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Unresolved issues in the surgical treatment of chronic heart failure

ESC Congress 2010

Heart Failure

An extremely interesting session gathered top experts in the field of surgical therapies for heart failure.

Mitral regurgitation (MR) was addressed by O Alfieri from Milan, a worldwide recognized expert in valvular heart repair. MR has an adverse impact on survival but the question that arises is which patients benefit from surgical repair. There are conflicting data on the advantage of mitral valve repair over optimal medical treatment in patients with advanced heart failure and poor left ventricular function and therefore patient selection is critical. Definite contraindications to mitral valve surgery are right ventricular dysfunction, absence of contractile reserve and heavy co-morbidities.

Although a survival benefit was observed in the more recent era with the use of strictly undersized rigid complete mitral rings, recurrent mitral regurgitation and absence of reverse remodeling is observed in patients with end systolic diameter > 51mm and those with increased duration of heart failure. In these patients, the incidence of residual or recurrent MR is up to 30% and is related to decreased survival.

Although undersized annuloplasty with new types of rings may be effective, mitral valve replacement with preservation of the subvalvular apparatus is indicated in case of complex multiple jets, absence of annular dilatation, severe tethering (tented area>4cm²), posterior leaflet-annular plane>45 degrees and advanced LV remodeling. Other procedures have been used in small patient series such as papillary muscle repositioning, leaflet extension, section of secondary chordae and sling around the papillary muscles. Finally, resynchronization, atrial fibrillation ablation and correction of associated tricuspid insufficiency need to be considered.

The benefit in survival of an external myocardial constraint (Cor Cap TM) placed around the left ventricle remains to be demonstrated, although it has been shown to effectively decrease ventricular volumes and improve functional capacity(R Bonifazi, Bari).

What about surgical ventricular remodeling, an operation developed by V. Dor and evaluated in the STICH trial ? Timothy Gardner (Newark, USA) reviewed the methodology and results of this large randomized trial (1000 patients) comparing CABG alone vs CABG+ventricular remodeling (SVR) that has shown no survival benefit of associating a ventricular reduction and myocardial revascularisation in patients with anterior LV akinesia and reduced EF. A sub-analysis of this study tried to find out if there was a benefit in patients with larger LV volumes, but found no difference in mortality. Gardner stressed the various flaws of this study (LV volume criteria for inclusion not always met, LV volumes inadequately measured, viability not assessed, only 50% of patients in NYHA III/IV, more than half of SVR patients did not achieve adequate volume reduction) and concluded that it may be premature to consider that SVR has no value. However the only patients that could benefit from a SVR added to CABG are those with large hearts, anterior wall akinesia without viability.

Regarding ventricular assist devices (VAD), we learned from M Stueber (Hannover, Germany) that reduction in the size and changes in the technology have occurred in recent years with non pulsatile devices having proven clear superiority in terms of survival compared with pulsatile devices. Based on improved survival and reduced rate of complications, consideration for implantation of a centrifugal non pulsatile LVAD should now be considered on a predictive probability of survival (Seattle Heart failure model) around 25%, although better models of prediction are needed. The reliability of these support systems allow long term support to an eventual heart transplantation, providing satisfactory exercise capacity, and can therefore be considered more than a simple bridge to transplant.

One of the unsolved issues in these patients is bleeding, namely gastro-intestinal bleeding. Bleeding might be related to acquired Von Willebrand Factor syndrome due to cleavage of parts of this protein, because of high shear stress, leading to a functionally inactivated protein, a condition that is only diagnosed through electrophoresis techniques.




Unresolved issues in the surgical treatment of chronic heart failure
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.