Surgical therapy for heart failure

Today's healthcare delivery system is challenged with an escalating number of heart failure patients who have exhausted medical therapy and overwhelmed the limits of organ transplantation. Scientific and technological advances over the last 20 years have now brought new surgical options to this vast patient population, ranging from ventricular restoration surgery to surgical gene therapy and beyond. This article reviews the myriad of surgical options that are available to these patients, their benefits and shortcomings, as well as potential future directions.

Determinants of long-term mortality of current palliative surgical treatment for dilated cardiomyopathy

OBJECTIVE

Dynamic cardiomyoplasty and partial left ventriculectomy have shown limited and controversial results in the treatment of dilated cardiomyopathies. This study investigates causes and determinants of long-term mortality after these procedures.

METHODS

Forty-three patients submitted to dynamic cardiomyoplasty and 43 who underwent partial ventriculectomy were studied. Patients were in New York Heart Association (NYHA) class III or IV before the procedures. In dynamic cardiomyoplasty group, hospital mortality was 2.2% and patients were followed for 48+/-31 months. Nine hospital deaths occurred after partial ventriculectomy and the remaining patients were followed for 38+/-29 months.

RESULTS

For patients submitted to dynamic cardiomyoplasty, 1-year event-free survival was 81.3+/-5.9%; 2-year, 65.1+/-7.2%; and 6-year, 23.1+/-6.7%. Partial left ventriculectomy patients presented event-free survival rates of 58.1+/-7.5%, 46.6+/-7.6% and 21.6+/-6.4% at the same periods, respectively. Late deaths were equally related to heart failure progression and arrhythmia events in both groups. Preoperative NYHA class IV, pulmonary hypertension and absence of left ventricular (LV) function improvement at the time of the final event were identified as independent predictors of poor long-term event-free survival and heart failure progression in cardiomyoplasty patients, while NYHA class IV, elevated serum nor-epinephrine and absence of LV function improvement were associated with these events after partial left ventriculectomy. Arrhythmia related deaths were only predicted by previous events of sustained ventricular tachycardia in partial left ventriculectomy group.

CONCLUSIONS

Long-term results of dynamic cardiomyoplasty and partial left ventriculectomy are limited by patients' preoperative condition, by the loss of LV function benefits and by high incidence of sudden cardiac death. Palliative surgical treatment of dilated cardiomyopathies needs to be indicated earlier and may achieve better efficiency with the combination of different procedures to provide sustained improvement of LV function, to interrupt the progressive remodeling process and to prevent sudden cardiac death.

Left ventricular aneurysmectomy: endoventricular circular patch plasty or septoexclusion

BACKGROUND

Septoexclusion is a technique described by Guilmet in the mid 1980s. Its indications and midterm results are evaluated and compared to those obtained with the Dor operation.

METHODS

From January 1998 to April 2001, 79 patients had an exclusion of scars following myocardial infarction in left anterior descending artery (LAD) territory. Fifty of them (63.3%) had the Dor operation (Group D) and 29 (36.7%) the Guilmet operation (Group G). Dor technique was used when the involvement of the septum and the free wall was roughly similar. Guilmet technique was indicated when the septum was involved at a greater extent than the free wall. Ejection fraction (EF) was lower and end-diastolic volumes were higher in Group G. Incidence of functional mitral regurgitation was similar in both groups.

RESULTS

Thirty-day mortality was 7.6% (8.0% in Group D versus 6.9% in Group G, p = ns). After a mean of 21.0 +/- 8.5 months, five patients (6.9%) died, two in Group D and three in Group G. Causes of death were cardiac related in four and not cardiac related in one. Mean follow-up of the 68 survivors was 24.3 +/- 12.0 months (range: 4-38 months). Fifty patients (73.5% of the survivors) improved (28 in Group D and 22 in Group G, p = 0.026), whereas in 18, New York Heart Association (NYHA) class remained unchanged or worsened. Both groups showed an increase of EF and a volumetric reduction, whereas stroke volume remained unchanged. Fewer patients had mitral regurgitation than in the preoperative period (41.3% versus 65.8%, p = 0.013) and at a lesser extent (1.7 +/- 0.7 versus 0.7 +/- 0.6, p < 0.001).

CONCLUSIONS

Our results show that both Dor and Guilmet techniques are effective in the surgical treatment of left ventricular dyskinetic or akinetic areas related to LAD territory. Each technique has its own indications and has to be addressed to patients with different extension of septal scars.

Cardiomyoplasty: ventricular reconstruction after tumor resection

OBJECTIVE

Although cardiac transplantation has been performed for complete removal of ventricular tumors, complete surgical resection with ventricular reconstruction is desirable. Thus patients with benign tumors would probably be cured, and those with malignant tumors would have a better prognosis. In this study extensive and complete surgical resection of ventricular tumors is followed by anatomic and functional ventricular reconstruction with a dynamic cardiomyoplasty procedure.

METHODS

Seven patients (mean age, 32.7 years) underwent complete resection of ventricular tumors. Histologic types were distributed as follows: fibroma in 2 patients and sarcoma, lymphosarcoma, hemangioma, lipoma, and metastatic angiosarcoma, respectively, in the remaining 5 patients. Six of the patients were considered candidates for heart transplantation because of the extent of tumor invasion. Surgery consisted of 4 steps: (1) tumor resection; (2) coronary artery resection (when invaded by the tumor) and coronary artery bypass grafting; (3) valvular reconstruction (when possible) or replacement; and (4) ventricular wall reconstruction with a pericardial patch for closure of the ventricular defect (neoendocardium) covered by the electrostimulated latissimus dorsi muscle flap (neomyocardium).

RESULTS

All patients survived surgical intervention, but 2 late postoperative deaths are reported. Among the surviving patients, early complications played a major role in their postoperative course and consisted of arrhythmias, atrioventricular block necessitating a dual-chamber pulse generator, respiratory insufficiency, and heart failure. Two patients were assisted postoperatively with an intra-aortic balloon pump. On postoperative follow-up (mean, 72.4 +/- 8.5 months), an improvement in the patients' functional status was observed. Patients moved from a mean New York Heart Association functional class of 2.8 to a mean functional class of 1.2.

CONCLUSIONS

The excellent long-term evolution without recurrence, ventricular dysfunction, and/or thromboembolic complications implies that cardiomyoplasty could be recommended as an alternative to heart transplantation for the therapy of large ventricular tumors.

[Dynamic cardiomyoplasty: evaluation of an alternative procedure in the treatment of terminal heart failure]

Dynamic cardiomyoplasty (DCMP) was developed as an alternative treatment for patients with end-stage heart failure. The first clinical application of this technique was in 1985 by Carpentier und Chachques. Since then, DCMP has been performed in more than 1000 patients world-wide. During the initial experience with DCMP, survival for NYHA class IV patients was clearly shown to be much worse than that for class III patients. By careful patient selection, operative mortality has decrease from 31% in the past to less than 5% today. The vast majority of patients have demonstrated significant improvement in NYHA class and overall quality of life with only minor effects on systolic cardiac function. Clinical work, as well as recent animal work supports the hypothesis that by a combination of long-term elastic constraint and active dynamic assist, DCMP decreases myocardial wall stress. This process results in a "reverse remodeling" of the insufficient heart with an improvement of the "contractility reserve". To prove the effectiveness of DCMP versus medical therapy alone, the C-SMART study started in 1994, as the first and only randomized trial. Unfortunately the study was stopped in 1998 due to slow patient recruitment after enrolling 103 patients. The study showed that, from a symptoms standpoint, patients with DCMP were improved over those who were medically treated. However, there was no significant difference for survival between the two groups after 12 months. The lack of a clear survival advantage and the relatively poor and inconsistent hemodynamic benefit of DCMP have hindered its acceptance to date as a treatment alternative for patients with end-stage heart failure. The ultimate role of DCMP in the treatment of heart failure will depend on the outcome of future developments to improve the contractility and the long-term durability.

Dynamic cardiomyoplasty: expectations and results

BACKGROUND

Cardiac transplantation is an option for only a small minority of patients with severe, chronic congestive heart failure. Transformed skeletal muscle has the potential to provide a durable form of fatigue-resistant muscle power to assist the cardiovascular system.

METHODS

Since the first dynamic cardiomyoplasty performed by Carpentier and colleagues in 1985, the techniques to make this operative procedure an effective assist to the failed myocardium have been refined. Much has been learned about optimum patient selection so that perioperative morbidity and mortality is minimized. The cardiomyostimulator developed by Medtronic has undergone several revisions, primarily so that the stimulation of the muscle wrap is adaptive to variations in cardiac performance, such as those that occur with arrhythmia or during exercise.

RESULTS

A review of the data to date suggest a substantial number of patients who undergo the procedure experience an enhanced quality of life, and an alleviation of their heart failure symptoms. Details of patient selection underscore that cardiomyoplasty is not an alternative to transplant. Seriously compromised patients with low peak oxygen uptake and very low ejection fractions have the highest short term mortality.

CONCLUSIONS

Dynamic cardiomyoplasty remains a promising surgical option for patients with moderately-severe congestive heart failure (i.e. NYHA Class III patients). The ongoing randomized trial comparing cardiomyoplasty to standard medical therapy is expected to provide more detailed information about the benefits of this procedure.

Surgical approaches to arresting or reversing chronic remodeling of the failing heart

Chronic ventricular remodeling is a central feature of heart failure that strongly correlates with a poor prognosis. Several recent surgical treatments for heart failure may derive benefit by their ability to arrest or substantially reverse this remodeling process. Dynamic cardiomyoplasty involves wrapping the heart with the latissimus dorsi muscle and stimulating the muscle to assist contraction. The wrap itself may provide a constraint helping to limit progressive cardiac dilation and/or assist in reversing this process. Left ventricular assist devices almost completely unload the heart and augment systemic circulation, thereby reducing neurohumoral activation. These combined effects seem to alter the chamber and cellular phenotype, and reversal of some molecular changes are associated with failure. Lastly, the partial ventriculectomy procedure directly reverses remodeling by acute removal of a portion of the lateral wall. Only preliminary nonrandomized trial data are currently available for each of these therapies with larger trials under way. However, early results are intriguing and are yielding insights into these mechanisms.

Dynamic cardiomyoplasty: clinical follow-up at 12 years

OBJECTIVE

The purpose of this study is to evaluate the long-term outcome of dynamic cardiomyoplasty. This surgical technique was conceived to assist the failing heart. The many proposed mechanisms of action of cardiomyoplasty are: (1) systolic assist; (2) limitation of ventricular dilation; (3) reduction of ventricular wall stress (sparing effect); (4) ventricular remodeling with an active girdling effect; (5) angiogenesis; and (6) a neurohumoral effect.

METHODS

We investigated 95 patients in our hospital undergoing this procedure due to severe chronic heart failure, refractory to optimal medical treatment. Patients had a mean age of 51 +/- 12 years. The etiology of heart failure was ischemic 55%, idiopathic 34%, ventricular tumor 6%, and other 5%. The mean follow-up was 44 months.

RESULTS

The mean New York Heart Association (NYHA) functional class improved postoperatively from 3.2 to 1.8. Average radioisotopic left ventricular (LV) ejection fraction increased from 17 +/- 5 to 27 +/- 4% (P < 0.05). Stroke volume index increased from 32 +/- 7 to 43 +/- 8 ml/beat per m2 (P < 0.05). The heart size remained stable over the long term. Following cardiomyoplasty, the number of hospitalizations due to congestive heart failure was reduced to 0.4 hospitalizations/patient per year (preoperative: 2.5, P < 0.05). Computed tomography scans showed at long term a preserved latissimus dorsi muscle structure in 84% of patients. Survival probability at 7 years is 54%. Six patients underwent heart transplant after cardiomyoplasty (mean delay: 25 months), due to the natural evolution of their underlying heart disease. There were no specific technical difficulties.

CONCLUSIONS

Clinically, this procedure reverses heart failure, improves functional class and ameliorates quality of life. The latissimus dorsi muscle histological structure is maintained at long-term, when postoperative electrostimulation is performed, avoiding excessive stimulation. Cardiomyoplasty may delay or prevent the progression of heart failure and the indication of cardiac transplantation.

Retrospective risk analysis for early heart-related death after cardiomyoplasty. The Worldwide Cardiomyoplasty Group

BACKGROUND

Dynamic cardiomyoplasty is an evolving treatment for heart failure that uses an electrically stimulated latissimus dorsi muscle wrapped around the heart to improve cardiac function. Preoperative patient characteristics and deaths after cardiomyoplasty have been recorded during the past 5 years in a cumulative database representing worldwide experience of 42 medical centers.

METHODS

Statistical models of hazards (monthly death rates) were used to identify risk factors for transiently increased risk of cardiovascular mortality within 2 months after cardiomyoplasty.

RESULTS

Actuarial survival (n = 261) was 88%, 80%, and 76% at 1, 3, and 6 months after cardiomyoplasty, respectively. The peak hazard of 6% dying per month occurred during the first month after the surgical procedure. Lower ejection fraction, increased number of major coronary arteries with > or = 70% stenotic lesions, and lower chronotropic responses during exercise were independent risk factors for the transient increase in early cardiovascular mortality. Early risk of cardiovascular mortality was significantly reduced as centers gained experience with more than 3 patients.

CONCLUSION

Early survival after cardiomyoplasty has improved with experience and might be reduced further by preoperative assessments that identify patients at highest risk.

Pericardium-lined skeletal muscle ventricles: up to two years' in-circulation experience

BACKGROUND

Skeletal muscle ventricles (SMVs) are autologous pumping chambers constructed from skeletal muscle. Skeletal muscle ventricular rupture and thromboembolism have complicated chronic models of this method of skeletal muscle cardiac assist.

METHODS

The SMVs were constructed from the latissimus dorsi muscle in 10 dogs. The inner surface of each SMV was lined with autologous pericardium harvested at the time of SMV construction. After a 3-week period of vascular delay and 6 weeks of electrical conditioning to convert the muscle to a fatigue-resistant state, SMVs were connected to the descending thoracic aorta and stimulated to contract during cardiac diastole.

RESULTS

Initial hemodynamics revealed that SMV contraction at 33 Hz increased diastolic pressure 24.7% (60.8 +/- 7.3 mm Hg versus 80.3 +/- 8.8 mm Hg). Skeletal muscle ventricle relaxation decreased presystolic pressure 14.4% (59.9 +/- 7.7 mm Hg versus 51.3 +/- 7.5 mm Hg) and decreased peak systolic pressure 4.1% (90.2 +/- 7.3 mm Hg versus 86.5 +/- 5.8 mm Hg). Hemodynamics were assessed at 1 to 2 weeks, then at 1, 2, 3, and 6 months, and at 6-month intervals thereafter. Hemodynamic performance remained stable for the duration of this study. After 2 years of pumping continuously in circulation, SMV contraction resulted in a 34.8% augmentation of diastolic pressure (63.6 +/- 6.6 mm Hg versus 85.3 +/- 6.4 mm Hg), a 17.2% decrease in presystolic pressure (54.7 +/- 3.73 mm Hg versus 45.3 +/- 4.1 mm Hg), and a 4.2% decrease in peak systolic pressure (95.3 +/- 10.4 mm Hg versus 91.3 +/- 12.3 mm Hg). Three dogs survived to 2 years with the SMVs in circulation. No animal showed evidence of thromboembolism during serial echocardiography or at autopsy and no SMVs ruptured.

CONCLUSIONS

These data demonstrate that SMVs can provide effective hemodynamic assist over an extended period without specific complications related to the SMVs.

Long-term outcome, survival analysis, and risk stratification of dynamic cardiomyoplasty

METHODS

To analyze the long-term outcome of dynamic cardiomyoplasty, we retrospectively studied 127 consecutive patients who underwent this procedure in Paris, France (n = 76), São Paulo, Brazil (n = 37), and Portland, Oregon (n = 14). Preoperative data were collected for patients operated on between January 1985 and June 1994 and examined with respect to effect on long-term survival. Patients had a mean age of 50 +/- 13 years and were predominantly male (82%). In 46% the cause of disease was ischemic. Concomitant operations were performed in 22 patients.

RESULTS

Operative mortality was 12% (15/127). Kaplan-Meier survival +/- standard error at 1 through 5 years was 73% +/- 4%, 57% +/- 5%, 49% +/- 6%, 44% +/- 6%, and 40% +/- 7%, respectively. There was a distinct improvement at 6 months in New York Heart Association functional class (3.2 +/- 0.05 vs 1.7 +/- 0.07, p < 0.0001) and a small but significant increase in left ventricular ejection fraction (20% +/- 0.8% vs 23% +/- 1.5%, p = 0.04). Ninety-day mortality was associated with low right ventricular ejection fraction, a blunted hemodynamic response to exercise testing, and requirement for an intraaortic balloon pump at the time of the operation. Using a stepwise Cox regression method of multivariable survival analysis (n = 101), we determined that atrial fibrillation, New York Heart Association class IV, high pulmonary capillary wedge pressure, and balloon pump use were independent variables simultaneously associated with poor overall survival. When metabolic testing variables were added to this model, peak oxygen consumption eliminated both pulmonary capillary wedge pressure and functional class from the model, albeit with fewer (n = 74) patients.

CONCLUSION

Dynamic cardiomyoplasty is an evolving therapy for symptomatic congestive heart failure, the results of which may be enhanced by intelligent, risk-sensitive patient selection.

[Dynamic cardiomyoplasty: models of action and indications]

Cardiomyoplasty, proposed as an alternative to cardiac transplantation for the first time in 1985, has been carried out in over 500 patients over the world. The functional improvement after the procedure may be spectacular. The haemodynamic improvement at rest is generally small in terms of pre and postoperative ejection fractions. A dynamic effect of systolic assistance due to stimulation of the latissimus dorsi may be demonstrated in some cases by analysis of ventricular pressure-volume curves. However, it is probable that cardiomyoplasty prevents ventricular remodelling (girdling effect) and that chronic stimulation of latissimus dorsi, necessary to prevent atrophy and fibrosis, reduces wall stress. Therefore, many mechanisms, probably associated, may explain the clinical efficacy of cardiomyoplasty. Though the contraindications of this technique are now better known, its role with respect to cardiac transplantation in cases of severe congestive cardiac failure resistant to medical therapy still remain undefined.

Dynamic cardiomyoplasty in the treatment of dilated cardiomyopathy: current results and perspectives

BACKGROUND

The purpose of this article is to provide an overview of the current indications, results, and perspectives of dynamic cardiomyoplasty in the treatment of patients with dilated cardiomyopathy. Particular emphasis is placed on the clinical experience with 36 patients operated at the São Paulo Heart Institute between 1988 and 1995.

METHODS

Based on several clinical reports, the mechanisms of action of dynamic cardiomyoplasty in these patients include the enhancement of left ventricular systolic function, by the direct action of synchronized skeletal muscle flap contraction and the reversion of chamber remodeling. Moreover, both mechanisms seem to be responsible for improved diastolic function properties and for the decrease of ventricular wall stress. Besides the acceptable hospital mortality observed for patients with dilated cardiomyopathy ranging from 0% to 8% with this surgical procedure, clinical improvement after dynamic cardiomyoplasty has been demonstrated as a prevailing and significant outcome.

RESULTS

Nevertheless, the 1-year survival for these patients ranges from 82% to 86% and the 5-year survival on the order of 41% to 49%. In addition, the analysis of factors influencing the outcome showed that cardiomyoplasty long-term survival was significantly affected by the severity of preoperative clinical compromise and cardiac function impairment. On the other hand, patients with dilated cardiomyopathy who were operated in functional Class III or intermittent Class IV and with pulmonary vascular resistance below 4 Wood units, present survival rates on the order of 79% at 2 years and of 64% at 5 years of follow-up, which are similar to those reported after cardiac transplantation.

CONCLUSIONS

Furthermore, technological advances incorporated in the new cardiomyostimulators may ameliorate skeletal muscle flap performance at long term. Other developments are also discussed in this field.

Cardiomyoplasty--the beginning of a new era

Cardiomyoplasty is a surgical treatment for a well-defined group of patients who suffer from congestive heart failure. The procedure is not a contraindication to perform a future heart transplantation, when indicated. The clinical results up to 7 years after cardiomyoplasty are encouraging, but there is still a gap between the significant functional capacity improvement of the patients after cardiomyoplasty and the moderate hemodynamic change. Experimental data and recent measurements in patients provide new insights in understanding the physiologic effect of cardiomyoplasty.

Lessons learned before and after cardiomyoplasty: risk sensitive patient selection and post procedure quality of life

BACKGROUND

This paper unveils some of the clinical lessons we have learned from caring for cardiomyoplasty patients over the past 7 years. We examine both the clinical and scientific rationale for expanding the time frame of "procedural mortality" from 30 days to 90 days.

METHODS

Utilizing this definition of procedural mortality, preoperative patient variables were applied to postoperative patient outcomes in order to develop a risk sensitive method of patient selection. Preoperative atrial fibrillation, elevated pulmonary capillary wedge pressure, decreased peak oxygen consumption, and the requirement of intra-aortic balloon pump at the time of cardiomyoplasty, were all found to be independent risk factors for early death following cardiomyoplasty.

RESULTS

This analysis, which has been previously published, is reviewed and enhanced with the mathematical equations for duplicating these relative risk calculations. The mathematical model presented herein allows a method of risk stratification, which obviates the need for randomized congestive heart failure controls in the future. In the absence of a statistically regulated control population, we also examine the 1-year clinical outcomes of the nonrandomizd control group of patients, who were followed during the North American FDA Phase II Cardiomyoplasty Trial.

CONCLUSIONS

This quality of life comparison with cardiomyoplasty patients at 1 year revealed a significant decrease in intensive care unit patient-days, a significant increase in activity of daily living score, and a significant improvement in New York Heart Association functional class as compared to control.

Dynamic cardiomyoplasty in South America

BACKGROUND

Dynamic cardiomyoplasty has been proposed in the treatment of severe cardiomyopathies. However, few reports to date have shown significant numbers of patients collected on a multicenter basis.

METHODS

From July 1987 to June 1994, dynamic cardiomyoplasty was performed in 112 patients in South America. The indications were dilated cardiomyopathy in 96 patients, Chagas' disease cardiomyopathy in 13, and ischemic cardiomyopathy in 3. Left latissimus dorsi muscle was used in all patients.

RESULTS

The thirty-day mortality rate was 8.1%, and patients were followed up for 22.1 +/- 18.6 months. Data of surviving patients show that 47.3% were in New York Heart Association functional class I, 45.6% in class II, and 7% in class III or IV 1 year after the operation. The 1-year survival was 78.4%; 2-year, 59.7%; and 5-year, 41.7%. The survival at 1 year was 86.1% for patients with dilated cardiomyopathy and 40% for those with Chagas' disease. At 5 years, these values were 49.8% and 9.5%, respectively. Long-term survival was also significantly affected by preoperative functional class and pulmonary vascular resistance. However, patients operated on in class III or intermittent class IV and without elevated pulmonary vascular resistance had survival rates of 91.5% at 1 year and 76.7% at 5 years of follow-up.

CONCLUSIONS

Cardiomyoplasty improves the functional status of patients with severe cardiomyopathies. Otherwise, long-term survival after this procedure is limited in patients with Chagas' disease and by patients' condition before the operation.

Clinical cardiomyoplasty: review of the ten-year United States experience

BACKGROUND

Clinical trials of dynamic cardiomyoplasty were pioneered at Allegheny General Hospital beginning in September 1985. Data from 9 years of experience with the procedure at this institution and more recent data from newer cardiomyoplasty centers have been analyzed for outcome analysis and future trends.

METHODS

Each patient underwent a cardiomyoplasty procedure using the left or right latissimus dorsi muscle. Thirty-four patients were studied at Allegheny: 5 patients implanted with dual chamber pacemakers as single stimulus myostimulators, 11 patients composing the phase I Food and Drug Administration trial of the Medtronic burst myostimulator, and 18 patients entered in the phase II Medtronic trial. Patients from seven additional centers entered the phase II trial in 1991. Fifty-seven patients completed follow-up studies to 1 year after operation in this trial.

RESULTS

Operative mortality was 5/57 (11%) in the American phase II group and 5/34 (15%) in the Allegheny group (1/18, 6% for Allegheny phase II). Nineteen patients (19/57, 33%) from the combined phase II population died in the first year, and 10/34 (29%) in the Allegheny study. The predominant cause of postdischarge death was arrhythmia (12/19, 63% American; 7/10, 70% Allegheny). In all groups significant improvement was seen in quality of life and functional class. Phase II patients demonstrated significant increases in ejection fraction and stroke work.

CONCLUSIONS

Failure to sustain improvement and arrhythmia-related death are complex challenges for this procedure; however, realistic solutions have been proposed and are under investigation.

Dynamic cardiomyoplasty: indication, surgical technique, and results

The efficacy of dynamic cardiomyoplasty is still controversial. To date more than 400 patients have been operated worldwide. In recent years the indication and the surgical technique have become more uniform, which makes results from different centers eligible for comparison. We performed cardiomyoplasty exclusively in patients with contraindications for heart transplantation, such as chronic and recurrent infections or severe, irreversible sequelae of diabetes. Between August 1990 and October 1994, 8 isolated cardiomyoplasty procedures were performed in patients with cardiomyopathy (EF 14-32%, all in NYHA III). One patient died 2 months after surgery. Reported are the results of 7 patients after a mean follow-up of 41.1 +/- 14.1 months. Considerable symptomatic improvement was found in 6 or 7 patients, 3 of whom went back to work. One patient with severe pulmonary hypertension exhibited no improvement. In the others NYHA class improved by at least one. Echocardiography showed an increase in fractional shortening in all patients. LVEF increased from 21.2 +/- 5.2% to 38.1 +/- 15.9% (n = 7, p < 0.015) at 1 year, to 36.6 +/- 17.6% (n = 6, p < 0.05) at two years, and to 36.4 +/- 18.9% (n = 5, NS) at three years. Pulmonary artery pressure tended to decrease at rest over time. Resting lung function showed no change of vital capacity and FEV1. No significant change in exercise level and maximal O2-consumption during treadmill testing was observed. One patient died 34 months after the operation from sudden death. Our preliminary results show that patients after cardiomyoplasty may exhibit an impressive clinical improvement with less striking changes of objective hemodynamic parameters. This data is in agreement with the results of all other investigators. Some possible mechanisms of action are discussed and a risk profile suggested. According to the current state of experience with cardiomyoplasty, we do not consider this method an alternative to heart transplantation, but reserve it for patients with contraindications for heart transplantation.