缺血性和非缺血性心肌病的外科治療

1、Non-transplant surgical treatment for ischemic and non-ischemic cardiomyopathy,Hayama Heart CenterTadashi Isomura, Jyoji Hoshino, Yasuhisa Fukada, Shintaro Katahira,Operation for DCM (Dilated cardiomyopathy),Surgical t

2、reatment for ischemic or non-ischemic dilated cardiomyopathy (DCM) is a challenging treatment. Left ventricular restoration (LVR) or valve surgery with other aggressive treatment was conducted and evaluated.,Dyskinesis=

3、LV aneurysm,Akinesis=Ischemic DCM,Dor. V; Current Opinion in Cardiology 1997, 12: 534,ICM : LV Remodeling,DCM,noMRPreop LVG,Non-ischemic DCM,CAG, LVG, BiopsyCardiac echo :Color kinesisScintigramCine-MRISpeckle trac

4、king image 　 Radial, Circumferential, Longitudinal,Examination before operation,,,,Radial Strain,Septal,Lateral,Posterior,Normal,Septal,Lateral,Posterior,Normal Heart,,Speckle tracking image : Circumferential strain,

5、DCM,Normal,DCM (n=466)　　　　　　　　　　　　　　　　1997～2008.7,Operative procedures for DCMLeft Ventricular Restoration (LVR) EVCPP (Dor), SAVE, PLV (Batista)Mitral Valve SurgeryCABGCRT-D, Cryoablation ………,①EVCPP（Dor), ②S

6、AVE、③PLV(Batista),LVR,Indication for SAVE,Indication for PLV,SAVE（Septal anterior Ventricular Exclusion with large patch）,Ischemic DCM (n=176),1997～2008.7,Surgical procedures for Non-ischemic DCM,-2006.5,With LVR (n=168

7、),Without LVR (n=122),Surgical results for DCM (N=466),Prognosis of CHF of Stage C,Circulation 2007;115:1563-1570Prevalence of CHF in the Community--- Ammar KA et al.,,,1,0,0.2,,,2,3,4,5,6,7,Survival rate,0.4,0.6,0.8,1.

8、0,,,,,,,,,,,years,,0,,A,,B,,C1,,C2,,Circulation 2007;115:1563-1570Prevalence of CHF in the Community--- Ammar KA et al.,,,1,0,0.2,,,2,3,4,5,6,7,Survival rate,0.4,0.6,0.8,1.0,,,,,,,,,,,years,,0,,A,,B,,C1,,C2,,D,Prognosis

9、 of CHF of Stage D,,,,,,,,,,,,,,,0,2,4,6,8,10,12,1.0,0.8,0.6,0.2,0.0,Years since operation,,,,ICM and solo CABGA prospective ten-year follow-up,Shah et.al. JTCS 2OO3; 126:1320 - 7,0.4,Estimate of Survival,57,EF < 35%

10、,n =,20.3%,55.7%,,Conclusion:Revascularization may have the advantage of preserving the remaining left ventricular function. However, the long-term mortality remains high.,,Survival Rate (%),1.0,0.1,0.2,0.3,0.4,0.5,0.6,0

11、.7,0.8,0.9,0.0,1　　　　　2　　　　　3　　　　　4　　　　　5　　　　　6　　　　　7,SAVE　63.4％,EVCPP　55.6％,ICM and LVR 　ICM　SAVE or EVCPP follow-up,EVCPP　85.6％,SAVE　86.0％,2000.5-,1997-,2000.5～2007.6,CRT-OFF,,,,,,Radial Strain,35M,DCM:SAVE,MVP,CRT,Sep

12、tal,Lateral,Posterior,SAVE+CRT and Stain,CRT-ON,,,,,,Radial Strain,35M,DCM:SAVE,MVP,CRT,Septal,Lateral,Posterior,SAVE+CRT and Stain,Batista operation (PLV)?,Modified Batista OperationIndication=Posterolateral akinesis w

13、ith speckle tracking echo1. Partial left ventriculectomy at the posterior wall between bilateral papillary muscle (Volume reduction)2. Papillary muscle plication (Preservation of papillary muscle-mitra

14、l valve continuity）3.Cryoablation at the cut edge and mitral annulus (Prevention of macro-reentry),Mid-SAX; Circumferential strain,Pre,Post,,,Lengthening,,Lengthening,,Shortening,Shortening,,,,,,,-15%,,,PLV,postop,PL

15、V,preop,PLV and Stain,,Survival Rate (%),6,PLV 36.5％,SAVE　52.1％,Valve 58.4％,0.0,Non-ischemic DCM follow-up,Modified Batista 93.75％（N=24),years,Mitral surgery for Functional MR?,Intra-operative volume test for MR,Volume

16、 Reduction,Volume Loading,Presence of MR,Surgical treatment for ischemic MR,Does the mitral trigone dilate in ischemic MR?,The mitral trigone dose dilate.,JTCS 124 No.6 1216-1224,LV dilatation,Ischemia,LV EDP,Two undersi

17、zed ring annuloplasty =Improve annular dilatationPapillary muscle plication =Improve mitral tethering,Mitral Valve Plasty,Dilated cardiomyopathyPapillary muscle plication,In non-ischemic DCM preoperative status

18、 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

19、 for indicated patients with both ischemic and non-ischemic DCM.,,,Conclusion2-1,Surgical treatment for ischemic or non-ischemic dilated cardiomyopathy (DCM) is a challenging treatment. The development of the procedures