缺血性和非缺血性心肌病的外科治疗课件.ppt

1、HAYAMA HEART CENTERNon-transplant surgical treatment for ischemic and non-ischemic cardiomyopathyHayama Heart CenterTadashi Isomura,Jyoji Hoshino,Yasuhisa Fukada,Shintaro KatahiraHAYAMA HEART CENTEROperation for DCM(Dilated cardiomyopathy)Surgical treatment for ischemic or non-ischemic dilated cardi

2、omyopathy(DCM)is a challenging treatment.Left ventricular restoration(LVR)or valve surgery with other aggressive treatment was conducted and evaluated.HAYAMA HEART CENTERDyskinesis=LV aneurysmAkinesis=Ischemic DCMHAYAMA HEART CENTERDor.V;Current Opinion in Cardiology 1997,12:5341991.12 35y M1999.6 4

3、3y MHAYAMA HEART CENTERDCM,noMRPreop LVGNon-ischemic DCMHAYAMA HEART CENTER CAG,LVG,Biopsy Cardiac echo:Color kinesis Scintigram Cine-MRI Speckle tracking image Radial,Circumferential,LongitudinalExamination before operationHAYAMA HEART CENTERRadial StrainSeptalLateralPosteriorNormalSeptalLateralPos

4、teriorNormal HeartNormal HeartHAYAMA HEART CENTERSpeckle tracking image:Circumferential strainDCMNormalHAYAMA HEART CENTERIschemic/Non-ischemic176/290Age579range2983Male/Female379/87NYHA class/257/209Elective/Emergent380/86DCM (n=466)19972008.7HAYAMA HEART CENTEROperative procedures for DCMLeft Vent

5、ricular Restoration(LVR)EVCPP(Dor),SAVE,PLV(Batista)Mitral Valve SurgeryCABGCRT-D,Cryoablation HAYAMA HEART CENTEREVCPP（Dor),SAVE、PLV(Batista)LVRHAYAMA HEART CENTERRegional hetrogeneity in Mid-SAX LV wall shortening;PLV candidates-30-20-1001020Circumferential strain,%Antero-Lateral Posterior Infero-

6、Septal Septal Indication for SAVEIndication for PLVHAYAMA HEART CENTERSAVE（Septal anterior Ventricular Exclusion with large patch）HAYAMA HEART CENTEREVCPP(Dor)98SAVE(or overlap)63(3)PLV(Batista)15CABG(n=143)2.71.3/patientMitral90(51)MVR/MVP18/72Tricuspid29Cryoablation78（44）IABP/LVAD27/3Ischemic DCM

7、(n=176)19972008.7HAYAMA HEART CENTERSurgical procedures for Non-ischemic DCM-2006.5PLV(Batista)111（66）SAVE(or Overlap)57（3）MVP/MVR84/74（94）82/26（89）TAP/TVR83/4（52）78/5（68）AVR617Cryoablation6110PM plication32（19）11（9）CRT32（19）21（17）IABP/LVAD39/419/1With LVR(n=168)Without LVR(n=122)HAYAMA HEART CENTER

8、Ischemic DCM(n=176)Non-ischemic DCM(n=290)Hospital death Elective6/150(4.0%)18/230(7.8%)Emergent8/26(31.0%)29/60(48.3%)Late follow up NYHA class 1-2132148 NYHA class 3-4 9 20Late death20(CHF11,VT7,non-cardiac2)75(CHF52,VT12,non-cardiac11)Surgical results for DCM(N=466)HAYAMA HEART CENTERPrognosis of

9、 CHF of Stage Cyears0ABC1C2HAYAMA HEART CENTERyears0ABC1C2DPrognosis of CHF of Stage DHAYAMA HEART CENTER0246810121.00.80.60.20.0Years since operation A prospective ten-year follow-upShah et.al.JTCS 2OO3;126:1320-70.4Estimate of Survival57EF 35%n=20.3%55.7%Conclusion:Revascularization may have the a

10、dvantage of preserving the remaining left ventricular function.However,the long-term mortality remains high.HAYAMA HEART CENTERSurvival Rate(%)1.00.10.20.30.40.50.60.70.80.90.01234567SAVE 63.4EVCPP 55.6ICM and LVR ICMSAVE or EVCPP follow-up EVCPP85.6SAVE86.02000.5-1997-2000.52007.6HAYAMA HEART CENTE

11、RCRT-OFFRadial Strain35M,DCM:SAVE,MVP,CRTSeptalLateralPosteriorSAVE+CRT and StainHAYAMA HEART CENTERCRT-ONRadial Strain35M,DCM:SAVE,MVP,CRTSeptalLateralPosteriorSAVE+CRT and StainHAYAMA HEART CENTERHAYAMA HEART CENTERModified Batista OperationIndication=Posterolateral akinesis with speckle tracking

12、echo1.Partial left ventriculectomy at the posterior wall between bilateral papillary muscle (Volume reduction)2.Papillary muscle plication(Preservation of papillary muscle-mitral valve continuity）3.Cryoablation at the cut edge and mitral annulus (Prevention of macro-reentry)HAYAMA HEART CENTERMid-SA

13、X;Circumferential strainPLV,postopPLV,preopPLV and StainHAYAMA HEART CENTERHAYAMA HEART CENTER21345Survival Rate(%)1.00.10.20.30.40.50.60.70.80.96PLV 36.5SAVE52.1Valve 58.40.0Non-ischemic DCM follow-upModified Batista 93.75（N=24)yearsHAYAMA HEART CENTERHAYAMA HEART CENTERIntra-operative volume test

14、for MRVolume ReductionVolume LoadingHAYAMA HEART CENTERIschemic Mitral Regurgitation:Long-Term Outcome and Prognostic Implications With Quantitative Doppler Assessment Circulation,Apr 2001;103:1759-1764.Figure 1.Survival(SE)after diagnosis according to presence of IMR.Presence of MRHAYAMA HEART CENT

15、ERDoes the mitral trigone dilate in ischemic MR?The mitral trigone dose dilate.HAYAMA HEART CENTERLV dilatationIschemiaLV EDPHAYAMA HEART CENTERTwo undersized ring annuloplasty =Improve annular dilatationPapillary muscle plication =Improve mitral tethering HAYAMA HEART CENTERHAYAMA HEART CENTERHAYAM

16、A HEART CENTERDegreeControl (n=5)10811DCM with Papillary muscle plication (n=12)Before op11810After op1068DistanceControl(n=5)4.40.5cmDCM with Papillary muscle plication(n=12)Before op7.80.8cmAfter op6.30.9cmHAYAMA HEART CENTERIn non-ischemic DCM preoperative status was more severe than that of isch

17、emic DCM and the late results showed better in ischemic DCM than those in non-ischemic DCM.However,aggressive non-transplant surgical treatment with LVR or valve surgery can be useful for indicated patients with both ischemic and non-ischemic DCM.Conclusion2-1HAYAMA HEART CENTERSurgical treatment for ischemic or non-ischemic dilated cardiomyopathy(DCM)is a challenging treatment.The development of the procedures does improve the operative and long-follow-up results.Conclusion2-2HAYAMA HEART CENTER