transplantation cardiaque aspect chirurgicaux zannis k, vermes e, kirsch m service de chirurgie...

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