缺血性和非缺血性心肌病的外科治疗课件

1、Non-transplant surgical treatment for ischemic and non-ischemic cardiomyopathyHayama Heart CenterTadashi Isomura, Jyoji Hoshino, Yasuhisa Fukada, Shintaro KatahiraOperation for DCM (Dilated cardiomyopathy)Surgical treatment for ischemic or non-ischemic dilated cardiomyopathy (DCM) is a challenging t

2、reatment. Left ventricular restoration (LVR) or valve surgery with other aggressive treatment was conducted and evaluated. Dyskinesis=LV aneurysmAkinesis=Ischemic DCMDor. V; Current Opinion in Cardiology 1997, 12: 5341991.12 35y M1999.6 43y MICM : LV RemodelingDCM,noMRPreop LVGNon-ischemic DCMCAG, L

3、VG, BiopsyCardiac echo :Color kinesisScintigramCine-MRISpeckle tracking image Radial, Circumferential, LongitudinalExamination before operationRadial StrainSeptalLateralPosteriorNormalSeptalLateralPosteriorNormal HeartOperative procedures for DCMLeft Ventricular Restoration (LVR) EVCPP (Dor), SAVE,

4、PLV (Batista)Mitral Valve SurgeryCABGCRT-D, Cryoablation EVCPP（Dor), SAVE、PLV(Batista)LVRIndication for SAVEIndication for PLVIschemic 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

5、 9 20Late death20 (CHF11,VT7, non-cardiac2)75 (CHF52,VT12, non-cardiac11)Surgical results for DCM (N=466)Prognosis of CHF of Stage CCirculation 2007;115:1563-1570Prevalence of CHF in the Community- Ammar KA et al.100.2234567Survival rate0.40.60.81.0years0ABC1C2Circulation 2007;115:1563-1570Prevalenc

6、e of CHF in the Community- Ammar KA et al.100.2234567Survival rate0.40.60.81.0years0ABC1C2DPrognosis of CHF of Stage D0246810121.00.80.60.20.0Years since operation ICM and solo CABGA prospective ten-year follow-upShah et.al. JTCS 2OO3; 126:1320 - 70.4Estimate of Survival57EF 35%n =20.3%55.7%Conclusi

7、on:Revascularization may have the advantage of preserving the remaining left ventricular function. However, the long-term mortality remains high.CRT-OFFRadial Strain35M,DCM:SAVE,MVP,CRTSeptalLateralPosteriorSAVE+CRT and StainCRT-ONRadial Strain35M,DCM:SAVE,MVP,CRTSeptalLateralPosteriorSAVE+CRT and S

8、tainBatista operation (PLV)?Modified Batista OperationIndication=Posterolateral akinesis with speckle tracking echo1. Partial left ventriculectomy at the posterior wall between bilateral papillary muscle (Volume reduction)2. Papillary muscle plication (Preservation of papillary muscle-mitral valve c

9、ontinuity）3.Cryoablation at the cut edge and mitral annulus (Prevention of macro-reentry)Mid-SAX; Circumferential strainPrePostLengtheningLengtheningShorteningShortening-15%PLV,postopPLV,preopPLV and Stain21345Survival Rate (%)1.00.10.20.30.40.50.60.70.80.96PLV 36.5SAVE52.1Valve 58.40.0Non-ischemic

10、DCM follow-upModified Batista 93.75（N=24)yearsMitral surgery for Functional MR?Intra-operative volume test for MRVolume ReductionVolume LoadingPresence of MRSurgical treatment for ischemic MRDoes the mitral trigone dilate in ischemic MR?The mitral trigone dose dilate.JTCS 124 No.6 1216-1224LV dilata

11、tionIschemiaLV EDPTwo undersized ring annuloplasty =Improve annular dilatationPapillary muscle plication =Improve mitral tethering Mitral Valve PlastyMitral Annuloplasty Using Undersized Circumferential RingDilated cardiomyopathyPapillary muscle plicationDegreeControl (n=5)10811DCM with Papillary mu

12、scle plication (n=12)Before op11810After op1068DistanceControl(n=5)4.40.5cmDCM with Papillary muscle plication (n=12)Before op7.80.8cmAfter op6.30.9cmIn non-ischemic DCM preoperative status was more severe than that of ischemic 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.Conclusion2-1Surgical