Surgical therapy in advanced heart failure

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Abstract

Congestive heart failure (CHF) affects about 1% of adults in the United States and is a contributing factor in >250,000 deaths per year. In an increasingly elderly population, the surgical treatment of CHF made great progress during the past 3 decades, consuming enormous health care resources. Heart transplantation is still the most effective therapy for end-stage heart disease, with the 10-year survival rate after transplantation approaching 50%. Efforts to increase the supply of donor organs have failed to improve the shortage, underscoring the crucial need for alternatives to cardiac allotransplantation. Alternative surgical options to end-stage heart transplantation are rapidly evolving. Left ventricular assist devices have been used as a bridge to heart transplantation for patients who otherwise might die awaiting a new heart. There is also continued interest in the use of these devices either to bridge patients to full recovery or to destination therapy, without the need for heart replacement. Left ventricular reconstruction, including the Batista and Dor procedures, along with mitral valve repair, cardiomyoplasty, and extreme coronary artery bypass graft surgery, are now being increasingly performed as alternative options. The history, status, and personal experience of surgical treatment of end-stage heart disease are discussed.

Section snippets

Heart transplantation

Heart transplantation remains the most effective therapy for end-stage heart disease.8 After the introduction of new immunosuppressive drugs, Stanford University reported a considerable improvement in heart transplantation survival results from 41% to 68% and from 24% to 46% after 5 and 10 years, respectively.9

From 1985 to 2001 at the A. De Gasperis Department of Cardiac Surgery heart transplant program (which was started during the cyclosporine-based immunosuppression era), 610 patients

Alternative surgical options

The issues summarized above, along with the biomedical improvements and the progress of surgical and intensive care strategies, have led to interest in different surgical options for the treatment of patients with end-stage heart disease. Apart from the extension of indications for conventional surgery in patients with severe left ventricular dysfunction and CHF, great progress has been made in the development of new surgical approaches including (1) left ventricular reconstruction procedures;

End-stage cardiomyopathy and coronary revascularization

The most common cause of CHF in the developed world is coronary disease. For those on the waiting list at our center, the incidence of ischemic cardiomyopathy is 55.5%. For many years, the role of coronary artery bypass grafting (CABG) has not been well defined in this group of patients. According to the Coronary Artery Surgery Study (CASS), the results of CABG in patients in the 1980s with severe left ventricular dysfunction and CHF were not encouraging.16 Great progress has been made over the

Mitral valve repair

Mitral valve incompetence is functional when the patient has a mitral regurgitation along with global systolic dysfunction of the left ventricle without structural alterations of leaflets and subvalvular apparatus.27 The clinical relevance of functional mitral incompetence in patients with CHF depends primarily on quality of life and overall prognosis. The pathogenetic hypothesis of functional mitral valve incompetence relies on geometric remodeling of the left ventricle with “misalignment” of

Ventricular assist device as a bridge to transplantation

The mechanical assist device aims to achieve an appropriate cardiac output in patients with end-stage heart disease who are not suited for conventional medical and surgical treatment. The clinical use of VAD started in the 1960s in patients with acute heart failure. In 1969, Cooley et al34 successfully applied, for the first time, an assist device as a bridge to heart transplantation, opening a new era in cardiac surgery. Since the 1980s, technologic advances have resulted in the development of

Conclusions

In the absence of a definitive cure for the treatment of the primary disease that leads to CHF, combined medical and surgical therapy will continue to be the standard of care.39 Heart transplantation is still the most successful option for such patients, but it is limited by inadequate supply of organs. Increasing use of mechanical assist systems has been suggested in patients with end-stage heart disease as a bridge to heart transplantation, to recovery, or to permanent application.

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