dilated cardiomyopathy
DESCRIPTION
management of DCMTRANSCRIPT
Surgery for DCM and RCM
Dr Amjad Shaikh
Introduction
Main treatment is for heart failure which is the end result of DCM and RCM.
Most of the surgeries still are under development.
Best treatment is heart transplant.
Surgery for DCM
Partial left ventriculectomy( Batista) Ventricular restoration Ventricular shape change and
constraint devices Direct cardiac or aortic compression
devices Dynamic cardiomyoplasty Biventricular pacing Mechanical circulatory support
Batista operation
Batista procedure, was developed and introduced by the Brazilian cardiac surgeon Batista.
Batista hypothesized that an enlarged, dilated ventricle would be a more effective pump if the size could be reduced, hence restoring the normal volume/mass/diameter relationship of the left ventricle.
The law of LaPlace states that wall stress is directly proportional to ventricular pressure and radius and inversely proportional to wall thickness.
removing a triangular wedge of the lateral wall of the left ventricle, which typically weighs more than 100 g . The incision begins at the apex of the left ventricle and extends to the atrioventricular groove.
Typically a posterolateral branch of the left coronary artery is removed with the excised specimen. Because of the change in geometry and juxtaposition of the papillary muscles, the mitral valve is repaired to ensure competency.
Batista performs a mitral valve repair (Alfieri technique), in which the anterior and posterior leaflets are sutured resulting in a double-orifice mitral valve, which yields the characteristic figure-of-eight appearance when the mitral valve is viewed in the short-axis echocardiographic view
Batista surgery
2D Echo: figure of eight
Advantages: it improves systolic function and hence cardiac output..
Limitations: It removes functioning though
weakened myocardium. It may actually decrease net ventricular pumping capacity by affecting diastolic compliance.
Ventricular restoration
Anatomical basis: - heart is dual spiral helix( torrent –
Gausp) -configuration of muscle fibers at apex is
figure of eight which provides mechanism for ventricular ejection and suction of filling.
Aim of surgery: convert spherical heart to normal
elliptical heart
Ventricular shape change and constraint devices These devices change left ventricular shape
or to restrain ventricular dilatation of heart. McCarthy and schenk used myosplints: three of devices are placed
perpandicular to long axis of left ventricle.Chaudhary used prosthetic jacket of knitted
polyster mesh: it prevents progressive left ventricular remodelling and abolished functional mitral valve regurgitation.
Direct cardiac or aortic compression devices It helps failing heart by direct compression of heart
and aorta. It avoids interaction between blood and foreign
surface of assist device. Ease of application and ease of removal.
A: The cardio support system: it surrounds both ventricles to the AV groove - -200 mm Hg pressure for vaccume seal. - compression bladder inflated and deflated in
synchrony with cardiac contraction. - short term use for cardiogenic shock.
B: The heart booster: - multiple small parallel
compression tubes covering both ventricular chembers.
- hydraulic drive system fills and empties the tubes
- still under development stage
C: Kantrovitz CARDIOVAD( LVAD):
Principle: diastolic augmentation like IABP.
- the pump is warn externally and provides the stroke volume of up to 60 ml via the tube through the skin.
Dynamic Cardiomyoplasty
Basic: use of the skeletal muscle wrapped around heart which is stimulated electrically to augment or restore contractility of ventricles.
Kantrovitz and McKinon used first in 1959.
Latissimus dorsi muscle used. Electrodes are implanted in muscle and
stimuled in synchronization with heart Late deaths are seen due to ventricular
arrhythmias and fibrillation.
Mechanical circulatory support It is a means of imparting energy for
forward flow of blood in the body by man made device.
It can be
A: - temporary
- interim
- permanent
B: - internal (implantable)
- external( partially implantable, paracrporeal)
Implantable or partialy implantable A: Ventricular Assist Device: - VADs are connected to the failing
heart in parallel. - it pumps all or part of stroke volume.- It generally bypass the failing heart.- It takes blood from atria in to the
pump and return to great arteries beyond the ventricle.
- It provides pulsatile blood flow
Paracorporeal VADS
Abiomed VAD
Thoratec VAD
It is particularly useful in smaller adults or older children.
Pumping ventricle is mounted on the abdomen and canula from ventricle are brought out of mediastinum as drainage tube.
Rate is determined automatically. The pump is flow limited to about
5l/m.
Implantable VADS
Thoratec heartmate VAD II used as bridge to heart transplant.
It improves the chance for survival until the suitable donor can be located.
Pump is driven pneumatically or electrically.
Many newer modifications are available now.
Total artificial heart
Both ventricles are replaced by biventricular pneumatic pulsatile blood pump maintaining natural atria as inflow chambers.
cardiowest C-70
Recent advances
Now continuous flow and centrifugal pumps are available.
these are smaller pumps Energy requirement is low Pumps do not require compliance
chamber. Disadvantages: needs anticoagulants thrombus
formation hemolysis.( Nimbus heartmate II VAD)
Last resort….
Heart transplant…
Thank you….