Surgical therapy for heart failure

Today’s healthcare delivery system is challenged with an escalating number of heart failure patients who have exhausted medical therapy and overwhelmed the limits of organ transplantation. Scientific and technological advances over the last 20 years have now brought new surgical options to this vast patient population, ranging from ventricular restoration surgery to surgical gene therapy and beyond. This article reviews the myriad of surgical options that are available to these patients, their benefits and shortcomings, as well as potential future directions.     

Surgical therapy for heart failure

Today's healthcare delivery system is challenged with an escalating number of heart failure patients who have exhausted medical therapy and overwhelmed the limits of organ transplantation. Scientific and technological advances over the last 20 years have now brought new surgical options to this vast patient population, ranging from ventricular restoration surgery to surgical gene therapy and beyond. This article reviews the myriad of surgical options that are available to these patients, their benefits and shortcomings, as well as potential future directions.     

Surgical treatment for chronic heart failure

Advances in the surgical treatment of chronic heart failure including ventricular re-modeling, artificial heart technology and bridge to recovery have revolutionized cardiac surgical management. This article summarizes the most popular surgical treatment of heart failure with experiences from various institutes. The author has stated that he does not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article.     

Surgical options for the treatment of heart failure

This article will examine the role of specific surgical interventions for congestive heart failure (CHF). The most definitive surgical option for severe end-stage heart failure is cardiac transplantation. In general, patients considered for heart transplant should have severe heart disease despite all other therapies with a high risk of death within 1 year. Noncardiac conditions that would by themselves shorten life expectancy or increase the risks of rejection, infection, or other fatal complication, should not be present. However, in light of the limited donor pool, complications associated with long-term immunosuppressive therapy, and the ever-increasing number of CHF patients, the role of cardiac transplantation for CHF will continue to be limited. The conduct of and evaluation for cardiac transplantation has been well described previously and therefore will not be evaluated in this review (1); however, there has been recent progress in the genetic modification of animal organs for potential use in transplantation (xenografts) (2). If these developments come to fruition, then cardiac transplantation/organ replacement may become a surgical option for a much greater number of CHF patients. One alternative approach to complete cardiac transplantation is the surgical placement of transformed cells into the diseased myocardium, briefly discussed under "Future Directions." This article will examine surgical options that are currently being used for CHF patients, surgical modalities that are currently under clinical evaluation, and finally, potential future therapies with respect to surgical options for heart failure.     

Outpatient management of chronic heart failure

Critical to the success of managing heart failure is appropriate outpatient follow up. Various models of care integrate medical care, pharmacologic intervention, and patient education and support. Key factors in any program are frequent patient assessment with rapid response to even subtle changes in the patient's condition. As the disease progresses, alternative care options such as palliative care and hospice should be integrated into the patient's care regimen.     

Observation unit management of heart failure

The acute exacerbation of HF can be treated successfully in the OU. There are significant benefits, such as admission avoidance, decreased 90-day readmissions, and decreased costs. HF requires a comprehensive management program with extensive involvement from a multidisciplinary team committed to improving care for this population, however.     

Contemporary management of pediatric heart failure

The spectrum of causes of pediatric heart failure is broad and differs significantly from that seen in most adult patients. Left-to-right shunts and outflow obstruction lesions are responsible for a large number of pediatric cases of heart failure. Most of these are now treated successfully with surgery or catheter intervention. Medical therapy is the mainstay of care for myocardial disorders with diuretics, angiotensin-converting enzyme inhibitors, beta-blockade and cardiac glycosides. There are few prospective trials of these agents in a pediatric population, but extrapolated data support their use in children. In addition to medical therapy, interventions such as automatic implantable cardioverter defibrillators and resynchronization therapy have become increasingly common in pediatric heart disease, as well as in adult patients with congenital heart disease.     

New directions in heart failure management

Approximately 4.8 million Americans are afflicted with heart failure; this accounts for 800,000 to 900,000 hospital admissions annually. Astute management in the primary care setting is essential for decreasing mortality and minimizing the risk for hospitalization. Although heart failure was initially viewed as a hemodynamic disorder, current evidence overwhelmingly supports that neurohormones, such as angiotensin II and aldosterone, contribute significantly to disease progression. The benefits of angiotensin-converting enzyme inhibitors and other drugs that block these substances are well established. This article discusses current management options that retard left ventricular remodeling to improve systolic function over time.     

Fluid management strategies in heart failure

In patients with chronic heart failure, fluid retention (or hypervolemia) is often the stimulus for acute decompensated heart failure that requires hospitalization. The pathophysiology of fluid retention is complex and involves both hemodynamic and clinical congestion. Signs and symptoms of both hemodynamic and clinical congestion should be assessed serially during hospitalization. Core heart failure drug and cardiac device therapies should be provided, and ultrafiltration may be warranted. Critical care, intermediate care, and telemetry nurses have roles in both assessment and management of patients hospitalized with acute decompensated heart failure and fluid retention. Nurse administrators and managers have heightened their attention to fluid retention because the Medicare performance measure known as the risk-standardized 30-day all-cause readmission rate after heart failure hospitalization can be attenuated by fluid management strategies initiated by nurses during a patient's hospitalization.     

Use of erythropoietin in heart failure management

OBJECTIVE: To review the use of erythropoietin for anemia in heart failure (HF). DATA SOURCES: Peer-reviewed articles in MEDLINE (1966-June 2004) were identified and citations from available articles were reviewed using the search terms anemia, erythropoietin, and heart failure. DATA SYNTHESIS: Anemia worsens HF prognosis. Clinical studies in patients with New York Heart Association Class III/IV HF who had hemoglobin <12 mg/dL and were refractory to maximal medical management showed that erythropoietin improves symptoms. Larger scale studies with mortality endpoints are required to confirm the benefits. CONCLUSIONS: In selected patients with severe, chronic HF, erythropoietin may be considered for functional improvement. However, routine use of this treatment strategy is not recommended until more data are available.