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Key Concepts

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  • Epidemiology

    • Congestive heart failure (CHF) is the most prevalent medical problem in Western society as the leading cause of death in the United States. Ischemic cardiomyopathy (ICM) is the leading cause of CHF, affecting 75 percent of patients with CHF.

  • Pathophysiology

    • ICM is generally caused by a full-thickness myocardial infarction (MI), followed by ventricular remodeling. This remodeling process can result in progressive dilation of the ventricle, leading to an increase in the end-diastolic diameter and volume, an increase in left ventricular wall stress and oxygen demand, a loss of the left ventricle’s natural elliptical shape with the development of a more rounded form, the development of mitral insufficiency and, ultimately, a worsening of global systolic function.

  • Clinical features

    • Progressive CHF due to ICM results in debilitating congestive symptoms, including dyspnea, fatigue, peripheral edema and, in its end stages, acute and/or chronic multisystem organ failure. Classically, patients are candidates for surgical ventricular remodeling (SVR) if they have had an anterior MI, have a large area of akinesis or dyskinesis, and have clinical evidence of CHF.

  • Diagnostics

    • Preoperative diagnostics include cardiac catheterization with coronary angiography. Other potentially useful diagnostics include myocardial viability and magnetic resonance imaging studies.

  • Treatment

    • The surgical goals of SVR include complete revascularization of all viable territories, exclusion of akinetic and dyskinetic segments with a concomitant reduction in the size of the nonfunctioning anteroseptal portion of the heart, recreation of the elliptical shape of the heart, and repair of any valvular incompetence by valve repair or replacement.

  • Outcomes/prognosis

    • SVR has been shown to improve ventricular size, morphology, left ventricular ejection fraction (EF), stroke-volume index, endocrine markers of CHF, ventricular energetics, ventricular synchrony, and mechanical efficiency. Clinically, it results in improved functional capacity (New York Heart Association class) and an excellent 5-year survival in very sick patients. Further study and experience are needed to optimize patient selection and timing for surgical intervention as well as to better define the mechanistic basis behind the beneficial effects of SVR.

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Introduction

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Congestive heart failure (CHF) is a major medical problem facing Western society today. It is the leading cause of death in the United States, representing over one-quarter of all deaths and is expected to become even more significant in the years ahead.1 The incidence of new CHF cases are on the rise as more than 400,000 new cases per year continue to add to the over 5 million people living with CHF in the United States.1 Ischemic cardiomyopathy (ICM) is the leading cause of CHF, affecting some 75 percent of patients with this condition.2,3 Medical and surgical therapies have been shown to be effective in improving survival and quality of life in CHF patients.4 Coronary artery bypass grafting (CABG) has been shown to be effective in some patients with ICM, but heart transplantation and left ventricular assist devices are more effective in patients with advanced heart failure.5 Surgical ventricular ...

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