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TRANSPLANTATION CARDIAQUE Aspect chirurgicaux ZANNIS K, VERMES E, KIRSCH M Service de Chirurgie Thoracique et Cardiovasculaire Hôpital Henri Mondor, Créteil,

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Présentation au sujet: "TRANSPLANTATION CARDIAQUE Aspect chirurgicaux ZANNIS K, VERMES E, KIRSCH M Service de Chirurgie Thoracique et Cardiovasculaire Hôpital Henri Mondor, Créteil,"— Transcription de la présentation:

1 TRANSPLANTATION CARDIAQUE Aspect chirurgicaux ZANNIS K, VERMES E, KIRSCH M Service de Chirurgie Thoracique et Cardiovasculaire Hôpital Henri Mondor, Créteil, France

2 Spécificité de la Transplantation Cardiaque Organe : unique Fonction : vitale, non interrompable Tolérance limitée à lischémie (4 à 6 h)

3 Organisation donneur receveur

4 The Heart Donnor

5 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

6 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

7 Donor / Recipient Matching ABO Patient size donor ± 20% of recipient oversizing if high PVR Pre-transplantation crossmatch if anti-HLA antibodies

8 Donor Heart Retrieval Sternotomy / pericardotomy Inspection contractility cardiac disease / injury Palpation ascending aorta coronary arteries

9 Donor Heart Retrieval

10 The Heart Recipient

11 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

12 Circulation Extra Corporelle

13 Oxygénateur - Echangeur thermique

14 CEC / Cardioplégie

15 Conséquences de la CEC 1)Sang dégradation mécanique des éléments figurés du sang troubles de lhémostase (saignement) SIRS immuno-dépression 2)Cerveau embolies (cruorique, calcaire, air) hypo-perfusion 3)Poumons mécanique surcharge hydrique SDRA 4) Reins

16 Donor Heart Implantation Standard

17 Donor Heart Implantation Bicaval Technique

18 Insuffisance CardiaqueHenri 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

19 Henri Mondor Left Ventricular Remodeling Alterations in LV Chamber Geometry LV dilation LV wall thinning Increased LV sphericity Mann, Circulation, 1999 Myocardial Changes myocyte loss (necrosis, apoptosis) extracellular matrix (degradation, fibrosis) Alterations in Myocyte Biology excitation contraction coupling myosin heavy chain gene expression ß-adrenergic desensitization hypertrophy myocytolysis cytosquelettal proteins Remodelage

20 Henri Mondor Left Ventricular Wall Stress Laplace Law Wall Stress = Pressure x Radius 2 (Wall thickness) Sub - endocardial hypoperfusion Expression of stress activated genes Remodelage

21 Consequences on Mitral Valve displacement of papillary muscles leaflet tethering and mitral valve tenting annular dilatation Henri MondorRemodelage

22 Henri Mondor Functional Mitral Valve Incompetence Blondheim Am Heart J LVEF < 40% LVED Ø > 60 mm Remodelage

23 Left Ventricular RestorationHenri 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

24 Left Ventricular RestorationHenri Mondor Endoventricular Patch Plasty Dor Procedure

25 Left Ventricular RestorationHenri Mondor RESTORE Group 12 centers n = 1198 Pre-op Post-op EF (%) LVESVI (mL/m 2 ) Hosp 5.3 % Feedom from rehosp for CHF 78 % at 5 years Athanasuleas, JACC, 2004

26 Left Ventricular RestorationHenri Mondor Partial Left Ventriculectomy Batista Procedure

27 Left Ventricular RestorationHenri Mondor Cleveland Prospective Trial May Dec transplant candidates Idiopathic dilated cardiomyopathy NYHA III or IV LVEDD > 70 mm Franco-Cereceda, JTCS, mth 1 year 3 years 80 % 49 % 26 % 1 mth 1 year 3 years 99 % 80 % 60% Pre-op Post-op EF (%) LVEDD (cm)

28 Over-corrective Annuloplasty Left Ventricular RestorationHenri Mondor

29 Left Ventricular RestorationHenri Mondor Mitral Valve Repair in Heart Failure June Jan patients NYHA III or IV, LVEF < 25% Smolens, Eur J Heart Fail, 2000 Pre-op Post-op Echo Parameter EF (%) LVEDV (mL) Qc (l/min) Sphericity (D/L) Functional NYHA VO 2 max (mL/Kg/min) Operative 1 year survival 2 years survival 5% 80% 70%

30 Left Ventricular RestorationHenri Mondor Mitral Valve Repair in Heart Failure Wu, JACC, – pts with LV dysfunction and MR 419 surgical candidates 126 MVA, 293 non-MVA All ptsNI-DCM only

31 Hvass, Ann Thorac Surg, 2003 Papillary Muscle Sling Left Ventricular RestorationHenri Mondor

32 Percutaneous Mitral Procedures Left Ventricular RestorationHenri Mondor

33 Left Ventricular RestorationHenri Mondor Evolving Technologies : CorCap CSD COMPLIANCE longitudinal > circumferential

34 Left Ventricular RestorationHenri Mondor Evolving Technologies : CorCap CSD Clinical safety study

35 Assistance circulatoire Pulsatiles TAH Para-Corporeal Pneumatic VAD Implantable Electro-Mechanical VAD Axial Centrifugal Non Pulsatiles Assistance

36 Les objectifs en attente de transplantation en attente de récupération implantation définitive Assistance

37 Deux situations Insuffisance cardiaque (aiguë / chronique) Défaillance bi-ventriculaire Défaillance multi-viscérale BiVAD Défaillance VG isolée / dominante LVAD Assistance Simplicité Versatilité Pulsatilité Disponibilité Durabilité Autonomie

38 THORATEC® L-VAD / Bi-VADPara- / Intra-corporel Assistance

39 THORATEC® Console Fixe / Portable Assistance

40 IMPLANTATION TECHNIQUE

41 Novacor®Heartmate XVE® SYSTEMES ELECTRIQUES IMPLANTABLES / PULSES Assistance

42 SYSTEMES ELECTRIQUES IMPLANTABLES / PULSES LVAD n = 280 Controls n = 48 HEARTMATE VE MULTICENTRIC TRIAL Frazier, J Thorac Cardiovasc Surg, 2001 REMATCH TRIAL Park, J Thorac Cardiovasc Surg, 2005 LVAD n = 68 OMM n = 61 p = Assistance

43 TURBO - POMPES CLASSIFICATION POMPES AXIALES écoulement axial POMPES CENTRIFUGES écoulement radial Assistance

44 TURBO - POMPES POMPES AXIALES INCOR ®

45 TURBO-POMPES AVANTAGES THEORIQUES peu volumineuses peu déléments mobiles pas de valves meilleur rendement énergétique pas de bruit MAIS … DEBIT NON PULSE ? Assistance

46 TURBO-POMPE = NON-PULSEE ? Jarvik 2000 Frazier, Circulation, 2002 INCOR LVAD Doppler art. fém. com. gche 22 mois dimplantation, 7500 t/min Assistance

47

48 CONCLUSION Stevenson, Circulation;2003: Assistance Circulatoire Mécanique


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