Heart transplantation and alternative surgery

Heart failure is a common source of morbidity and mortality with a poor survival for patients with NYHA class III/IV symptoms. Despite the advent of medical treatments some patients may benefit from surgical treatments. The mainstay of surgical treatment is heart transplantation to which the others are compared. For carefully selected recipients, transplantation improves survival and quality of life. Selection includes a serial assessment of severity of heart failure, risk of surgery, social support and the presence of contraindications to surgery. The selection and management of brainstem dead potential donors is important in optimizing the yield of hearts suitable for patients awaiting transplantation. Postoperatively, the risk of cellular rejection is reduced by the use of ciclosporin, azathioprine and prednisolone immunosupression while the risk of infection with pneumocystis carinii, toxoplasmosis and cytomegalovirus can be reduced by co-trimazole, pyrimethamine and ganciclovir, respectively. New immunosupression drugs such as tacrolimus or mycophenolate mofetil may improve on this while pravastatin and diltiazem may reduce allograft vasculopathy. Alternative surgical treatments include revascularization, mitral valve surgery, biventricular pacing, ventricular assist devices and ventricular geometrical surgery. Revascularization may reverse dysfunction in hibernating myocardium. Mitral valve surgery may restore mitral valve function secondary to left ventricular dilation while surgical geometrical surgery restores the shape of the ventricle. Biventricular pacing may resynchronize the heart and improve LV function while long term ventricular assist devices may enable patients to survive until transplantation or even allow a bridge to permanent recovery. Total artificial heart replacement, xeno or cellular transplantation are still at the experimental and/or early clinical trial stage and their potential as a treatment for heart failure remains uncertain.