Surgical treatments for heart failure

Reverse ventricular remodeling: mechanical options

PURPOSE OF REVIEW

The aim of this review is to update the cardiovascular clinician on the current status of surgical therapies aimed at achieving reverse ventricular remodeling.

RECENT FINDINGS

Relevant research focusing on mechanical options for reverse ventricular remodeling will be referenced and summarized.

SUMMARY

Heart failure is a tremendous burden on society in terms of both lives lost and healthcare costs. Knowledge of both medical and surgical therapies aimed at improving ventricular efficiency and reversing ventricular remodeling should be in the armamentarium of clinicians treating heart failure patients.

Nontransplant surgical alternatives for heart failure

Heart failure is a tremendous burden on society, and on the health care system in particular. Historically, medical treatments have been the only therapies available because patients were felt to be too high risk to undergo conventional cardiac surgical procedures. Cardiac transplantation remains an established therapy for certain patients with end-stage heart failure but it is limited by donor availability and the need for lifelong immunosuppression. Recent advances in myocardial protection, operative techniques, and perioperative care have made it possible for conventional surgery, such as coronary bypass, ventricular reconstruction, and valve repair, to be offered to many patients with advanced heart failure with good short- and long-term results. In 2005, few patients are inoperable.

Revascularization and ventricular restoration in patients with ischemic heart failure: the STICH trial

PURPOSE OF REVIEW

As techniques for the management of patients with ischemic heart failure have evolved, controversy has arisen with respect to the roles of revascularization and ventricular restoration procedures. This review addresses current thinking on the management of these patients and describes a prospective randomized trial that will have an impact on future treatment selection.

RECENT FINDINGS

Although the basis for improved survival with coronary artery bypass grafting lies in the viability of ischemic myocardium, nuclear medicine studies and stress echocardiography have failed to adequately select for tissues that are capable of recovery. Recent studies have suggested an additional benefit to combining ventricular restoration with bypass surgery. However, the role for these techniques has not been definitively established.

SUMMARY

The currently enrolling Surgical Treatment for Ischemic Heart Failure (STICH) trial promises to address these issues and thereby improve the management of patients with this disease.

Left Ventricular Assist Devices as Destination Therapy

Although an estimated 16,500 Americans annually could benefit from a heart transplant, in 1999 only 2184 heart transplants were performed in the United States. These statistics emphasize the severity of the shortage of available hearts for transplantation. Circulatory support provided by an implantable Left Ventricular Assist Device (LVAD) that meets Food and Drug Administration approval as destination therapy is a promising alternative that impacts patient survival. As medical technology creates smaller implantable battery-powered circulatory assist devices that allow patients to safely live independently in the community, nursing's role must change in response. Long-term LVAD patients require strategic, anticipatory planning for extended care and emergency preparedness for mechanical support. Therefore, practitioners must familiarize themselves with these devices as they care for larger numbers of patients with implanted LVADs who require assessment and treatment of noncardiac problems during their lengthened lifespan.

New surgical therapies for heart failure

A growing number of patients present with heart failure. Some of them may qualify for surgical correction of their cardiac condition. Since heart transplantation will always be available to only a small number of patients, several new surgical techniques have been developed for approval in heart failure patients. Classic interventions such as revascularization, valve repair, or valve replacement have been improved and modified to meet the need of heart failure patients. Several of these techniques are currently under investigation in large clinical trials. These trials will definitely have an impact on the development of surgical treatment of patients with heart failure.

Evolving strategies for surgical management of patients with severe left ventricular dysfunction

As a result of an increasing population with advanced congestive heart failure and the lack of growth in cardiac transplantation, surgical treatments for heart failure have been re-examined. These therapies represent the evolution of well-known operations such as coronary bypass surgery and valve surgeries, and the more novel left ventricular reconstruction and operations aimed at inhibiting left ventricular remodeling. When performed by surgeons with experience in this evolving speciality within cardiovascular surgery, surgery for advanced heart failure is a treatment of choice for many patients.