Surgery and Devices:

Revascularization Surgery

Revascularization surgery helps to restore blood flow to the heart. It can treat blocked arteries in patients with coronary artery disease and may help selected patients with heart failure. Surgery types include coronary artery bypass graft (CABG) and angioplasty (also called percutaneous coronary intervention [PCI]). CABG is a traditional type of open heart surgery. Angioplasty uses a catheter to inflate a balloon inside the artery. A metal stent may also be inserted during an angioplasty procedure. [For more information, see In-Depth Report #03: Coronary artery disease.]

Pacemakers

Pacemakers, also called pacers, help regulate the heart� ' s beating action, especially when the heart beats too slowly. Biventricular pacers (BVPs) are a special type of pacemaker used for patients with heart failure. Because BVPs help the heart� ' s left and right chambers beat together, this treatment is called cardiac resynchronization therapy (CST).

BVPs are recommended for patients with moderate-to-severe heart failure that is not controlled with medication therapy and who have evidence of left-bundle branch block on their EKG. Left-bundle branch block is a condition in which the electrical impulses in the heart do not follow their normal pattern, causing the heart to pump inefficiently.

Implantable Cardioverter Defibrillators (ICDs)

Patients with enlarged hearts are at risk for having serious cardiac arrhythmias that are associated with sudden death. Implantable cardioverter defibrillators (ICDs) have been shown to reduce the incidence of sudden-death in patients with symptomatic heart failure and an ejection fraction less than 30%. Generally, patients should also be on full medical therapy. Studies have also found ICDs effective in preventing sudden death from severe rhythm disturbances in patients with a history of these serious arrhythmias and in patients with genetic hypertrophic cardiomyopathy.

In recent years, certain ICD models and biventricular pacemaker-defibrillators have been recalled by the manufacturers because of circuitry flaws. However, doctors stress that the chance of an ICD or pacemaker saving a person� ' s life far outweigh the possible risks of these devices failing.

Ventricular Assist Devices

A growing array of heart devices and machines are being used in heart failure treatment. Ventricular assist devices are machines that help improve pumping actions. They have gained widespread acceptance for use as a bridge to transplant in patients who are on medications but still have severe symptoms and are awaiting a donor heart. Increasingly, though, doctors are exploring the possibility that such devices may be satisfactory treatments themselves, forestalling the need for a transplant altogether in some patients. Therefore they may be used as short-term (less than 1 week) or longer term support.

Ventricular assist devices include:

• Left ventricular assist devices (LVADs) are used for patients whose heart beat has slowed dangerously to help take over the pumping action of the failing heart. Until recently, these machines required remaining in the hospital. Smaller battery-powered implanted LVAD units are now allowing many patients to leave the hospital while they wait for a transplant.
• Intra-aortic balloon pumps are helpful for temporarily maintaining heart function in patients with left-side failure who are waiting for transplants and for those who develop a sudden and severe deterioration of heart function. The IABP is an implanted thin balloon that is usually inserted into the artery in the leg and threaded up to the aorta leading from the heart. Its pumping action is generating by inflating and deflating the balloon at certain rates.
• Fully implanted miniature artificial pumps that assist the heart are also being tested.

Short-term support may be provided for patients who have reached end-stage disease in order to “bridge” them until an appropriate heart for transplantation is available. Some patients may require short-term support while the heart muscle recovers after a serious cardiac event. Permanent use to chronically support a patient is also increasing.

Complications after implantation of these devices are not insignificant, as are some of the long-term complications in patients who make it through after surgery. The risks involved with many of these devices include bleeding, blood clots, and right-side heart failure. Infections are a particular hazard.

Heart Transplantation

Patients who suffer from severe heart failure and whose symptoms do not improve with drug therapy or mechanical assistance may be candidates for heart transplantation. Some 3,600 people are awaiting a transplant, although only about 2,000 operations are performed each year.

The most important factor for heart transplant eligibility is overall health. Chronological age is less important. Most heart transplant candidates are ages 50 - 64 years.

While the risks of this procedure are high, the 1-year survival rate is about 86% for men and 84% for women. Five years after a heart transplant, about 71% of men and 67% of women remain alive. In general, the highest risk factors for death 3 or more years after a transplant operation are coronary artery disease and the adverse effects (infection and certain cancers) of immunosuppressive drugs used in the procedure. The rejection rates in older people appear to be similar to those of younger patients.

Implantable Artificial Heart

In 2004, the FDA approved a temporary artificial heart (Syncardia) intended to keep patients alive in the hospital while they waited for a heart transplant. In 2006, the FDA approved the first permanent implantable artificial heart (AbiCor). The AbiCor is available only for patients who are not eligible for a heart transplant and who are not expected to live more than a month without medical treatment. The device requires a large chest cavity, which means that most women will not be eligible for it. Of the 14 men who have received the AbiCor, the average survival was less than 5 months after surgery. Only one patient was discharged from the hospital. The device� ' s manufacturer is working on a new model that it hopes will extend survival.