Surgery for End Stage Heart Failure

The outcome for end stage heart failure is very poor, with a markedly decreased quality of life and a limited life expectancy. Clinical improvement and improved life expectancy noted with use of ACE inhibitors, Beta blockers, and spironolactone , but in the absence of alternative strategies, annual death rates exceed 12%/year.

Variety of surgical procedures can be utilized to treat patients with end stage heart failure, depending on the cause of their disease:

Coronary artery bypass surgery should be performed in patients with ischemic myocardium (heart muscle). This can improve anginal symptoms and in many cases improve ventricular function, lower the risk of sudden cardiac death, and improve life expectancy or survival.

Mitral valve repair  with small synthetic rings can be offered to patients with severe mitral incompetence to help in restoring the normal shape of the left ventricle and relieve symptoms of congestive heart failure.

Cardiac resynchronization therapy (using a heart pacemaker with special adjustment to synchronize the beating of the atria and both ventricles) has been demonstrated to improve heart failure symptoms and exercise tolerance, and may reduce mitral incompetence.

Procedures that reduce the size of the left ventricle or limit its expansion may reduce tension on the ventricular wall with the expectation that relief of congestive heart failure symptoms will result. One of these Left ventricle reconstructive procedures is the DOR operation which can be used for patients with areas of non functioning heart muscle secondary to myocardial infarction (heart attack). In this operation the scared heart tissue is excised and the mycocardium is revascularized with bypass grafts. The mitral valve can be repaired or replaced also. These procedures can be performed with moderately low risk, producing symptomatic improvement and an increase in long-term survival.

The Batista operation or left ventriculectomy was popularized in the late 1990s but has since been abandoned. In this procedure, some of the heart muscle in these “flabby” hearts is removed, resulting in significant improvement in cardiac function in some patients. However, long-term follow-up is limited, and the results are unpredictable. Some patients had excellent results for years, whereas in others, treatment failed, and their weakened hearts required heart transplantation. However, it conceptually brought to light the concept of improving ventricular contractile efficiency by reducing ventricular volume.

Techniques and devices that prevent ventricular dilatation, such as a cardiomyoplasty are being investigated as means of improving symptoms of heart failure. Cardiomyoplasty involves freeing up a back muscle called the latissimus dorsi. The main blood supply and nerve supply are left intact. The muscle is then placed inside the chest and wrapped around the heart, where it is stimulated with a pacemaker for several weeks to make it more fatigue resistant. After this period, the muscle is stimulated with a special type of pacemaker so it contracts in synchrony with the heart in hopes of helping the function of the patient’s own failing heart muscle.

When the patient has advanced heart failure and is not a candidate for any of   the above procedures, cardiac transplantation  should be considered. Insertion of a left ventricular assist device (LVAD) should be considered when a patient develops progressive deterioration despite use of maximal medical therapy and an intra aortic balloon pump. This can provide adequate bridging to transplantation.

A left ventricular assist device  may be used as destination (Final) therapy when a patient is not considered to be a transplantation candidate. In this case a device is operated with a battery that is usually supplied in the form of a jacket.

Muscle and stem cell transplantation  into areas of scared myocardium are being under investigation as a means of improving ventricular function.