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Surgery For Heart Failure

With simple changes and a better understanding of the condition, many people live full and active lives. The time to take charge of your health is today. Surgery for treating heart problems includes procedures such as coronary artery bypass grafts, coronary angioplasty, coronary stenting, and heart transplants, operations for congenital defects and heart valve defects, and implanting cardiac defibrillators.

Highlights:

Heart Failure

Heart failure is a condition in which the heart does not pump enough blood to meet the needs of the body's tissues. Heart failure can develop slowly over time as the result of other conditions (such as high blood pressure and coronary artery disease) that weaken the heart. It can also occur suddenly as the result of damage to the heart muscle.

Symptoms:

Common signs and symptoms of heart failure include:

  • Fatigue
  • Shortness of breath
  • Wheezing or cough
  • Fluid retention and weight gain
  • Loss of appetite
  • Abnormally fast or slow heart rate

Treatment:

Treatment for heart failure depends on its severity. Patients with very weakened hearts may need surgery or implanted devices, such as pacemakers or implantable cardioverter defibrillators. All patients need to make lifestyle changes, including restricting salt in their diets.

To understand what occurs in heart failure, it helps to be familiar with the anatomy of the heart and how it works. The heart is composed of two independent pumping systems, one on the right side, and the other on the left. Each has two chambers, an atrium and a ventricle. The ventricles are the major pumps in the heart.

Introduction:

The external structures of the heart include the ventricles, atria, arteries, and veins. Arteries carry blood away from the heart while veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide.

The Right Side of the Heart. The right system receives blood from the veins of the whole body. This is "used" blood, which is poor in oxygen and rich in carbon dioxide.

  • The right atrium is the first chamber that receives blood.
  • The chamber expands as its muscles relax to fill with blood that has returned from the body.
  • The blood enters a second muscular chamber called the right ventricle.
  • The right ventricle is one of the heart's two major pumps. Its function is to pump the blood into the lungs.
  • The lungs restore oxygen to the blood and exchange it with carbon dioxide, which is exhaled.

The Left Side of the Heart. The left system receives blood from the lungs. This blood is now rich in oxygen.

  • The oxygen-rich blood returns through veins coming from the lungs to the heart.
  • The heart receives the oxygen-rich blood from the lungs in the left atrium, the first chamber on the left side.
  • Here, it moves to the left ventricle, a powerful muscular chamber that pumps the blood back out to the body.
  • The left ventricle is the strongest of the heart's pumps. Its thicker muscles need to perform contractions powerful enough to force the blood to all parts of the body.
  • This strong contraction produces systolic blood pressure (the first and higher number in blood pressure measurement). The lower number (diastolic blood pressure) is measured when the left ventricle relaxes to refill with blood between beats.
  • Blood leaves the heart through the aorta, the major artery that feeds blood to the entire body.

The Valves. Valves are muscular flaps that open and close so blood will flow in the right direction. There are four valves in the heart:

  • The tricuspid regulates blood flow between the right atrium and the right ventricle.
  • The pulmonary valve opens to allow blood to flow from the right ventricle to the lungs.
  • The mitral valve regulates blood flow between the left atrium and the left ventricle.
  • The aortic valve allows blood to flow from the left ventricle to the aorta.

Surgery is aimed at stopping further damage to the heart and improving the heart's function. Surgical procedures for heart failure treatment include:

High risk conventional surgeries

  • Coronary artery bypass surgery
  • Valve surgery

Surgery of the ventricle

  • LV reconstruction surgery (Dor Procedure)
  • Implantable left ventricular assist device (LVAD)
  • Heart transplant
  • New innovations

High risk conventional surgeries:

Coronary artery bypass surgery

The most common surgery for heart failure treatment is bypass surgery. If a coronary artery becomes blocked, less oxygen-rich blood reaches the heart muscle. The heart muscle becomes "starved" for blood (ischemia) and is unable to pump normally; heart failure occurs. Your doctor will determine if your heart failure is caused by coronary artery disease and if you have blockages that can be "grafted" or bypassed. Although patients with heart failure are at an increased surgical risk, new strategies before, during and after surgery have decreased the risk and improved outcomes.

As heart failure progresses, remodeling of the left ventricle causes the papillary muscles (which support the mitral valve leaflets) to stretch out of shape, causing the valve to leak. Mitral valve repair usually involves reshaping the leaflets and providing support to the mitral valve with a ring. Experience at the Cleveland Clinic Foundation has shown that repair of the mitral valve:

  • Preserves the natural anatomy of the heart
  • Improves cardiac function
  • Decreases symptoms
  • Improves survival
  • Decreases complications and risks

If the aortic valve leaks, aortic valve repair or replacement may be an option.

Surgery of the ventricle:

Left ventricular reconstructive surgery (Dor Procedure)

Pulling of pursestring and closing of left ventricle

When a heart attack occurs in the left ventricle (left lower pumping chamber of the heart), a scar forms. The scarred area can become thin and bulge out with each beat. The bulging thin area is called an aneurysm. These changes, along with other heart damage you may have, may result in heart failure. Initially your heart is able to handle pumping harder, but over time, your left ventricle becomes larger than normal and pumps less effectively. Infarct exclusion surgery allows the surgeon to remove the infarcted (dead) area of the heart tissue and/or the aneurysm and return the left ventricle to a more normal shape. The goal of the heart failure treatment surgery is to improve heart failure and/or angina (chest pain) symptoms and possibly improve the pumping ability of your heart.

Implantable left ventricular assist device (LVAD)

The LVAD is known as the "bridge to transplantation" for those whose medical therapy has failed and are hospitalized with end-stage systolic heart failure. This device helps your heart pump blood throughout your body. CCF is one of the few institutions worldwide who have access to all clinically available mechanical ventricular assist systems including the Heartmate, Novacor, Thoratec, and Abiomed devices, allowing us to choose the machine, which will best suit an individual patient's clinical needs. For selected individuals with severe, refractory heart failure, we can now offer the option of permanent LVAD therapy or "destination therapy." Cleveland Clinic surgeons are participating in two randomized trials comparing permanent support with an implantable (Novacor) and a continuous flow (Debakey) pump to the Heart mate device.

Heart transplant:

When systolic heart failure is severe enough, a heart transplant may be suggested.

Heart (cardiac) transplant involves replacing a diseased heart or heart and lungs with a healthy donor organ or organs. The donor organ is completely removed from someone who has died, then kept cool in a special solution as it is transported. The disease heart is removed, leaving the back walls of the atria (heart's upper chambers). The hearts are sewn, atria to atria into the chest, the blood vessels are reconnected, and blood flows through the new heart into the body.

Heart assisted device:

A Ventricular assist device, or VAD, is a mechanical circulatory device that is used to partially or completely replace the function of a failing heart. Some VADs are intended for short term use, typically for patients recovering from heart attacks or heart surgery, while others are intended for long term use (months to years and in some cases for life), typically for patients suffering from congestive heart failure.

VADs need to be clearly distinguished from artificial hearts, which are designed to completely take over cardiac function and generally require the removal of the patient's heart.

VADs are designed to assist either the right (RVAD) or left (LVAD) ventricle, or both at once (BiVAD). Which of these types is used depends primarily on the underlying heart disease and the pulmonary arterial resistance that determines the load on the right ventricle.

LVADs are most commonly used, but when pulmonary arterial resistance is high, right ventricular assistance becomes necessary. Long term VADs are normally used to keep patients alive with a good quality of life while they wait for a heart transplantation (known as a "bridge to transplantation"). However, LVADs are sometimes used as destination therapy and sometimes as a bridge to recovery.

In the last few years, VADs have improved significantly in terms of providing survival and quality of life among recipients.