Heart Failure Surgery

Overview

Heart failure, also known as congestive heart failure, happens when the heart muscle is unable to pump blood as efficiently as it should. When this happens, blood frequently backs up and fluid can accumulate in the lungs.

Shortness of breath, extreme fatigue, and leg edema are frequent signs and symptoms of heart failure. Shortness of breath is frequently worse after activity or while lying down, and it might wake you up at night. A restricted capacity to exercise is another common symptom. Chest pain, especially angina, is not usually caused by heart failure.

The severity and etiology of the condition determine treatment. The majority of persons with heart failure do not require surgery and will be managed with medications. Heart surgery is only performed when doctors believe it can relieve a problem with the heart valves or the heart's blood supply, and only if the heart is strong enough. In most situations, surgery will not be able to treat heart failure.

Treatment for chronic stable moderate heart failure often consists of lifestyle changes such as quitting smoking, increasing physical activity, and making dietary modifications, as well as drugs. Cardiovascular resynchronization therapy (CRT) or cardiac contractility modulation may be beneficial in some moderate or severe situations. In patients with severe disease that continues after all previous efforts, a ventricular assist device (for the left, right, or both ventricles) or, in rare cases, a heart transplant may be advised.

What Is Heart Failure?

Heart failure (HF), also known as congestive heart failure (CHF) and (congestive) cardiac failure (CCF), is a group of symptoms caused by the failure of the heart's function as a pump that supports blood flow through the body; its signs and symptoms are caused by a structural and/or functional abnormality of the heart, which disrupts its filling with blood or ejecting it during each heartbeat.

Almost six million Americans suffer heart failure, and more than 870,000 people are diagnosed with heart failure each year. Heart failure (congestive heart failure) is the most common reason for hospitalization in persons over the age of 65.

Coronary artery disease, including a prior myocardial infarction (heart attack), high blood pressure, atrial fibrillation, valvular heart disease, excessive alcohol use, infection, and cardiomyopathy of unclear etiology, is the leading cause of heart failure.

These alter the structure or function of the heart, resulting in heart failure. The two kinds of left ventricular heart failure – heart failure with reduced ejection fraction or systolic heart failure and heart failure with intact ejection fraction – are determined by whether the left ventricle's capacity to contract or relax is impaired.

How Can I Prevent Heart Failure?

Although certain risk factors, such as age, family history, or race, are beyond your control, you may adjust your lifestyle to improve your chances of avoiding heart failure. You can accomplish the following:

• Maintaining a healthy weight.
• Consumption of heart-healthy foods.
• Regular exercise.
• Stress management.
• Putting an end to the usage of tobacco products.
• I don't drink alcohol.
• I do not use recreational drugs.
• Taking care of any other medical issues that may put you at danger.

When Is Surgery Used To Treat Heart Failure?

Most persons with heart failure are treated with a combination of lifestyle modifications and drugs. Maintaining a heart-healthy diet, remaining physically fit, and avoiding smoking and excessive alcohol use can all help to improve symptoms and quality of life. Medications may also be used to treat the symptoms of heart failure and to improve the heart's function.

However, some persons with heart failure may benefit from surgery. Cardiac failure can be caused by a variety of conditions, including coronary artery disease, atrial fibrillation, and heart valve disease, among others. To address these underlying concerns, surgical treatments may be performed. 

In some circumstances, such as heart transplantation, surgery is performed to treat persons with severe heart failure who cannot be helped by lifestyle modifications or medicines. In some circumstances, therapy entails the surgical insertion of a mechanical device, such as a pacemaker, that aids in the healthy functioning of the heart.

Types of Therapeutic Surgical Procedures For Heart Failure

Heart failure is treated using a variety of surgical procedures. Some individuals may require open-heart surgery, although others may benefit from a minimally invasive technique with less incisions than an open-heart operation. Doctors will assess which surgical solution is most suited to each patient's circumstances.

Among the surgical procedures performed to treat heart failure are:

Heart Procedures:

During surgery, the patient may be hooked up to a heart-lung bypass machine, which takes over the functions of the heart while the surgeon conducts the procedure.

1. Coronary Artery Bypass Graft (CABG):

The arteries that carry oxygen-rich blood to the heart muscle become restricted and stiff owing to plaque deposition in coronary artery disease (known as atherosclerosis). This limits the volume of blood that travels through the arteries to the heart, which can weaken the heart muscle and reduce its capacity to pump blood. CABG (pronounced "cabbage") surgery can help with this issue.

A surgeon grafts a portion of healthy blood vessel (a vein or artery obtained from elsewhere in the body) to the damaged coronary artery during this treatment. Above and below the restricted part of the coronary artery, the ends of the healthy blood vessel are attached.

This permits blood to bypass the constricted part of the coronary artery by passing through the newly linked blood channel. CABG can be performed by open-heart surgery or using a less invasive method. 

2. Heart Transplantation:

Some patients suffer from severe, progressive heart failure that cannot be treated with drugs or dietary and lifestyle modifications. A heart transplant may be the only successful therapy option in such circumstances.

Surgeons replace the damaged heart with a healthy heart from a donor who is brain dead. Finding a donor heart that closely matches the tissues of the person undergoing the transplant might take months. However, the matching procedure enhances the possibility that the heart will be accepted by the recipient's body.

During a transplant operation, the surgeon links the patient to a heart-lung machine, which substitutes the heart and lungs. The damaged heart is subsequently removed and replaced with the donor heart by the surgeon. Finally, the major blood arteries have been linked, and the new heart is functioning.

During the first several years following a heart transplant, the outlook is favorable. In reality, almost 90% of patients survive their surgeries for more than a year. However, the number of patients receiving heart transplants remains relatively modest — around 2,500 per year.

3. Percutaneous Coronary Intervention (PCI):

When the blood flow to the heart muscle is restricted due to blockages in the coronary arteries, heart failure can develop. Removing these blockages can improve overall heart function, which may alleviate or eliminate symptoms of heart failure. PCI, also known as angioplasty, is a type of operation used to unblock clogged blood arteries.

The operation is typically carried out in a cardiac catheterization lab. A short tube (catheter) with a little deflated balloon on the end is inserted and pushed through an incision in the groin (or other region where the artery may be accessible) to the affected artery. The balloon is then inflated to press the artery open. Once the artery has been fully opened, the balloon is withdrawn.

A stent may be placed during the procedure to keep the blood vessel open. Although there’s a slight risk of damage to the artery during PCI, this procedure usually improves the patient’s condition.

4. Heart Valve Repair/Replacement: 

Heart failure is sometimes caused by a defective or diseased heart valve. Heart valves regulate the flow of blood inside the heart. When the valves don’t work properly, this puts extra strain on the heart and can lead to heart failure.

Medical management is the initial step in treating certain valve issues. Surgically correcting the issue frequently improves or cures the condition as well.

A mechanical valve constructed of metal and plastic, as well as one made of human or animal tissue, can be used as a replacement valve. During the procedure, the patient is hooked up to a heart-lung machine, which delivers blood to the brain and body. The faulty valve has been removed and replaced.

Patients may be given medications after the procedure, depending on the kind of replacement heart valve utilized, to prevent blood clots from developing around the new heart valve. This therapy is frequently long-term in order to verify that the replacement valve functions correctly. Most heart valve operations are successful; however, the procedure is only considered when a faulty or damaged valve threatens someone's life.

Some people may be able to have their heart valves replaced without undergoing surgery. However, eligibility for this type of surgery is very specific.

5. Aneurysm Repair Surgery:

A scar may develop when a heart attack happens in the left ventricle. With each beat, the scarred region might thin and protrude out. An aneurysm is a bulging, thin region of the body. These changes, together with any additional cardiac abnormalities you may have, may result in heart failure. Your heart will initially pump harder, but with time, the left ventricle will become bigger than normal and pump less effectively.

The damaged heart muscle and/or aneurysm tissue are removed during the Modified Dor aneurysm repair operation to restore the left ventricle to a more normal shape. In certain circumstances, a patch is applied to the previously scarred region. The objective is to increase your heart's capacity to pump blood.

6. Dynamic cardiac myoplasty:

The intention here is to re‐power the failing heart using autologous skeletal muscle.

Skeletal muscle (latissimus dorsi muscle) is mobilized on its neurovascular pedicle and introduced into the chest by a minor thoracotomy and wrapped around the heart to provide power to ventricular contraction, thus increasing systolic performance.

It is continually timed in order to first convert rapid twitch muscle to slow twitch muscle, and then to synchronize skeletal wrap contraction with cardiac contraction. 

Patients who have heart failure but do not have NYHA class IV, mitral regurgitation, atrial fibrillation, pulmonary wedge pressure >25 mm Hg, ejection fraction 12%, multivessel coronary artery disease, or peak oxygen consumption of 10 ml/kg/min are targeted, as poor surgical outcomes have been reported in these groups.

Implantable medical devices:

Doctors may surgically implant a mechanical device to help the heart improve its ability to pump blood.

1. Cardiac Resynchronization Therapy (CRT):

To properly pump blood, the ventricles, the heart's two lower, muscular chambers, must contract in a synchronized beat. The contraction of the ventricles is not adequately coordinated in some persons with heart failure, reducing the volume of blood the heart can pump. 

The ventricles are resynchronized using CRT. A surgeon installs a tiny pacemaker (known as a biventricular pacemaker) in the chest during this minimally invasive surgery. When the ventricle contractions are not synchronized, the device sends an electrical impulse to the ventricles to resynchronize them.

• Benefits of CRT

Because CRT improves the efficiency of the heart and increases blood flow, patients have experienced relief from various heart failure symptoms, such as shortness of breath. Clinical investigations have also shown that there is a reduction in hospitalization and morbidity, as well as an improvement in quality of life.

• Who is a candidate for CRT?

CRT is generally reserved for individuals with moderate to severe heart failure symptoms and whose left and right heart chambers do not beat in synchrony. CRT, on the other hand, is not for everyone and is not appropriate for individuals with moderate heart failure symptoms, diastolic heart failure, or who do not have problems with the chambers not beating together. 

It is also not appropriate for those who have not exhausted all medical options for treating their problem. CRT has been shown in trials to be equally helpful for both men and women.

2. Implantable Cardioverter-Defibrillator (ICD):

 Arrhythmia, or irregular heart rate, can lead to heart failure. To treat this disease, a surgeon may implant an ICD, which is a device that detects irregular heartbeats and sends an electrical impulse to the heart to restore the rhythm. A minimally invasive approach is used for ICD implantation.

3. Ventricular Assist Device (VAD). 

VADs are mechanical pumps driven by batteries that assist the ventricles in pumping blood to the lungs and throughout the body. VADS are typically implanted by open-heart surgery. Tubes link the device to the heart and blood arteries, and a cable connects the device to a power source and computerized controller that are transported outside the body through a hole in the belly. VADs can be used temporarily, such as while a patient awaits a heart transplant, or they can be left in place permanently.

• When is an VAD used? 

This device, often known as a "bridge to transplant," is being employed in long-term treatment. People frequently have to wait a long time for a suitable heart to become available. During this time, the patient's already frail heart may degenerate more, causing it to lose its capacity to pump blood throughout the body. An LVAD can aid a weak heart and "buy time" for the patient, or it can completely obviate the need for a heart transplant. Recently, LVADs have been utilized as "destination therapy" in patients with end-stage heart failure when heart transplantation is not a possibility.

• How does an VAD work? 

A popular kind of VAD includes a tube that draws blood from the left ventricle and directs it to a pump. The pump then delivers blood to the aorta (the large blood vessel leaving the left ventricle). This has a significant impact on the weaker ventricle. The pump is positioned in the upper abdomen. Another tube connected to the pump is brought out of the abdominal wall and joined to the pump's battery and control system. VADs are now portable and are frequently used for weeks to months at a time. Patients with VADs can be discharged from the hospital and live a normal life while waiting for a donor heart to become available.

Potential Complications During and After

Some of the most frequent complications of cardiac surgery are routinely dealt with in the hospital throughout the hours and days following recovery. Staff and lab tests are used to keep a close eye on the patient for these issues.

• Bleeding: This can happen at the incision site or from the region of the heart where the procedure is being conducted.
• Abnormal Heart Rhythm: In rare circumstances, a temporary or permanent internal pacemaker may be required to treat this condition.
• Ischemic Heart Damage: Heart tissue damage caused by a lack of blood supply to the heart.
• Death: When the heart is halted for a surgical operation, the chance of death increases.
• Stroke: Often caused by clots that form in the blood after surgery
• Blood Loss: In some cases, a transfusion may be necessary.
• Emergency Surgery: If a problem is discovered after surgery, emergency surgery may be necessary to repair any problems.
• Cardiac Tamponade (Pericardial Tamponade): A potentially fatal disorder in which the pericardium, the sac around the heart, becomes engorged with blood. This makes it difficult, if not impossible, for the heart to operate normally.

Conclusion

Heart failure is a chronic disorder in which your heart is unable to pump blood efficiently enough to satisfy your body's demands all of the time. Exercise and medication are used to treat heart failure at first, and surgical techniques may be used if the condition worsens.

Irregular heartbeat, sudden cardiac arrest, heart valve problems, an accumulation of fluid in your lungs, and pulmonary hypertension are some of the consequences of heart failure.

Treatments indicated in Stages A, B, and C are typically included in the treatment plan for persons with Stage D heart failure. Furthermore, it includes evaluation for more advanced treatment options, such as primary heart surgery (e.g., heart transplant, CABG) or implanted cardiac devices such as ventricular assist devices.