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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
Inspection
contractility
cardiac disease / injury
Palpation
ascending aorta
coronary 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 CEC
1) Sang
dégradation mécanique des éléments figurés du sang
troubles de l’hémostase (saignement)
SIRS
immuno-dépression
2) Cerveau
embolies (cruorique, calcaire, air)
hypo-perfusion
3) Poumons
mécanique
surcharge hydrique
SDRA
4) Reins
Donor Heart Implantation
Standard
Donor Heart Implantation
Bicaval 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
Remodelage
Henri Mondor
Left Ventricular Remodeling
Alterations in Myocyte Biology
excitation contraction coupling
myosin heavy chain gene expression
ß-adrenergic desensitization
hypertrophy
myocytolysis
cytosquelettal proteins
Myocardial Changes
myocyte loss (necrosis, apoptosis)
extracellular matrix (degradation, fibrosis)
Alterations in LV Chamber Geometry
LV dilation
LV wall thinning
Increased LV sphericity
Mann, Circulation, 1999
Remodelage
Henri Mondor
Left Ventricular Wall Stress
Laplace Law
Wall Stress =
Sub - endocardial
hypoperfusion
Pressure x Radius
2 (Wall thickness)
Expression of
stress activated genes
Remodelage
Henri Mondor
Consequences on Mitral Valve
 displacement of papillary muscles
 leaflet tethering and mitral valve tenting
 annular dilatation
Remodelage
Henri Mondor
Functional Mitral Valve Incompetence
1986 - 1988
LVEF < 40%
LVED Ø > 60 mm
Blondheim
Am Heart J
1991
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 Plasty
Dor Procedure
Left Ventricular Restoration
Henri Mondor
RESTORE Group
12 centers
1998 - 2003
n = 1198
EF (%)
LVESVI
Pre-op Post-op
29
39
80
57
(mL/m2)
Athanasuleas, JACC, 2004
Hosp † 5.3 %
Feedom from rehosp for CHF
78 % at 5 years
Left Ventricular Restoration
Henri Mondor
Partial Left Ventriculectomy
Batista Procedure
Left Ventricular Restoration
Henri Mondor
Cleveland Prospective Trial
May 1996 - Dec 1998
62 transplant candidates
Idiopathic dilated cardiomyopathy
NYHA III or IV
LVEDD > 70 mm
Pre-op Post-op
EF (%)
16
31.5
LVEDD (cm) 8.4
5.9
Franco-Cereceda, JTCS, 2001
1 mth 99 %
1 year 80 %
3 years 60%
1 mth 80 %
1 year 49 %
3 years 26 %
Left Ventricular Restoration
Henri Mondor
Over-corrective Annuloplasty
Left Ventricular Restoration
Henri Mondor
Mitral Valve Repair in Heart Failure
June 1993 - Jan1999
92 patients
NYHA III or IV, LVEF < 25%
5%
Operative †
1 year survival 80%
2 years survival 70%
Pre-op
Echo Parameter
EF (%)
16
LVEDV (mL)
281
Qc (l/min)
3.1
Sphericity (D/L)
0.82
Functional
NYHA
3.2
VO2 max (mL/Kg/min)14.5
Smolens, Eur J Heart Fail, 2000
Post-op
26
206
5.2
0.74
1.8
18.6
Left Ventricular Restoration
Henri Mondor
Mitral Valve Repair in Heart Failure
1993 – 2002
682 pts with LV dysfunction and MR
419 surgical candidates
126 MVA, 293 non-MVA
All pts
Wu, JACC, 2005
NI-DCM only
Left Ventricular Restoration
Henri Mondor
Papillary Muscle Sling
Hvass, Ann Thorac Surg, 2003
Left Ventricular Restoration
Henri Mondor
Percutaneous Mitral Procedures
Left Ventricular Restoration
Henri Mondor
Evolving Technologies : CorCap CSD
COMPLIANCE
longitudinal > circumferential
Left Ventricular Restoration
Henri Mondor
Evolving Technologies : CorCap CSD
Clinical safety study
Assistance
Assistance circulatoire
Pulsatiles
 Para-Corporeal Pneumatic VAD
Non Pulsatiles
 Axial
 Implantable Electro-Mechanical VAD
 Centrifugal
 TAH
Assistance
Les objectifs
 en attente de transplantation
 en attente de récupération
 implantation définitive
Assistance
Deux situations
Insuffisance cardiaque
(aiguë / chronique)
Défaillance bi-ventriculaire
Défaillance multi-viscérale
Défaillance VG
isolée / dominante
BiVAD
LVAD
 Simplicité
 Versatilité
 Pulsatilité
 Disponibilité
 Durabilité
 Autonomie
Assistance
THORATEC®
L-VAD / Bi-VAD
Para- / Intra-corporel
Assistance
THORATEC®
Console Fixe / Portable
IMPLANTATION TECHNIQUE
Assistance
SYSTEMES ELECTRIQUES
IMPLANTABLES / PULSES
Novacor®
Heartmate XVE®
Assistance
SYSTEMES ELECTRIQUES
IMPLANTABLES / PULSES
HEARTMATE VE
MULTICENTRIC TRIAL
REMATCH TRIAL
LVAD n = 68
OMM n = 61
p = 0.0077
LVAD n = 280
Controls n = 48
Frazier, J Thorac Cardiovasc Surg, 2001
Park, J Thorac Cardiovasc Surg, 2005
Assistance
TURBO - POMPES
CLASSIFICATION
POMPES AXIALES
écoulement
axial
POMPES CENTRIFUGES
écoulement
radial
TURBO - POMPES
POMPES AXIALES INCOR®
Assistance
TURBO-POMPES
AVANTAGES 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 LVAD
Doppler art. fém. com. gche
22 mois d’implantation, 7500 t/min
Assistance
Assistance Circulatoire Mécanique
CONCLUSION
Stevenson, Circulation;2003:3059-63