Surgery, Mitral Regurgitation, and Heart Failure: The Valves Are All Repairable But the Patients Are Not

Abstract

Despite advances in medical and surgical therapy, heart failure continues to be a formidable problem. More than 5 million individuals are affected by heart failure in the United States, and it is estimated that 550 000 new cases are diagnosed annually (www.americanheart.org). Advances have been made with medical therapy and cardiac resynchronization, but despite such measures, outcomes remain poor in individuals with advanced heart failure.1 Cardiac transplantation, the ultimate therapy for end-stage heart failure, is plagued by the limited supply of donor hearts and the need for lifelong immunosuppression. It remains, and will always be, a therapy that benefits, at best, only a few thousand individuals each year. Ventricular assist devices are improving but are still limited by problems such as infection and thromboembolism. Although several promising ventricular assist devices are in trial or recently approved, they are only available for those with the most advanced heart failure.2,3 For all intents and purposes the field of mechanical assistance remains, if not in its infancy, in its childhood. Many patients once thought to need transplant can benefit from conventional surgery like bypass and valve repair. Mahon et al4 from the Cleveland Clinic demonstrated equivalent intermediate survival for transplant and conventional surgery in a group of patients initially referred for transplant. We have learned from the ventricular reconstruction literature that many patients with advanced cardiomyopathy can have excellent long-term survival after conventional surgery.5–7 Surgeons who frequently deal with ischemic cardiomyopathy now no longer focus on left ventricular function, but rather the degree of hibernating myocardium that can be revascularized.8 Modern surgical heart failure specialists look for targets of opportunity which, when corrected, will help their patients’ compromised ventricles function more efficiently and potentially reverse remodel. Many heart failure patients can benefit from conventional surgical repairs but it …