Surgical therapy in advanced heart failure: non-transplant operations

In Western countries 70% of heart failure patients have coronary artery disease (CAD) with transient ischaemic dysfunction, hibernating myocardium or scar. The remainder have idiopathic dilated cardiomyopathy (DCM), hypertension or valvular heart disease. Left ventricular (LV) shape and volume are important determinants of symptomatic status and outcome. Whilst LV ejection fraction (EF) alone is a poor predictor of survival in the presence of reversible ischaemia, the onset of mitral regurgitation portends a poor prognosis. CAD surgery addresses the three V's: vessels (obstructed coronary arteries), valve (mitral) and left ventricle (dyskinesia or scar). Revascularization of hibernating myocardium can improve LV function and longevity with outcomes superior to transplantation. After recent clinical trials the benefits of mitral repair and LV remodelling are less certain. Aortic valve disease responds to conventional valve surgery and DCM patients with secondary mitral regurgitation may improve after valve repair. Surgery must be considered before co-morbidity, such as renal dysfunction, substantially increases operative risk. In the presence of poor LV function (LVEF 10-30%) hospital mortality can be avoided by elective deployment of an intra-aortic balloon pump or left ventricular assist device.