Chapters Transcript Video Surgical Therapies for Acute and Chronic Heart Failure Well, thanks for sticking around to the very end. Uh we'll get through the next set of slides in about 45 minutes or so. Alright, so certainly when we talk about heart failure, we can't talk about heart failure while talking about heart transplant. And I think that, personally, I'm very blessed to be part of the transplant team here and throughout my career to be able to take what's patients living with on the left and turning into what's on the right. It really is a true miracle medicine that we can do this and patients can live decades if not longer with a new heart. To put this in cardiology view. Uh The echo on the left is pre and the echo on the right is post transplant. Okay. But we deal with heart failure and shock in cardiac surgery along a broad spectrum of pathologies. And what I thought I would do would be just to highlight a few of them over the next few minutes. And so, um I went through my files and pulled out a few pictures that sort of represent what we deal with in terms of heart failure and shock from a surgical basis. I'll give you the answer for the treatment for all of these. It's all surgery. Uh So certainly what's important though. Uh and it's been highlighted multiple times over the last eight hours or so is a multidisciplinary approach to identify, investigate and make a treatment plan in an expeditious manner and then to act and act appropriately to uh have the best possibility for the best outcome. Alright, so let's first talk about a few urgent emergent indications. Not exactly a forum podiums. Talk about, talk about tamponade. But certainly we see this a lot. It's a great imitator. We misdiagnosis a lot. And there is a role for surgical drainage. May not be the first therapy oftentimes uh aspiration or drain can do it, but for recurrent fusions or for large infusions, certainly dealing with the window is can be therapeutic as well as diagnostic. I'm not sure many people in the audience have seen a side like this. What you see in the middle is a 45 caliber slugs sitting in the aortic root. This patient presented with tamponade after being shot in the chest. Uh and uh the call was for tamponade but he ended up getting this taken out of the valve mitral valve replaced and he walked out of the hospital about six days later. We certainly see a fair number of mechanical complications for M. I We haven't really talked about that much today, but certainly the ones that we see that can be very devastating. The cute popular muscle ruptures which you can see on the top of the slide and then ventricular septal defects. And what may be a little hard for you to see. But what you're doing is you're looking through the left ventricle, you're looking into the right ventricle hole about three inches by two inches, which is the entire septum uh And this used to be seen a lot more before early intervention. But actually in areas where there's sort of underrepresented treatment and sort of slow access to treatment. We do see this not infrequently and the mortality, if not treated is almost unity. Uh certainly that we can have a considerable number of survivors if we act and act especially pre shock. See all right, uh, pulmonary embolism. I know many of you are on this side. Didn't didn't hear dr dexter's talk about the multiple different modalities of treatment for pulmonary embolism. Those of us who take pulmonary embolism. Now we tend to take pictures and show one another because apparently that's interesting. But certainly pe is not a lung problem. It's a heart problem and not everybody in medicine knows that. And the reason I have this picture on top is what you see on the left side. The fat part of this rhombus was actually across the atrial septal defect sitting in the left atrium. It can be absolutely devastating if this gets across. And so there is a role and I think an underutilized role for acute removal pulmonary embolism. Certainly there's a lot of data that demonstrate that long term pulmonary hypertension is reduced with full clearance and especially with an inter cardiac shunt. We do a fair number of these as well and the RV cannot tolerate cute after load. And that's why For heart transplants were very careful about who we select in terms of pulmonary hypertension because the normal 18 or 20 year old heart put into pulmonary hypertension does not do well. We see this every time with pulmonary embolism. So the more sub acute and chronic constrictive pericarditis which we see once in a while um certainly um has its uh symptom Atala ji. And most of the time the treatment if possible is uh complete cardi ectomy, para cardi ectomy. What you can see on the right of the slide is half the heart, mostly the left ventricle that I've been able to clear off. I'm sorry if it's a little bit red with the way these cases are uh you can actually see the lb moving and the rest of it is just this massive, thickened pericardium that grows onto and into the heart. Sometimes we can do this off pump. Oftentimes we go on pump to facilitate human dynamic support. Um it's it's amazing to see at least as a surgeon. Um these hearts just totally respond when you crack the egg and remove it. They go from just these tiny little restricted hearts to full uh excellent by ventricular function. LV aneurysm repair. I don't know why I took this video but we did because I thought the repair was nice. But but certainly um you know post M. I. Or other ideologies of LV aneurysms. Uh been a lot of talk about stitch trial from about a dozen years ago and that it doesn't work for many patients. But actually there are subsets of patients where resection of the aneurysm can improve both cardiac output injection fraction. Uh It does remove this fourth rhombus. Um It certainly works best in the sub acute to chronic when you have a nicely formed rim that you can put a patch on and reconstruct the LV. Again, a cardiologist view of this uh you can see the pre imposed for this patient. The blue shows the actual aneurysm and on the right side to see the actual reconstruction. It's uh it's actually fantastic when you get a good result like this. There actually companies that are trying to market a perk you tania's approach to this. So we were involved with that a few years ago. It's not a big market for it, but the one patient that we did, which was the first in the United States, actually went from an ef 24 to about 45% came off the transplant list and is doing well. Um Native and prosthetic valve disease, both stenosis and regurgitation. Um You know, the standard still if possible, is to do an open surgical repair replacement. Uh There's no repairing these uh these valves that you see on the left is the underside of the valve in the middle, which is a mitral valve uh and taking it out, putting a brand new valve and certainly can affect the patient's quality and quantity of life on the right is very rare but a cyanotic prosthetic mitral valve that was done surgically. Um There's no real way to fix that other than to replace it. Um At least at this point uh cabbage. We talked about the indications a lot today for PC. I. But certainly cabbage does have its role, especially for ischemic cardiomyopathy. There's a lot of data out there for both doing this and doing that. But certainly there's favorable data for um uh coronary bypass grafting in ischemic cardiomyopathy, especially with our chair revascularization and nothing beats a lima. L. A. D. Uh and I think that will continue. Um It's the only two pictures I had of a cabbage, um holes in the heart certainly can cause uh heart failure. Um Big holes like this is the largest atrial septal defect. Can't see the whole thing, but it's down to the valve. Not really amenable to a per container. This option um can be readily fixed with surgical patching either with autologous pericardium or with bovine pericardium. The results are excellent. Well, short term and long term inter inter cardiac masses which we do see uh certainly present uh fairly frequently with shortness of breath and sometimes heart failure symptoms. This is a atrial maxima the size of the bottom. Mylar lemon um So about four centimeters patient presented with syncope and shortness of breath uh and left sided heart failure symptoms that uh um He took it out. I like this picture because it's a green mass. And so it's like billy burden and it's just kind of cool. But with the circle shows is actually the stock of Soma, which is only a couple of millimeters. And this thing was flopping around across the across the mitral valve. Um so it's certainly a high risk, not just obstruction but embolization. So the goals of surgical intervention to improve cardiac function appropriate patients and improve quality and quantity of life. And it really is this interdisciplinary approach, finding the appropriate patients uh for the appropriate time and during during the right intervention that that leads to the best outcomes. And I really just have one more slide and then let's go back to transplantation. What makes transplantation possible is really the courage of the donors and their families. And we talk a lot about transplant and great outcomes and all this. But it's all predicated on really this most generous gift. And I want you to think about that. Um and if you're not a donor considered becoming a donor and talking to your families about that because really we need that to really pay it forward. The gift of life. That's all I have. Thanks Published December 7, 2022 Created by Related Presenters Chris Sciortino, M.D. Surgery - Cardiothoracic View full profile
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