The Surgical Treatment of End-Stage Heart Failure

Cardiac failure remains the leading cause of death in the Western World today. After myocardial insult, as the heart remodels and dilates, an increase in wall tension occurs secondary to increased radius of curvature, leading to increased myocardial oxygen consumption, decreased subendocardial blood flow, impaired energetics, and increased arrhythmias. Poor prognosis directly correlates with the degree of remodeling. Despite improvements in left ventricular function and long-term outcomes seen with pharmacologic therapy, the results remain far from perfect and the mortality continues to be high. The surgical armamentarium for treating end-stage heart failure is broad and new types of surgical treatments continue to emerge as alternatives to cardiac transplantation for the treatment of end-stage heart failure. Furthermore, surgical therapies that were once contraindicated for use in the failing heart are now being used to halt or reverse ventricular remodeling and improve cardiac function. Therefore, an aggressive approach to surgical revascularization, correction of mitral insufficiency, surgical reversal of left ventricular remodeling, and long-term use of mechanical ventricular assistance should be considered in any heart failure patient who has exhausted pharmacologic therapy.