Post on 03-Apr-2015
TRANSPLANTATION CARDIAQUE
Aspect chirurgicaux
ZANNIS K, VERMES E, KIRSCH M
Service de Chirurgie Thoracique et Cardiovasculaire
Hôpital Henri Mondor, Créteil, France
Spécificité de la Transplantation Cardiaque
Organe : unique
Fonction : vitale, non interrompable
Tolérance limitée à l’ischémie (4 à 6 h)
Organisation
donneur
receveur
The Heart Donnor
Cardiac Donor Evaluation
Past medical history and physical examination
ECG
Chest X-ray
Arterial blood gases
Laboratory tests (ABO / troponin / HIV, HBV, HCV,
CMV, toxo)
Echocardiogram ± coronary angiogram
Cardiac Donor Selection
Age < 55 years
Absence of the following :
prolonged cardiac arrest
prolonged severe hypotension
need for high-dose inotropic support
pre-existing cardiac disease
severe chest trauma, evidence of cardiac injury
septicemia
extracerebral malignancy
positive serologies for HIV, HBV, HCV
Donor / Recipient Matching
ABO Patient size
donor ± 20% of recipient
oversizing if high PVR
Pre-transplantation crossmatch if anti-HLA antibodies
Donor Heart Retrieval
Sternotomy / pericardotomy
Inspectioncontractilitycardiac disease / injury
Palpationascending aortacoronary arteries
Donor Heart Retrieval
The Heart Recipient
Heart Transplantation
Operative preparation of the recipient
sternotomy / vertical pericardotomy
bicaval and aortic cannulation (heparin)
initiation of cardiopulmonary bypass
Recipient cardiectomy
Donor heart implantation
left atrium, right heart, pulmonary artery, aorta
Weaning of CPB
Closure
Circulation Extra Corporelle
Oxygénateur - Echangeur thermique
CEC / Cardioplégie
Conséquences de la CEC1) Sang
dégradation mécanique des éléments figurés du sangtroubles de l’hémostase (saignement)SIRSimmuno-dépression
2) Cerveauembolies (cruorique, calcaire, air)hypo-perfusion
3) Poumonsmécaniquesurcharge hydriqueSDRA
4) Reins
Donor Heart ImplantationStandard
Donor Heart ImplantationBicaval Technique
Insuffisance Cardiaque Henri Mondor
Les alternatives à la transplantation
Corriger la cause- Chirurgie coronaire- Chirurgie valvulaire
Corriger les conséquences du remodelage- Restauration ventriculaire
Substitution- Assistance mécanique de la circulatoire
Henri Mondor
Left Ventricular Remodeling
Alterations in LV Chamber GeometryLV dilationLV wall thinningIncreased LV sphericity Mann, Circulation, 1999
Myocardial Changesmyocyte loss (necrosis, apoptosis)extracellular matrix (degradation, fibrosis)
Alterations in Myocyte Biologyexcitation contraction couplingmyosin heavy chain gene expressionß-adrenergic desensitizationhypertrophymyocytolysiscytosquelettal proteins
Remodelage
Henri Mondor
Left Ventricular Wall StressLaplace Law
Wall Stress = Pressure x Radius
2 (Wall thickness)
Sub - endocardialhypoperfusion
Expression of stress activated genes
Remodelage
Consequences on Mitral Valve
displacement of papillary muscles
leaflet tethering and mitral valve tenting
annular dilatation
Henri MondorRemodelage
Henri Mondor
Functional Mitral Valve Incompetence
BlondheimAm Heart J
1991
1986 - 1988LVEF < 40%LVED Ø > 60 mm
Remodelage
Left Ventricular Restoration Henri Mondor
Left Ventricular Restoration
Left ventricular volume reduction- Endoventricular patch plasty (Dor)- Partial left ventriculectomy (Batista)
Mitral valve repair (Bolling)
Left ventricular restriction or striction
Left Ventricular Restoration Henri Mondor
Endoventricular Patch PlastyDor Procedure
Left Ventricular Restoration Henri Mondor
RESTORE Group
12 centers1998 - 2003
n = 1198
Pre-op2980
Post-op3957
EF (%)
LVESVI (mL/m2)
Hosp † 5.3 %
Feedom from rehosp for CHF78 % at 5 years
Athanasuleas, JACC, 2004
Left Ventricular Restoration Henri Mondor
Partial Left VentriculectomyBatista Procedure
Left Ventricular Restoration Henri Mondor
Cleveland Prospective TrialMay 1996 - Dec 1998
62 transplant candidatesIdiopathic dilated cardiomyopathy
NYHA III or IVLVEDD > 70 mm
Franco-Cereceda, JTCS, 2001
1 mth1 year3 years
80 %49 %26 %
1 mth1 year3 years
99 %80 %60%
Pre-op168.4
Post-op31.55.9
EF (%)
LVEDD (cm)
Over-corrective AnnuloplastyLeft Ventricular Restoration Henri Mondor
Left Ventricular Restoration Henri Mondor
Mitral Valve Repair in Heart Failure June 1993 - Jan1999
92 patientsNYHA III or IV, LVEF < 25%
Smolens, Eur J Heart Fail, 2000
Pre-op
162813.1
0.82
Post-op
262065.2
0.74
Echo Parameter EF (%) LVEDV (mL) Qc (l/min) Sphericity (D/L)
3.214.5
1.818.6
Functional NYHA VO2 max (mL/Kg/min)
Operative † 1 year survival 2 years survival
5%80%70%
Left Ventricular Restoration Henri Mondor
Mitral Valve Repair in Heart Failure
Wu, JACC, 2005
1993 – 2002682 pts with LV dysfunction and MR
419 surgical candidates126 MVA, 293 non-MVA
All pts NI-DCM only
Hvass, Ann Thorac Surg, 2003
Papillary Muscle Sling Left Ventricular Restoration Henri Mondor
Percutaneous Mitral Procedures Left Ventricular Restoration Henri Mondor
Left Ventricular Restoration Henri Mondor
Evolving Technologies : CorCap CSD
COMPLIANCElongitudinal > circumferential
Left Ventricular Restoration Henri Mondor
Evolving Technologies : CorCap CSD Clinical safety study
Assistance circulatoirePulsatiles
TAH
Para-Corporeal Pneumatic VAD
Implantable Electro-Mechanical VAD
Axial
Centrifugal
Non Pulsatiles
Assistance
Les objectifs
en attente de transplantation
en attente de récupération
implantation définitive
Assistance
Deux situations
Insuffisance cardiaque(aiguë / chronique)
Défaillance bi-ventriculaireDéfaillance multi-viscérale
BiVAD
Défaillance VG isolée / dominante
LVAD
Assistance
Simplicité Versatilité Pulsatilité Disponibilité
Durabilité Autonomie
THORATEC®L-VAD / Bi-VAD Para- / Intra-corporel
Assistance
THORATEC®Console Fixe / Portable
Assistance
IMPLANTATION TECHNIQUE
Novacor® Heartmate XVE®
SYSTEMES ELECTRIQUESIMPLANTABLES / PULSES
Assistance
SYSTEMES ELECTRIQUESIMPLANTABLES / PULSES
LVAD n = 280Controls n = 48
HEARTMATE VEMULTICENTRIC TRIAL
Frazier, J Thorac Cardiovasc Surg, 2001
REMATCH TRIAL
Park, J Thorac Cardiovasc Surg, 2005
LVAD n = 68OMM n = 61
p = 0.0077
Assistance
TURBO - POMPESCLASSIFICATION
POMPES AXIALES
écoulementaxial
POMPES CENTRIFUGES
écoulementradial
Assistance
TURBO - POMPESPOMPES AXIALES INCOR®
TURBO-POMPESAVANTAGES THEORIQUES
peu volumineuses
peu d’éléments mobiles
pas de valves
meilleur rendement
énergétique
pas de bruit
MAIS …
DEBIT NON PULSE ?
Assistance
TURBO-POMPE = NON-PULSEE ?
Jarvik 2000 Frazier, Circulation, 2002
INCOR LVADDoppler art. fém. com. gche
22 mois d’implantation, 7500 t/min
Assistance
Assistance
CONCLUSION
Stevenson, Circulation;2003:3059-63
Assistance Circulatoire Mécanique