINONE

 Shorter context-sensitive half-life

 More titratable
 Less adverse effects on platelets
 Similar pharmacodynamic profiles

Bailey JM, et al. Anesthesiology. 1994;81:616-622.

Kikura M, et al. Int Anesthesiol Clin. 1995;33:21-37.
Kikura M, et al. Anesth Analg. 1995;81:44-48.
Rathmell JP, et al. Anesth Analg. 1998;86:683-690.
Salmenpera M, et al. Anesth Analg. 1996;82:954-957.
SURGICAL APPROACHES TO HEART FAILURE

 High-risk myocardial revascularization

 Mitral valve reconstruction
 Orthotopic heart transplantation (OHT)
 Ventricular assist devices (as a bridge
to OHT, in lieu of OHT)
 Partial left ventriculectomy
 Cardiomyoplasty

Not currently approved by the FDA for use in the United States.
SURGICAL APPROACHES TO HEART FAILURE:
MITRAL VALVE RECONSTRUCTION

 Preservation of annular-chordal-papillary
muscle continuity
 Maintenance of ellipsoidal chamber geometry
 Maintenance of LV systolic function
 Lower LV volume
 Less end-systolic wall stress

Bolling SF, et al. J Thorac Cardiovasc Surg. 1998;115:381-386.

PARTIAL LEFT VENTRICULECTOMY
WITH MITRAL VALVE REPAIR


Not currently approved by the FDA for use in the United States.
MECHANICAL CIRCULATORY SUPPORT

 Intra-aortic balloon pump  TCI HeartMate left

 Abiomed BVS 5000 ventricular assist
device (LVAD)
 Bio-Medicus
 Novacor LVAD
 Thoratec
 Axial flow pumps

Farrar DJ, et al. Ann Thorac Surg. 1996;61:276-282.
Frazier OH, et al. Ann Surg. 1995;222:327-338.
Jett GK. Ann Thorac Surg. 1996;61:301-304.
McCarthy PM, et al. Sem Thorac Cardiovasc Surg.
1994;6:174-180.
Noon GP, et al. Ann Thorac Surg. 1996;61:291-295.
Torchiana DF, et al. J Thorac Cardiovasc Surg.
1997;113:758-769