Surgical Management of Heart Failure
by Dr. John Gassler and Dr. Gary Francis

See chfpatients.com/saver.htm and chfpatients.com/surgery.htm for more recent CHF surgery advances.

January, 2001 - Conventional heart failure treatment includes ACE inhibitors, beta-blockers, digoxin, diuretics, and spironolactone (Aldactone). Heart transplant is still the ultimate treatment for end-stage CHF, but shortage of donor hearts limits this option. Surgical approaches to end-stage CHF are changing. The role of many approaches remains to be proven:

  1. Reconstructive heart surgery, including the Batista procedure, the Dor procedure, and the modified Dor procedure, are now being done at some centers
  2. Mitral valve repair - even when there is no severe valve regurgitation - is being done for dilated cardiomyopathy patients. In some cases, heart size and function improve. In other cases, there is no sustained improvement or CHF may even worsen
  3. Cardiomyoplasty, in which skeletal muscle is wrapped around the heart was being tried, but abandoned. However, a heart wrap sprang from that trial and is being tested
  4. Restoring blood flow to the heart surgically, with bypass and TMR is being done in patients with severe ischemic cardiomyopathy who don't respond to standard therapy
  5. LVADs are used as a bridge to heart transplant. There is much interest in using LVADs to help patients recover heart function without transplant, but experience is limited. One concern is that prolonged use can lead to infection, which can lead to death

Left Ventricular Reconstruction

Heart reconstruction or size reduction procedures are alternatives to transplant. Removing portions of non-functioning heart muscle may return the heart to a more normal shape and size. It is hoped that reducing heart chamber sizes will reduce heart wall stress.

Batista Procedure

Dr. Randas Batista, a Brazilian heart surgeon, developed this technique, also called "partial left ventriculectomy." A section of the left ventricular wall is removed. The remaining free edges are repositioned and sewed together. The mitral valve is also repaired or replaced.
     All 120 patients in the first report were class 4, with EF less than 20%. The 30 day after-surgery death rate was 22%. Two year survival was 55%. CHF symptoms improved in 90% of survivors. Follow-up was lax and the report lacked scientific strength.
     Several centers have published their results with the Batista procedure. All show an immediate increase in EF and improved heart class. One report studied the Batista procedure in 57 patients, 95% of whom were awaiting transplant. Some mitral valve repair was done in all the patients and 60% also had tricuspid valve repair. EF increased from 14% to 23% and heart size went down. There was no significant change in cardiac output. There were no hospital deaths, but later death occurred in 12%, including sudden death in 5%. At one year, survival was 82%.
     Another study of 16 patients showed that many patients who have the Batista procedure require later listing for transplant, suggesting that this procedure is best as bridge to transplant.
     A third study followed 27 patients. Four percent died in-hospital and the survivors were followed for 11 months. EF went up from 18% to 28% but there was 25% mortality from worsening heart failure and arrhythmia.
     Long-term follow-up on patients is lacking. In one study, it was shown that improvement in heart function after the Batista procedure depended on how much fibrosis and heart cell enlargement was present before surgery. Despite apparent initial success, there is a high recurrence rate of CHF. About one-third of patients improve, one-third are unchanged, and one-third get worse. Late fatal arrhythmias plague this procedure, forcing use of ICDs. The Batista procedure has currently fallen out of favor with both cardiologists and surgeons.

Dor Procedure

Another approach to heart reconstruction is the Dor procedure, which is used after an aneurysm forms following heart attack. The Dor procedure is also called "endoventricular circular patch plasty" or EVCPP. It creates a looped stitch around a dead, scarred aneurysm to shrink the dead area. Any remaining defect can be covered by a patch made from Dacron or tissue. The remaining aneurysm scar is closed over the outside of the patch to make it more stable. The result is a more normal left ventricle shape and size.
     In the first 661 Dor procedure patients, operative death rate was 8%. If done on an urgent basis, mortality was 16% versus 6% when planned ahead. In patients with an EF less than 20%, mortality was 17% versus 1% in those with an EF over 40%.
     In 495 patients, EF went up from 33% to 45%. This improvement remained one year later. Heart class improved in 92% of patients. Also, 91% of patients with ventricular tachycardia were arrhythmia-free at one year.
     Analyzing 245 Dor procedure patients found that the size of the scar was important, not what type scar it was. Patients with a large area of scar had higher death risk: 12% versus 2%, but also had greater improvement in EF.
     Problems with Dor procedure data are that it all comes from a single medical center, follow-up data is incomplete, and there are no reported long-term results.

Mitral Valve Repair

Some mitral regurgitation is almost always seen in patients with severe DCM. We now know that the small valve muscles must be left intact. Valve repair can be combined with surgically restoring blood flow when coronary disease is present (as in bypass surgery).
     Factors that may prevent mitral valve repair in CHFers include primary mitral valve dysfunction, aortic insufficiency, and mitral regurgitation already occuring before the patient got CHF.
     Initial experience with mitral valve repair in CHF patients showed reduced heart size and improved heart function. When such patients are seen 4 months after surgery, there is often improved EF and cardiac output. This includes improved CHF symptoms and exercise tolerance. This benefit lasts for up to 2 years.
     In one study of 48 patients who had mitral repair, one year survival was 82% and 2 year survival was 71%. Hospitalizations for CHF went down and heart class improved. However, long-term follow-up data is scarce on CHFers.

Cardiomyoplasty

Cardiomyoplasty, also called "dynamic cardiomyoplasty," is a surgery that wraps the big back muscle (latissimus dorsi) around the heart. The back muscle is then trained with electrical impulses to contract in time with the heart, helping it beat more strongly. Symptoms improve after cardiomyoplasty, but we don't know why.
     Animal trials show that with electrical pacing, fast-twitch fibers change into . Studying autopsies of 3 such patients found significant but incomplete muscle fiber conversion. Also, a lot of muscle fiber had been replaced by fatty tissue.
     Another possible mechanism of benefit is that cardiomyoplasty may reverse remodeling of the failing heart. It may act as an elastic "girdle" around the heart to help reverse heart enlargement.
     In a report of 68 patients, in-hospital mortality was 12%. At 6 months, there were some improvements in EF, stroke volume, and heart class. There were no changes in peak oxygen consumption or PCWP. The survival rate at 6 months was 75% and at 12 months was 68%. Similar findings were seen in 261 patients from the Worldwide Cardiomyoplasty Group. Survival at one month was 88%, at 3 months it was 80%, and at 6 months it was 76%.
     Over time, surgical deaths have gone down from 31% to 3%, with heart class improving in 80% to 85% percent of hospital survivors. However, long-term data are scarce. The only large clinical trial of cardiomyoplasty has been stopped mainly due to doctors not referring enough patients.
     Quality of life and heart function can improve after cardiomyoplasty. However, there is not enough data to draw strong conclusions. Although 10 years of experience with cardiomyoplasty around the world suggests that there is sustained improvement in most patients, the future of this procedure for CHF patients is bleak.

Revascularization

More people now survive heart attacks but this increased survival translates into more patients with cardiomyopathy and heart failure. About 40% of heart tissue involved in a heart attack may recover, either spontaneously or after surgically restoring blood flow. Heart function may improve in some patients after such a procedure. This recoverable heart tissue is called "hibernating." As a general rule, potential for recovery is good enough to do surgery when less than 40% of the left ventricle is scarred or hibernating. If it is more than 40%, surgical mortality is much higher and recovering heart function is unlikely.

TMLR (Transmyocardial Revascularization)

TMLR is a technique for treating severe angina. There are no studies yet testing TMLR in CHFers. So far, patients with an EF less than 30% have been excluded from TMLR trials.

Updated June 12, 2004

All information on this site is opinion only. All concepts, explanations, trials, and studies have been re-written in plain English and may contain errors. I am not a doctor. Use the reference information at the end of each article to search MedLine for more complete and accurate information. All original copyrights apply. No information on this page should be used by any person to affect their medical, legal, educational, social, or psychological treatment in any way. I am not a doctor. This web site and all its pages, graphics, and content copyright © 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004 Jon C.

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