Congestive heart failure (CHF) has become a major worldwide public health problem. In our ever-aging population, medical advances that have extended our average life expectancy have also left more people living with chronic cardiac disease than ever before. More than 20 million people are affected worldwide. In the United States the estimated 2006 prevalence of heart failure in adults age 20 and older is 5.8 million yet less than 3000 are offered transplantation because of limitations of age, comorbid conditions, and donor availability. Despite the significant improvements with medical management hospital discharges for heart failure rose from 877,000 in 1996 to 1,106,000 in 2006 and mortality in the first year is one in five. CHF patients are repeatedly readmitted for inpatient care and the vast majority will die within 3 years of diagnosis.1
Orthotopic heart transplantation (OHT) offers successful and reproducible long-term results and is the treatment of choice for patients with medically refractory end-stage heart failure.2 Unfortunately, the obvious limitations to OHT include the need for immunosuppression and the severe shortage of donor organs. This past decade has seen the annual number of transplants performed worldwide plateau at less than 4000, down to only 3353 in 2008.3,4 This lack of donor availability has thus necessitated a rigorous selection criteria be applied to potential recipients in order to optimize the utility of these precious organs, indicated only for patients with end-stage cardiomyopathy in whom all other modes of therapy have been exhausted. Access to OHT has thus been restricted to those without comorbid medical conditions and relatively restricted to those younger than age 65. This leaves the vast majority of CHF patients seeking other options.
With significant technologic strides being made toward total implantability, the role for mechanical support is becoming more widely accepted as a bridge to recovery as well as a bridge to transplant. There have been a number of successful studies of ventricular assist devices (VADs) used as a bridge to recovery and the long-term efficacy for this purpose, and this use as a long-term therapy for chronic heart failure has become established by multicenter clinical trials.5–10 As a result continuous-flow left ventricular assist devices (LVADs) have emerged as the standard of care for advanced heart failure patients requiring long-term mechanical circulatory support. The long-term survival of circulatory support is increasing but does not yet equal survival after OHT, the gold standard treatment. Because many more people can benefit from this therapy, and with their improved durability, these devices are now an option in the management of patients with heart failure.
This clinical dilemma has provided the impetus for surgeons to develop new alternatives for the treatment of heart failure. As OHT and VAD use is more stringently applied, techniques to restore myocardial perfusion, eliminate valvular regurgitation, and restore ventricular geometry have emerged as a possible first-line surgical approach to heart failure. In response to the growing need for ...