Surgical Therapy for Heart Failure

Surgical Therapy for Heart Failure Craig H Selzman, MD, FACS, Rajendra S Bhati, MD, Brett C Sheridan, MD, FACS, William E Stansfield, MD, Michael R Mill, MD, FACS After a meeting of the American College of Cardiol- apy, patients with advanced HF are now much older, ogy in 2003, the cover of US News and World Report with more attendant comorbidities.3 HF is associated boldly proclaimed: “The end of heart disease.”1 The with staggering costs to society—estimated to be more media frenzy after one of the national cardiology than $30 billion last year—that are related to repeat meetings is always interesting to observe. The late- hospitalizations, loss of work potential, and prescription breaking trials of pharmacology, drug-eluting coro- medicines.3 Although medical therapy has greatly in- nary stents, and percutaneous heart valves conspire to creased the quality and length of life for these patients, make even the busiest cardiothoracic surgeon think of diagnosis of HF has traditionally carried a mortality rate his or her own professional future. But amid our car- of 20% within 1 year and 50% within 2 years.4 diologic colleagues’ excitement over the “vanishing HF is the clinical end point for a number of diseases scalpel”1 are some sobering statistics (Table 1). Car- resulting in myocardial dysfunction. Ischemic cardio- diovascular disease remains the leading cause of death myopathies (from coronary artery disease) and dilated in the US. Ischemic heart disease accounts for a large cardiomyopathies (either idiopathic or familial) make portion of these deaths. Although the number of pa- up the majority of cases. Many other diseases can also tients dying acutely from myocardial infarction has lead to end-stage heart failure, including valvular, con- decreased nearly 30% in the last 2 decades, the num- genital, metabolic, and inflammatory disorders. Patho- ber of patients dying from heart failure (HF) has dou- logically, cardiac remodeling is characterized by myocyte bled. Despite improving medical therapy, many of hypertrophy, chamber dilation, and changes in matrix these patients continue to have functional decline and composition. Ultimately, the fibrotic heart becomes ultimately die. Management of HF, as such, has more spherical and, subsequently, a less-efficient pump. evolved into a steadily growing discipline. This review An important goal is to identify and favorably intervene will discuss the role of surgical therapy for treating the before onset of terminal myocardial remodeling. enlarging population of patients with HF. Patients present with a variety of symptoms related to both systolic (poor antegrade pump function) and dia- HEART FAILURE—THE MODERN EPIDEMIC stolic (poor ventricular relaxation and compliance) dys- The American Heart Association’s latest update esti- function. Descriptions of patients with HF have been mates that nearly 5,000,000 Americans suffer from HF. noted as early as 1600 BC in the Ebers papyrus. Other Over 500,000 patients are newly diagnosed each year. references to “dropsy” (accumulation of lymph fluid) HF does not discriminate by gender, race, or age. It is and cardiac cachexia were noted by Hippocrates. Typical increasingly prevalent in men and women, Caucasian symptoms of HF include dyspnea on exertion, orthop- and non-Caucasian, and young and old. At age 40, the nea, paroxysmal nocturnal dyspnea, fatigue, and ab- lifetime risk of HF developing is 20%.2 Importantly, dominal symptoms related to right heart congestion. because of an aging population and better medical ther- These symptoms are often associated with several phys- ical findings, including elevated jugular venous pressure, Competing Interests Declared: None. a third heart sound, pulmonary congestion, and periph- Supported by the Franklin H Martin, MD, FACS, American College of eral edema. Surgeons Faculty Research Grant (CHS). Traditionally, the New York Heart Association Received January 20, 2006; Revised April 20, 2006; Accepted April 24, 2006. (NYHA) Classification has been used to define the func- From the Division of Cardiothoracic Surgery, Department of Surgery, Uni- versity of North Carolina, Chapel Hill, NC. tional limitations of patients with HF.Recent guidelines Correspondence address: Craig H Selzman, MD, Division of Cardiothoracic have suggested a new classification system that empha- Surgery, University of North Carolina at Chapel Hill, 3040 Burnett Womack Bldg, CB #7065, Chapel Hill, NC 27599-7065. email: selzman@med. sizes its evolution, progression, and structural deteriora- unc.edu tion (Table 2).5 This staging system encourages the same © 2006 by the American College of Surgeons ISSN 1072-7515/06/$32.00 Published by Elsevier Inc. 226 doi:10.1016/j.jamcollsurg.2006.04.022 Vol. 203, No. 2, August 2006 Selzman et al Surgical Therapy for Heart Failure 227 Table 1. 2005 Cardiovascular Disease Statistics* Abbreviations and Acronyms 13,000,000 Prevalence of coronary heart disease AF ϭ atrial fibrillation 865,000 Number of first or recurrent myocardial infarctions CABG ϭ coronary artery bypass grafting 494,382 Deaths from coronary heart disease CHF ϭ congestive heart failure 7,600,000 Number of patients who have survived a heart attack EF ϭ ejection fraction ϭ $142 HF heart failure billion Annual cost of caring for coronary heart disease LV ϭ left ventricle LVAD/RVAD ϭ left/right ventricular assist device *Data from Heart Disease and Stroke Statistics—Updates 2005. Dallas, TX: MR ϭ mitral regurgitation American Heart Association; 2005. NYHA ϭ New York Heart Association TAH ϭ total artificial heart VAD ϭ ventricular assist device ifestations of congestive heart failure (CHF). In partic- ular, blocking the renin-angiotensin and ␤-adrenergic systems improves mortality among patients with HF. levels of care of HF patients that we would use for can- Angiotensin-converting enzyme inhibitors, and angio- cer: identify and treat patients at risk for HF (ie, hyper- tensin receptor blockers, increase survival and decrease repeat hospitalizations.7 These benefits are also found in tension), with early disease (ie, diastolic dysfunction), ␤ with established disease (ie, medically managed HF), several types of -adrenergic blockers, including meto- 8,9 and with advanced disease (ie, medically refractory prolol and carvedilol. 4 Patients often have difficulty tolerating either HF). ␤ A host of diagnostic studies are available to study angiotensin-converting enzyme inhibitors or -blockers. A these patients. Transthoracic echocardiography with or number of additional medication regimens are also used in without pharmacologic stress is inexpensive and pro- managing these patients, including loop and thiazide di- vides functional and anatomic information. Radio- uretics and aldosterone antagonists. Diuretic therapy de- nucleotide scans can evaluate ejection fraction (EF), es- creases ventricular diastolic pressure, which reduces ventric- pecially of the right ventricle. MRI has recently proved ular wall stress, and maximizes subendocardial perfusion. to be a valuable resource in assessment of myocardial Digoxin, a cardiac glycoside, is used to help improve symp- function and viability. Right and left heart catheteriza- toms associated with CHF through improvement in car- tion assesses presence of coronary artery disease and pul- diac contractility. Although use of digoxin does not confer monary vascular disease. Finally, measurement of peak a survival benefit, it has reduced the number of hospitaliza- 10 oxygen consumption with exercise can help stratify the tions from worsening HF. Recently, there has been re- functional limitation of patients with HF. newed enthusiasm for vasodilator therapy using a combi- nation of hydralazine and isosorbide dinitrate.11 Finally, when patients are refractory to standard therapy, they often HEART FAILURE—MEDICAL THERAPY require hospitalization for IV diuretics, vasodilators, and Medical therapy, including preventive measures, serves inotropic agents. as the first-line strategy for treating patients with HF. In 1997, the Systolic Hypertension in the Elderly Program (SHEP) Cooperative Research Group followed over SURGICAL ALTERNATIVES FOR ADVANCED HF 5,000 patients with isolated systolic hypertension. HF Despite considerable improvements in medical therapy, occurred more than twice as often in the placebo group overall death rates for HF patients have failed to drop versus those treated with antihypertensive agents. Addi- appreciably. And, with nearly 10% of the population tionally, treated patients with an earlier myocardial in- over 75 years old diagnosed with HF, a more compli- farction had an 80% risk reduction in HF development cated set of patients is emerging and growing. Typically, compared with those not treated.6 Control of other risk patients over 65 years of age are not candidates for heart factors, including diabetes, coronary artery disease, and transplantation. Older patients can successfully receive structural valve disease, similarly prevents pathologic traditional approaches to heart operation,12 but resource ventricular remodeling and HF development. allocation and increased morbidity and mortality raise Once diagnosis of HF is established, a number of important societal issues.13 A number of innovative surgi- pharmacologic strategies exist to limit and reverse man- cal approaches have evolved to service these diverse, refrac- 228 Selzman et al Surgical Therapy for Heart Failure J Am Coll Surg Table 2. Heart Failure Classiﬁcations New York Heart Association ACC/AHA guidelines I No

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