7.2.

4 SURGERY A heart failure patient can undergo surgery if the functional pathology which causes the heart failure can be amended by surgery procedure and which is the strictly considered by specialists. However the decision to subject a patient to surgery should take into account the functional status, prognosis and co-morbid conditions of the patient. There are several types of surgery procedure under heart failure as follows :

a) Revascularization Procedures [1] Randomized trials datas were not found to support the use of revascularization surgery for the relief of symptoms due to HF. Revascularization is not advisable as routine management of patients with coronary artery disease and HF. The cases of operative mortality in these patients are also high. Coronary revascularization (by either coronary artery bypass surgery or PCI) should be considered in patients with HF and suitable coronary anatomy if they have: refractory angina or acute coronary syndrome, for relief of symptoms. Myocardial ischemia and viability should be demonstrated by tests such as dobutamine stress echocardiography, radionuclide myocardial perfusion scan or cardiac magnetic resonance imaging.

Percutaneous Coronary Intervention (PCI) [2] Blockage in the coronary arteries restrict the blood supply to the heart muscle and causes heart failure. Alternatives to removing these blockages can improve overall heart function, which may improve or resolve heart failure symptoms. PCI is one type of procedure to unblock vessels. A small tube or a catheter with a tiny deflated balloon on the end is inserted through an incision in the groin area and pushed through to the diseased artery. Then the balloon is inflated to push open the artery. The balloon is removed once the artery has been fully opened. 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 this procedure, PCI usually improves the patient's condition.

Coronary Artery Bypass Graft ( CABG) [2] Coronary artery bypass surgery figures out a different route the blood supply around a blocked section of the artery. Surgeons remove healthy blood vessels from another part of the body, such as a leg or the chest wall. They then surgically attach the vessel in such a way that the blood can flow around the blocked area.

b) Valve Surgery [4] Heart failure and severe mitral regurgitation may have symptomatic improvement after mitral valve surgery (valve repair or replacement). Patients with left ventricular systolic dysfunction undergoing surgical coronary revascularization who also have moderate to severe mitral regurgitation secondary to ventricular dilatation may be considered for concomitant mitral valve repair or replacement. Minimally invasive valve surgery is done through much smaller cuts than open surgery, or through a catheter inserted through the skin. Once the valve is repaired, we will have ring annuloplasty which is a ring-like part around the valve by sewing a ring of plastic, cloth, or tissue around the valve or valve repair in which the surgeon trims, shapes, or rebuilds one or more of the leaflets of the valve. It acts as a leaflet flaps that open and close the valve. Valve repair is best for the mitral and tricuspid valves. The aortic valve is usually not repaired. Unless if valve is too damaged, than a new valve replacement known as valve replacement surgery is needed in which the valve will be removed and put a new one in place. The main types of new valves are:

Mechanical : made of man-made materials, such as metal (stainless steel or titanium) or ceramic. This type serves for a long time but concurrently we need to consume blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of your life.

Biological : it is made of human or animal tissue and sustains these valves for 12 15 years, but you may not need to take blood thinners for life.

In some exceptational, surgeons can use your own pulmonary valve to replace the damaged aortic valve. The pulmonary valve is then replaced with an artificial valve (Ross Procedure). It is highly recommended for people who refuse to take blood thinners for the rest of their life.

c) Left Ventricular Reduction Surgery [1] Patients with a large discrete left ventricular aneurysm who develop heart failure, angina pectoris, thromboembolism, and tachyarrhythmias due to the aneurysm are best indicated for left ventricular aneurysmectomy . For those cases of patients with heart failure undergoing surgical coronary revascularization, who have areas of left ventricular dyskinesia or akinesia may be considered for concomitant left ventricular reduction surgery.

d) Left Ventricular Assist Devices [1] Left ventricular assist devices helps to bridge patients with heart failure to heart transplantation, to support patients with acute severe myocarditis with a view to recovery, and in some patients for permanent haemodynamic support. For those waiting list who have become refractory to all means of medical circulatory support should be considered for a mechanical support device as a bridge to transplant.

7.2.5 HEART TRANSPLANTATION Heart transplantation is the procedure by which the failing heart is replaced with another heart from a suitable donor.It is usually indicated for end-stage congestive heart

failure (CHF) who are estimated to have less than 1 year to live without the transplant and who are not candidates for or have not been helped by conventional medical therapy. In addition, most candidates are excluded from other surgical options because of the poor condition of the heart but however it is not strongly recommended in unstable geriatric. Candidates for cardiac transplantation generally present with New York Heart Association (NYHA) class III (moderate) symptoms or class IV (severe) symptoms.
[3]

Patients with

severe HF despite optimal medical therapy, and who meet the eligibility criteria, should be considered for heart transplantation and referred for further evaluation. Indicators of severe HF and consideration for heart transplantation include: Poor LVEF (<25%) Recurrent admissions or major limitation of the patients daily activities Poor effort tolerance i.e. peak VO2 less than 10 ml per kg per min with achievement of anaerobic metabolism iv inotropic dependence. Contraindications to cardiac transplantation include any malignancy within 5 years, diabetes mellitus with widespread microvascular complications, chronic kidney, liver or lung disease, pulmonary hypertension, or other medical or psychosocial issues that would impact survival.
[1]

References :

1.cpg 2- Principles of anatomy and physiology, 11th edition, Tortora Derickson 3 Adapted from Medscape http://emedicine.medscape.com/article/163062-overview 4. Bonow R0, Mann DL, Zipes DP, Libby P, et al. Braunwalds Heart Disease : A textbook of Cardiovascular Medicine, 9th edition, Saunders Elsevier 2011, Chap 66