Surgical Treatment of HEART FAILURE

Dr Saji Radhakrishnan MS MCh Consultant Cardiovascular Surgeon

When should surgical intervention be considered in heart failure? Noninvasive measurements The three most common etiologies leading to severe cardiac failure are ischemic heart disease, dilated cardiomyopathies and hypertensive cardiomyopathies.These scenarios generally lead predominantly to left ventricular failure but can produce right-sided failure as well. Surgical therapy for cardiac failure (of which most are generally used for left ventricular failure) include coronary revascularisation, ventricular remodeling, repair of mitral valvular regurgitation, the use of skeletal muscle pumps as assist devices, mechanical devices and heart transplant . In order to evaluate patients for surgical intervention, several parameters are used to assess the severity of myocardial dysfunction, to assess the optimal timing for surgical intervention and to evaluate the efficacy of any treatment. The New York Heart Association functional classification (NYHA) is a clinically useful stratification of patients in heart failure that has been shown to correlate well with treatment efficacy. For the surgeon, this classification provides a useful means of evaluating treatment efficacy. Noninvasive measurements Echocardiography: Left ventricular ejection fraction and left ventricular dimensions at end-diastole and endsystole: Serial measurements are useful in following the progression of cardiac failure. Regional wall motion abnormalities are useful when assessing ventricular aneurysms and areas of ischemia or infarction. It is also essential for evaluating surgical procedures involving ventricular remodeling.

Invasive measurements
Cardiac catheterization in deciding the proper timing and the method of intervention. In left ventricular failure, elevated left atrial pressures greater than 20mmHg, a cardiac index less than 2.0 L/min/m2, and clinical signs of pulmonary edema and peripheral organ hypoperfusion despite aggressive medical therapy are indications for surgical intervention. Elevated right atrial pressures greater than 20mmHg and clinical evidence of liver congestion, ascites, and peripheral edema in the setting of aggressive support of left ventricular function may indicate the need for surgical intervention to support the right heart. May also determine the type of surgical intervention to be offered. Severely increased pulmonary vascular resistance will exclude heart transplantation or indicate the high-risk nature of the procedure. In general, a pulmonary vascular resistance greater than 4 Wood units increases the likelihood of right heart dysfunction or failure in a transplanted heart, and vascular resistance greater than 6-8 Wood units with pulmonary vasodilator therapy generally indicates that heart transplantation alone will be unsuccessful.

Maximal exercise oxygen consumption

VO2 (ml/kg/min))quantify the functional disability of patients in heart failure and currently provides the most helpful prognostic indicator. Patients who, despite poor left ventricular ejection fractions, have a VO2 maximum greater than 18ml/kg/min have a good prognosis and can generally postpone surgical interventions. A VO2maximum of less than 12ml/kg/min carries a poor prognosis. The prognosis for the intermediate group is less clear. Coronary Artery Bypass and its Role in Ischemic Heart Failure

Currently, the most common cause of clinical heart failure is left ventricular dysfunction resulting from ischemic heart disease. As such, the most common surgical intervention is coronary revascularization. The amount of reversibly injured myocardium determied by various perfusion studies will determine the likelihood of improved ventricular function following revascularization. In order for surgical revascularization to provide a potential benefit, the viability studies should indicate that at least 20% or more of the total left ventricular volume is ischemic but not irreversibly damaged.

Surgical Ventricular Restoration (SVR) surgical remodeling of LV

Linear repair technique :

Patients suffering large transmural myocardial infarctions can go on to develop ventricular aneurysms. These areas of the ventricular wall are nonfunctional segments of scarred ventricular muscle and can become foci for the development of cardiac arrhythmias and intramural thrombi.Can cause obvious impairment of ventricular function by impeding mitral valve motion, resulting in mitral valve regurgitation. Left ventricular dilatation increases the energy demand of the ventricle,thus decreasing the efficiency of the ventricle as a pump. In accordance with the Law of Laplace decreasing the ventricular radius may decrease myocardial energy consumption and provide the ventricle with more mechanical advantage. Since the ventricular enddiastolic volume (EDV) is automatically reduced by this method, ejection fraction (EF) will increase with no improvement in stroke volume.

Ventricular Aneurysmectomy
and the "Dor Procedure":Dor introduced the technique known as endoventricular circular patch plasty, which avoided the alteration in ventricular shape produced by simple linear closure.The original linear resection involved scar excision leaving a rim which allowed closure in a straightforward linear manner. The technique proposed by Dor uses a patch in order to preserve the shape of the ventricular wall after scar excision. Additional benefit is the removal of thrombogenic and arrhythmogenic myocardium.Maintaining the ventricular geometry with patch closure allows the remaining nonischemic myocardial fibers to gain some mechanical advantage through alterations in loading conditions and ventricular pressure waveform, resulting in improved ventriculoar- terial coupling.

The "Batista" Operation: Patients with large dilated ventricles (end-diastolic dimensions greater than 65mm) might benefit from partial ventriculectomy. The group of patients considered for this intervention has global left ventricular dysfunction and, as a result of the extreme dilatation, severe mitral regurgitation. The operation involves resecting a portion of the left ventricle between the papillary muscles with repair, replacement or preservation of the mitral valve.

Repair of ischemic Mitral Regurgitation in Patients with Severe Left Ventricular Dysfunction
As heart failure progresses, remodeling of the left ventricle causes the papillary muscles (which support the mitral valve leaflets) to stretch out of shape, causing the valve to

leak. Mitral valve repair usually involves reshaping the leaflets and providing support to the mitral valve with a ring.

Repair of the mitral valve:

Preserves the natural anatomy of the heart Improves cardiac function Decreases symptoms Improves survival Decreases complications and risks

Skeletal Muscle Pumps

In some of the lesser used techniques skeletal muscle is used to provide ventricular support. Cardiomyoplasty : the use of skeletal muscle for ventricular augmentation by wrapping the ventricle( eg. Latissimus dorsi muscle) Aortomyoplasty : the use of skeletal muscle as a counterpulsation technique. Neoventricle: The use of skeletal muscle as a ventricle. The use of skeletal muscle as a power source for an assist device

Benefits:
Using skeletal muscle may avoid the use of foreign tissue and thus eliminate the need for immunosuppression.The difficulty of implanting longterm power supplies needed for mechanical support would be replaced by less energy-demanding muscle stimulators and pacers. Drawbacks: Skeletal muscle is limited without preconditioning to fatigue and does not exhibit the "all or none" properties typical of cardiac muscle Mechanical Circulatory Support Circulatory support devices can be used for either short-term support or chronic longterm support. These devices are referred to as LVADs (left ventricular assist

device) or RVADs (right ventricular assist device) or BiVAD based on whether they are used to support the left, right or both hearts. These devices are not helpful in the setting of acute lung injury and inability to oxygenate. Extracorporeal membrane oxygenation (ECMO) is needed in those patients and, in concept, is a form of cardiopulmonary bypass with an oxygenator that can be used for several days.

Totally Implantable Mechanical Hearts The Abiocor is a completely implantable pulsatile device that replaces the recipient right and left heart. The recipient heart is excised and the artificial one sewn in its place. No cables or cannulas traverse the skin and power is provided by a wireless transcutaneous system. Heart Transplantation Heart transplantation is undoubtedly currently the best long-term solution available for patients in chronic heart failure.The major indications for adult heart transplantation are ischemic heart disease and cardiomyopathy. The development of cardiac graft vasculopathy remains as the major long-term morbidity determining graft survival. The limited donor supply remains as the primary factor preventing many from being able to receive a transplant. Newer treatment options in pipeline Stem cell therapy,Gene therapy Conclusions Heart failure is a global health problem representing a major emotional and financial burden on society. Treatments include several medical and surgical options to improve the quality of life and survival of patients suffering from heart failure. The continued investigation of the many possible therapies will help tailor appropriate treatment to the needs of the patient. All hospitals performing open heart surgery need to be able to provide a form of acute support for a failing heart in order to allow time for the heart to recover or to transfer the patient to a transplant center. Heart transplantation remains the best alternative for some patients with end-stage heart disease. Currently, mechanical circulatory assist offers methods to bridge patients for transplant who would otherwise die on the waiting list. Soon, mechanical support may offer end therapy without the need to go on to transplantation. The use of skeletal muscle as a pump or as a cardiac assist and the use of surgical revascularization, remodeling and mitral valve repair may offer less expensive alternatives in these patients.