教育演講6:心衰竭診療之新進展 

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E6-4
Surgical treatment for heart failure: C-V surgeon’s perspective
Yih-Sharng Chen, MD, PhD
Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan

   Heart failure is a wide spectrum of the disease, ranging from mild to very severe, and the outcome may be poor than the terminal cancer because of the poor short-term result in severe heart failure. The causes of the heart failure may be derived form several factors, including valve, vessels, myocardium. Some of the etiologies are reversible at the beginning and it may progress to terminal stage.
  From the surgical viewpoint, which procedure and decision remains a dilemma in the critical status. New therapeutic concept from in 1-V (vessel) to 2-V (vessel and valve), and even to 3-V (vessel, valve, ventricle) has gradually changed choice of treatment procedure. For the extreme shock (CPR status), the choice of mechanical support is still debating. ECMO seems to be a reasonable device in the CPR status, and VAD was reserved for a more stable condition.
  In the setting of the aortic valve, regurgitation as well as stenosis has a high potential of recoverability. The dilated ventricle due to the aortic valve issue could be recover to near normal size and function unless the ventricle is too enlarged to reversed remodeling. In the setting of mitral valve, the symptom is not obvious, and however once the sign developed with worsening left ventricle function, the effect of mitral repair/replacement becomes controversial. Recent study in the role of mitral procedure in patient with mitral regurgitation and depressed left ventricle function demonstrate that mitral repair did not restore the ventricle function and it may have high incidence of recurrent mitral regurgitation. The outcome of mitral replacement seems to have the similar outcome in the group of mitral repair, but eh recurrent mitral regurgitation is less than in the replacement group. The concept of mitral replacement may be expected to become the main strategy in the chronic mitral regurgitation with poor left function.
  Another important setting is the adult congenital heart disease. The field is sometimes ignored by adult cardiologists. The most common cause is protein losing syndrome after the fontan procedure and the right ventricle dilatation after TOF repair. The latter one is easily corrected, and pulmonary valve implantation with or without RV restoration is the key procedure. Thefailed Fontan circulation is much more difficult to treat. Heart transplantation is the final way to rescue the proble.
  Cardiogenic shock (CS) remains the leading cause of death in patients hospitalized with acute myocardial infarction (AMI), and it is also associated with a poor prognosis. The severity of CS is widely varied despite that the definition of CS is persistent hypotension and tissue hyoperfusion due to cardiac dysfunction in presence of adequate intravascular filling pressure. It can be presented as low output and reversed with low dose of inotropes or high dose of catecholamines. It could be possible supported by IABP to get the adequate perfusion. Furthermore, the aggressive mechanical devices support, such as ECMO or VAD, might be required to maintain the perfusion.
  The SHOCK randomized trial demonstrated that in patients with AMI complicated with CS, early mechanical revascularization reduced 6- and 12- month mortality compared with initial medical stabilization. However, the mortality was still high in spite of the greater improvement from 1995 to 2004. Underlying etiologies should be early identified and treated. Supporting system, including proper catecholamine and timely mechanical support, should be initialized as early as possible to maintain the perfusion and prevent the tissue irreversible damage. It also provides adequate time to reverse the anatomical defect. Which procedure (PCI or surgery) for revascularization in AMI remains an unsolved problem.
  Heart transplantation remains the final solution for the patients surviving the acute failure and developing the chronic failure. There are some options before for heart transplantation and the surgical strategy had been evolving.
  In summary, the improvement of surgical treatment in heart failure still remains further investigation in spite of a lot of improvement in recent year.