Surgical Options for the Treatment of Heart Failure
There are multiple surgical options for the management of patients with congestive heart failure and end-stage heart disease. Those alternatives include:

1. 
   
   Coronary Artery Bypass Grafting (CABG)
   
   The role for CABG in patients with heart failure depends upon myocardial viability and adequacy of target vessels for revascularization. The presence of heart failure with congestive heart failure signals myocardial viability. However, most heart failure patients do not have angina and therefore, either echocardiographic or nuclear demonstration of viability and reversible ischemia is necessary before proceeding with CABG. The use of off-pump techniques and beating heart surgery have in our opinion lessened the morbidity and mortality associated with coronary revascularization in patients with severe left ventricular dysfunction and expanded our use in marginal patients. The ability to avoid global ischemic arrest by instead using transient periods of local ischemia with targeted revascularization have allowed us to aggressively pursue coronary revascularization in CHF patients whom we have reason to think left ventricular function will improve.
   
   
   
   
2. 
   
   Mitral Valve Repair
   
   Functional and/or ischemic mitral regurgitation is a disease of the left ventricle rather than the mitral valve. The consequences of ventricular dilation include dilation of the mitral annulus, apical and lateral displacement of the papillary muscles with tethering of the subvalvular apparatus and mitral leaflets leading to failure of coaptation. Numerous surgical techniques have been described to address the annular dilatation, which is due mainly to an increase in the septal lateral diameter. All annular remodeling techniques decrease the setal-lateral (anterior-posterior) diameter of the annulus enhancing leaflet coaptation. Most rings are complete and rigid or semi-rigid. Modification of these rings to increase the coaptation of the P3 segment in ischemic mitral regurgitation (IMR ring) or the GeoForm ring (Edwards Lifesciences, Irvine, CA), which includes enhanced distraction of the posterior annulus have recently been introduced into clinical practice. Also in clinical trials is the Coapsys device (Myocor, Inc., Maplegrove, MN), which places bridges on the outside of the ventricle and a tethering strand through the left ventricle to decrease the septal lateral diameter of the mitral annulus.
   
   
   
   
3. 
   
   Surgical Ventricular Restoration (SVR)
   
   In patients with ischemic heart disease and anteroapical dyskinesis or aneuryms, the Dor procedure and modifications by Menicanti have some role. With this technique the left ventricle is opened through the anteroapical scar and a mannequin device is used to size for appropriate right sizing of the left ventricle. A Dacron patch is then sutured the edges of the scar and the left ventricle closed over the Dacron patch. This technique prevents obliteration of the left ventricular cavity, which was a problem with some of the previous ventricular aneurysmectomy techniques. This technique is currently the subject of an NIH funded trial, the STICH trial.
   
   
   
   
4. 
   
   Restraint Devices
   
   A mesh-like cardiac support device, Acorn CorCap (Acorn Cardiovascular, St. Paul, MN), has been introduced with the purpose of providing end diastolic support and reducing the mechanical stress to cause reverse cardiac remodeling. The inital trial of 130 patients was completed, but did not receive FDA Panel approval. Post-hoc subgroup analysis, however, appears to demonstrate some benefit in those patients with moderate left ventricular dysfunction by preventing further ventricle dilation.
   
   
   
   
5. 
   
   Cardiac Transplantation
   
   Cardiac transplantation has become the routine last option in appropriate patients with end stage cardiomyopathy. Transplant is still limited by donor availability and the number of transplants performed in the United States has remained stable at approximately 2,500 annually. Appropriate candidates include those patients who are under age 65 (70 with nonischemic cardiomyopathy). Approximately one half of transplants are done for ischemic cardiomyopathy and the other half for nonischemic patients. One-year survival is greater than 90% and 50% survival is 9.6 years.
   
   
   
   
6. 
   
   Ventricular Assist Devices (VADs)
   
   VADs are used as a bridge to recovery (BTR) or bridge to transplantation (BTT) or as destination therapy (DT) in patients who are non-transplant candidates either because of age or comorbidity. The benefit of DT was demonstrated in the REMATCH trial (REMATCH-Subanalysis) where the two-year survival was 25% in patients with VADs and 8% with optimal medical management. Subsequent experience to the REMATCH trial have demonstrated improved survival 50% at 12 months and 35% at 24 months. It should be kept in mind that outcomes with this cohort of patients should not be evaluated in the context of transplant outcomes due to the fact that these patients are not all candidates for transplantation either due to advanced age or comorbidities.
   
   

Source: Content provided by the American College of Cardiology Foundation.