Heart failure module 6: surgical management

Released1 November 2017     Expires: 01 November 2019      Programme:

Surgical ventricular restoration

Surgical ventricular restoration (SVR) involves exclusion of scar on the ventricular wall from previous myocardial infarction.

The aims of SVR are to:

  • normalise ventricular geometry
  • improve myocardial perfusion
  • reduce left ventricular work
  • improve left ventricular contraction.

The early procedures were similar to partial left ventriculectomy for aneurysm, while the contemporary SVR involves resection of the non-functional myocardium before placement of an endoventricular Dacron patch to exclude the scar (figures 11a–d). It is usually done during CABG for patients with ischaemic cardiomyopathy and anterior wall akinesia or severe dyskinesia. It adds about 20 minutes to the procedure time without increasing operative risk.

Figure 11b. Surgical ventricular restoration by the Dor procedure. An interventricular stitch is placed to create a neoventricle
Figure 11b. Surgical ventricular restoration by the Dor procedure. An interventricular stitch is placed to create a neoventricle
Figure 11a. Surgical ventricular restoration by the Dor procedure. First the area of scar is identified and partially excised
Figure 11a. Surgical ventricular restoration by the Dor procedure. First the area of scar is identified and partially excised

Figure 11d. Surgical ventricular restoration by the Dor procedure. Finally the remaining scar is used to cover the patch or excised, and the defect is closed
Figure 11d. Surgical ventricular restoration by the Dor procedure. Finally the remaining scar is used to cover the patch or excised, and the defect is closed
Figure 11c. Surgical ventricular restoration by the Dor procedure. A Dacron patch is placed to create a neoventricle
Figure 11c. Surgical ventricular restoration by the Dor procedure. A Dacron patch is placed to create a neoventricle

In non-randomised studies, SVR improves LVEF and other haemodynamic variables. However, hypothesis 2 of the STICH trial compared outcomes of patients randomised to CABG plus SVR to CABG alone and found no significant difference in the composite endpoint of all-cause mortality or cardiovascular hospitalisation.

Percutaneous ventricular restoration has also been investigated: the Parachute device, a percutaneously delivered device that partitions the left ventricle as a means of ventricular restoration, appears safe and feasible in patients with heart failure and left ventricular dilatation.16 However, a phase III trial was terminated in June 2017.17

There may yet be sub-groups who do benefit from surgical or percutaneous ventricular restoration and, similar to the story with revascularisation, this book is not yet closed.

Valve surgery

An important cause of the heart failure syndrome is valvular heart disease. Every patient presenting with heart failure should be assessed for valvular disease: aortic stenosis is a particular common cause. Patients should be offered aortic valve replacement as a potentially curative procedure. In many patients, however, by the time they present, they may be too frail for open surgical valve replacement. In these cases, transcatheter aortic valve implant (TAVI) should be considered as being a lower risk alternative. TAVI is certainly superior to medical therapy in inoperable patients, and is increasingly being shown in trials to be as effective as surgical valve replacement in lower risk patients.

A more difficult problem is that of mitral valve surgery. Functional mitral regurgitation is very common in heart failure as a consequence of valve ring dilation together with tethering of the posterior leaflet of the valve. There are no good randomised trials of mitral valve surgery in this clinical situation, but data from registries suggest that there is little to be gained from a high risk procedure. Whether there is anything to be gained from mitral valve repair using percutaneous strategies (such as the MitraClip® or percutaneous valve prostheses) is not clear.

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References

1. National Institute for Health and Care Excellence. Implantation of a left ventricular assist device for destination therapy in people ineligible for heart transplantation. NICE Interventional procedures guidance [IPG516]. London: NICE, 2015. Available from: https://www.nice.org.uk/guidance/ipg516 [accessed 15th June 2017]

2. Kirklin JK, Naftel DC, Pagani FD et al. Seventh INTERMACS annual report: 15,000 patients and counting. J. Heart Lung Transplant. 2015;34(12):1495-504.  http://dx.doi.org/10.1016/j.healun.2015.10.003

3. Slaughter MS, Rogers JG, Milano CA, et al.; HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009;361:2241–51.  http://dx.doi.org/10.1056/NEJMoa0909938

4. Kirklin JK, Naftel DC, Kormos RL, Stevenson LW, Pagani FD, Miller MA, Timothy Baldwin J, Young JB. Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant 2013;32:141–56. https://doi.org/10.1016/j.healun.2012.12.004

5. Pagani FD, Aaronson KD, Kormos R et al. The NHLBI REVIVE-IT study: Understanding its discontinuation in the context of current left ventricular assist device therapy. J. Heart Lung Transplant 2016;35(11):1277-1283. https://doi.org/10.1016/j.healun.2016.09.002

6. Estep JD, Starling RC, Horstmanshof DA et al. Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients: Results From the ROADMAP Study. J Am Coll Cardiol 2015;66(16):1747-61. https://doi.org/10.1016/j.jacc.2015.07.075

7. Starling RC, Estep JD, Horstmanshof DA et al. Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients: The ROADMAP Study 2-Year Results. JACC Heart Fail 2017;pii:S2213-1779(17)30164-6. https://doi.org/10.1016/j.jchf.2017.02.016

8. Lund LH, Edwards LB, Kucheryavaya AY, et al.; International Society for Heart and Lung Transplantation. The registry of the international society for heart and lung transplantation: thirtieth official adult heart transplant report-2013; focus theme: age. J Heart Lung Transplant 2013;32:951–64. https://doi.org/10.1016/j.healun.2013.08.006

9. Banner NR, Bonser RS, Clark AL et al. UK guidelines for referral and assessment of adults for heart transplantation. Heart 2011;97:1520e1527. https://doi.org/10.1136/heartjnl-2011-300048

10. Dar O, Banner NR. Cardiac transplantation: who to refer and when. Br J Hosp Med 2013;74:258–63. https://doi.org/10.12968/hmed.2013.74.5.258

11. Hunt SA. Taking heart – cardiac transplantation past, present, and future. N Engl J Med 2006;355:231–5. http://dx.doi.org/10.1056/NEJMp068048

12. Cleland JG, Calvert M, Freemantle N, et al. The Heart Failure Revascularisation Trial (HEART). Eur J Heart Fail 2011;13:227–33. http://dx.doi.org/10.1093/eurjhf/hfq230

13. Velazquez EJ, Lee KL, Deja MA, et al.; STICH Investigators. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med 2011;364:1607–16. http://dx.doi.org/10.1056/NEJMoa1100356

14. Velazquez EJ, Lee KL, Jones RH, et al.; STICHES Investigators. Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med 2016;374:1511-1520. http://dx.doi.org/10.1056/NEJMoa1602001

15. US National Institutes of Health. ClinicalTrials.gov. Study of Efficacy and Safety of Percutaneous Coronary Intervention to Improve Survival in Heart Failure (REVIVED-BCIS2). Available from:  https://clinicaltrials.gov/ct2/show/NCT01920048. [accessed 20th June 2017]

16. Costa MA, Mazzaferri EL Jr, Sievert H, Abraham WT. Percutaneous ventricular restoration using the parachute device in patients with ischemic heart failure: three-year outcomes of the PARACHUTE first-in-human study. Circ Heart Fail 2014;7(5):752-8. https://doi.org/10.1161/CIRCHEARTFAILURE.114.001127

17. US National Institutes of Health. ClinicalTrials.gov. A Multinational Trial To Evaluate The Parachute Implant System (PARACHUTE). Available from:  https://clinicaltrials.gov/show/NCT01286116. [accessed 20th June 2017]

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