Dilated cardiomyopathy surgery

Jump to navigation Jump to search

Dilated cardiomyopathy Microchapters

Home

Patient Information

Overview

Historical Perspective

Pathophysiology

Classification

Causes

Differentiating Dilated cardiomyopathy from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Dilated cardiomyopathy surgery On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Dilated cardiomyopathy surgery

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Dilated cardiomyopathy surgery

CDC on Dilated cardiomyopathy surgery

Dilated cardiomyopathy surgery in the news

Blogs on Dilated cardiomyopathy surgery

Directions to Hospitals Treating Dilated cardiomyopathy

Risk calculators and risk factors for Dilated cardiomyopathy surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Sachin Shah, M.D.

Overview

Surgery and Device Based Therapy

Implantable cardiac defibrillators in dilated cardiomyopathy

Implantable cardiac defibrillators (ICDs) have also been extensively studied in systolic heart failure. A survival benefit has also been shown in select patient populations. ICDs are implanted in patients with systolic heart failure for primary prevention of sudden cardiac death. The AHA/ACC (American Heart Association/American College of Cardiology) class I indications for ICDs for primary prevention are: 1. EF < 35% due to prior MI, 40 days post MI, NYHA class II or III. 2. EF < 35% NYHA class II or III non ischemic dilated cardiomyopathy. 3. EF < 30%, prior MI, 40 days post MI, NYHA I. 4. EF < 40%, prior MI, NSVT and inducible VT/VF at EP study.

There are four major studies that have helped shape these indication for an ICD. The MADIT I evaluated NYHA class I to III heart failure patients with an EF < or = to 35%, with NSVT and inducible VT or VF on EP study and randomized 196 patients to ICD versus conventional medical therapy. The patients who received ICDs had improved survival at 5 years. 60% of patients received shocks by 2 years.[1] The findings from this study are encompassed in the remaining three studies.

Madit II randomized 1232 patients who had a prior MI > 1 month prior to enrollment, an EF < or = to 30% to ICD or medical therapy and after a follow up of an average of 20 months there was a survival advantage in the ICD group. The number needed to treat was 18 patients. [2]

MUSTT randomized 704 patients with an EF < or = to 40%, NSVT and inducible VT/VF at EP study to arrhythmia therapy (medications and ICDs) or no antiarrhythmia. At 5 years there was a 27 risk reduction in mortality in the antiarrhythmia group. The relative risk of mortality when comparing ICD vs. no ICD was 0.24. There was no difference in mortality in the antiarrhythmic medication vs. no antiarrthymic medication subgroups.[3]

SCD-HeFT randomized 2521 patients with class II or III CHF and EF < or = to 35% (ischemic or non ischemic) to three arms: 1. conventional therapy, 2. conventional therapy plus amiodarone, and 3. conventional therapy plus an ICD. After a median follow up of 46 months there was a relative risk of death of 0.77 in the ICD arm. Findings were similar in the ischemic and non-ischemic subgroups.[4]

NYHA class IV heart failure is a contraindication to ICD placement.

Indications for Surgery

In patients who have severe heart failure and are refractory to medical therapy cardiac transplantation may be an option (based upon patient characteristics such as age and comorbidities as well as disease characterisitics such as the etiology of dilated cardiomyopathy). As a bridge to cardiac transplantation multiple mechanical devices have been used. The most durable device is the LVAD (left ventricular assist device), certain patient populations not suitable for cardiac transplantation may also undergo LVAD placement by a cardiac surgeon as a "destination LVAD." This may be considered a palliative measure for end-stage heart failure patients. Other devices which may be more limited in the duration of use include the aortic balloon pump, Impella, and the PVAD (peripheral ventricular assist device) one of which is the Tandem Heart.

References

  1. N Engl J Med. 1996. Dec 355(26)
  2. N Engl J Med. 2002. Mar 346(12)
  3. N Engl J Med. 1999 Dec 341:1882-1890.
  4. N Engl J Med. 2005. Jan 352(3).