Overview Despite advances in medical management of heart failure (HF), there remain circumstances in which surgical procedures are the only or the best treatment option. Heart transplantation, the longest accepted surgical therapy, and procedures that (1) repair the heart, (2) reshape it, or (3) replace all or part of heart function are considered in this section of the guideline. Myocardial viability and revascularization are addressed in Section 13. Recommendation10.1It is recommended that the decision to undertake surgical intervention for severe HF be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions. Procedures should be done at centers with demonstrable expertise and multidisciplinary medical and surgical teams experienced in the selection, care, and perioperative and long-term management of high risk patients with severe HF. (Strength of Evidence = C) Specific Therapies Recommendation10.2Evaluation for heart transplantation is recommended in selected patients with severe HF, debilitating refractory angina, or ventricular arrhythmia that cannot be controlled despite drug, device, or alternative surgical therapy. (Strength of Evidence = B) Background The short- and long-term success of heart transplantation is limited by shortage of donor organs. Only 2016 human heart transplants were performed in the US in 2004, far below the 20,000 to 30,000 patients per year who could benefit from this therapy. Heart transplantation has demonstrated 1-year survival exceeding 80% and 5-year survival of 65%. It thus provides a survival benefit in certain well-selected patients with an otherwise poor prognosis of survival at 1 year.1Hosenpud J.D. Bennett L.E. Keck B.M. Fiol B. Boucek M.M. Novick R.J. The Registry of the International Society for Heart and Lung Transplantation: sixteenth official report—1999.J Heart Lung Transplant. 1999; 18: 611-626Abstract Full Text Full Text PDF PubMed Scopus (387) Google Scholar Consideration of heart transplantation for HF patients should be based on a comprehensive multidisciplinary evaluation of risks. Referral for cardiac transplantation should be entertained for those patients who demonstrate considerable limitation in their activities despite optimal medical therapy for persistent cardiac symptoms.2Mudge G.H. Goldstein S. Addonizio L.J. Caplan A. Mancini D. Levine T.B. et al.24th Bethesda conference: cardiac transplantation. Task Force 3: Recipient guidelines/prioritization.J Am Coll Cardiol. 1993; 22: 21-31Abstract Full Text PDF PubMed Scopus (255) Google Scholar Such patients typically are screened with a cardiopulmonary stress test. If peak aerobic capacity appears to be severely limited as indicated by a VO2max < 14 mL·kg·min or ≤55% of predicted for age and gender, transplantation may be considered.3Mancini D.M. Eisen H. Kussmaul W. Mull R. Edmunds Jr., L.H. Wilson J.R. Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure.Circulation. 1991; 83: 778-786Crossref PubMed Scopus (1456) Google Scholar, 4Stelken A.M. Younis L.T. Jennison S.H. Miller D.D. Miller L.W. Shaw L.J. et al.Prognostic value of cardiopulmonary exercise testing using percent achieved of predicted peak oxygen uptake for patients with ischemic and dilated cardiomyopathy.J Am Coll Cardiol. 1996; 27: 345-352Abstract Full Text PDF PubMed Scopus (289) Google Scholar In the presence of obesity, particularly in women, traditional VO2max measurements may not stratify risk effectively. In such instances, adjusting VO2 max for lean body mass may allow better risk stratification to plan transplantation. 5Osman A.F. Mehra M.R. Lavie C.J. Nunez E. Milani R.V. The incremental prognostic importance of body fat adjusted peak oxygen consumption in chronic heart failure.J Am Coll Cardiol. 2000; 36: 2126-2131Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar Vo2max may be less predictive of outcomes in patients taking β-blockers 6Shakar S.F. Lowes B.D. Lindenfeld J. Zolty R. Simon M. Robertson A.D. et al.Peak oxygen consumption and outcome in heart failure patients chronically treated with beta-blockers.J Card Fail. 2004; 10: 15-20Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar and the cutpoint may be closer to ≤12 mL·kg·min. In patients who cannot undergo exercise testing, or if the major indication is refractory debilitating angina or ventricular arrhythmia, transplantation may be considered based on quality of life limitations alone. It should be stressed that no single test should be used as an absolute to list a patient for transplantation. Evaluators must be mindful of all clinical characteristics. Widely accepted contraindications to cardiac transplantation include any malignancy within 5 years, diabetes mellitus with widespread microvascular complications, chronic kidney disease unlikely to reverse, irreversible pulmonary hypertension, or other medical or psychosocial issues that would impact survival.2Mudge G.H. Goldstein S. Addonizio L.J. Caplan A. Mancini D. Levine T.B. et al.24th Bethesda conference: cardiac transplantation. Task Force 3: Recipient guidelines/prioritization.J Am Coll Cardiol. 1993; 22: 21-31Abstract Full Text PDF PubMed Scopus (255) Google Scholar Recommendation10.3Isolated mitral valve repair or replacement for severe mitral regurgitation secondary to ventricular dilatation in the presence of severe left ventricular (LV) systolic dysfunction is not generally recommended. (Strength of Evidence = C) Background There is little randomized clinical trial evidence to support the benefit of mitral valve repair, and the observational data are limited and conflicting. The proposed pathophysiologic basis for this surgical approach is well known. As the ventricle dilates, the papillary muscles are displaced, coaptation of the mitral valve leaflets is decreased, and a central jet of mitral regurgitation appears. Previous reports of a prohibitive operative mortality for mitral valve replacement in patients with end-stage cardiomyopathy led to the denial of surgical mitral valve correction for patients with severe ventricular dysfunction and mitral regurgitation. Although the absence of controlled studies complicates interpretation, recent data indicate that mitral valve repair, which preserves the subvalvular apparatus and cardiac function better than mitral valve replacement, can be performed with an acceptable perioperative mortality and good medium-term survival at highly experienced centers. Mitral valve repair via an “undersized” annuloplasty repair effectively corrects mitral regurgitation in HF patients.7Smolens I.A. Pagani F.D. Bolling S.F. Mitral valve repair in heart failure.Eur J Heart Fail. 2000; 2: 365-371Crossref PubMed Scopus (42) Google Scholar Early results suggested that this technique might improve symptoms and favorably remodel the left ventricle8Romano M.A. Bolling S.F. Mitral valve repair as an alternative treatment for heart failure patients.Heart Fail Monit. 2003; 4: 7-12PubMed Google Scholar, 9Bishay E.S. McCarthy P.M. Cosgrove D.M. Hoercher K.J. Smedira N.G. Mukherjee D. et al.Mitral valve surgery in patients with severe left ventricular dysfunction.Eur J Cardiothorac Surg. 2000; 17: 213-221Crossref PubMed Scopus (166) Google Scholar; however, a subsequent small randomized trial indicated no benefit of mitral valve repair in patients with mitral regurgitation because of ventricular dysfunction.10Wu A.H. Aaronson K.D. Bolling S.F. Pagani F.D. Welch K. Koelling T.M. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction.J Am Coll Cardiol. 2005; 45: 381-387Abstract Full Text Full Text PDF PubMed Scopus (550) Google Scholar More controlled trials and registry data are needed before recommending this technique as an effective alternative to transplantation. Recommendation10.4Partial LV resection (“Batista procedure”) is not recommended in nonischemic cardiomyopathy. (Strength of Evidence = B) Background There is no compelling evidence demonstrating the benefits of this procedure.11Franco-Cereceda A. McCarthy P.M. Blackstone E.H. Hoercher K.J. White J.A. Young J.B. et al.Partial left ventriculectomy for dilated cardiomyopathy: is this an alternative to transplantation?.J Thorac Cardiovasc Surg. 2001; 121: 879-893Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar Recommendations10.5Patients awaiting heart transplantation who have become refractory to all means of medical circulatory support should be considered for a mechanical support device as a bridge to transplant. (Strength of Evidence = B)10.6Permanent mechanical assistance using an implantable assist device may be considered in highly selected patients with severe HF refractory to conventional therapy who are not candidates for heart transplantation, particularly those who cannot be weaned from intravenous inotropic support at an experienced HF center. (Strength of Evidence = B) Background Therapy with implantable LV assist devices (LVADs) can restore cachectic, end-stage class D patients to a vital life status.12Gammie J.S. Edwards L.B. Griffith B.P. Pierson 3rd, R.N. Tsao L. Optimal timing of cardiac transplantation after ventricular assist device implantation.J Thorac Cardiovasc Surg. 2004; 127: 1789-1799Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 13Kasirajan V. McCarthy P.M. Hoercher K.J. Starling R.C. Young J.B. Banbury M.K. et al.Clinical experience with long-term use of implantable left ventricular assist devices: indications, implantation, and outcomes.Semin Thorac Cardiovasc Surg. 2000; 12: 229-237Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 14Kherani A.R. Oz M.C. Ventricular assistance to bridge to transplantation.Surg Clin North Am. 2004; 84: 75-89Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Pulsatile pumps approved for bridge-to-transplantation include the DeBakey Child LVAD, the Novacor LVAS (Left Ventricular Assist System), the HeartMate VE LVAS, and the Cardiowest Temporary Total Artificial Heart.15Hayashi M. Tsutamoto T. Wada A. Maeda K. Mabuchi N. Tsutsui T. et al.Intravenous atrial natriuretic peptide prevents left ventricular remodeling in patients with first anterior acute myocardial infarction.J Am Coll Cardiol. 2001; 37: 1820-1826Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar Portable battery-powered devices allow patients to be discharged from the hospital after they are rehabilitated, typically while waiting for heart transplant.16Stevenson LW, Kormos RL, Barr ML, Costanzo MR, Desvigne-Nickens P, Feldman AM, et al. Mechanical cardiac support 2000: current applications and future trial design: June 15–16, 2000 Bethesda, Maryland. Circulation 2001;103:337–42.Google Scholar Well-established as a clinical bridge to cardiac transplantation, mechanical assist devices are evolving towards smaller devices with transcutaneous energy sources that reduce morbidity and avoid the frequent risk of infection. Continuous flow axial impeller pumps and centrifugal flow pumps have been introduced to clinical application, offering new advantages. Several studies have reported on 1 VAD with an 81% probability of patient survival 30 days after implant,17Salzberg S. Lachat M. Zund G. Oechslin E. Schmid E.R. DeBakey M. et al.Left ventricular assist device as bridge to heart transplantation—lessons learned with the MicroMed DeBakey axial blood flow pump.Eur J Cardiothorac Surg. 2003; 24: 113-118Crossref PubMed Scopus (43) Google Scholar, 18Frazier O.H. Myers T.J. Westaby S. Gregoric I.D. Use of the Jarvik 2000 left ventricular assist system as a bridge to heart transplantation or as destination therapy for patients with chronic heart failure.Ann Surg. 2003; 237 (discussion 636–7): 631-636Crossref PubMed Scopus (88) Google Scholar suggesting the possibility of circulatory support in patients with severe HF sufficient for them to recover and return to normal activities while awaiting heart transplantation. Another study reported on patients who underwent implantation of an LVAD as a bridge to transplant, demonstrating that patients previously felt to be ineligible for transplantation because of elevated pulmonary vascular resistance were subsequently able to undergo cardiac transplant.19Dowling R.D. Gray Jr., L.A. Etoch S.W. Laks H. Marelli D. Samuels L. et al.The AbioCor implantable replacement heart.Ann Thorac Surg. 2003; 75: S93-S99Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar A study of another LVAD in 22 patients as a bridge to transplant and 4 patients as destination therapy showed high initial mortality, but marked improvements in hemodynamics for those who survived, making inotropic therapy unnecessary.20Copeland J.G. Smith R.G. Arabia F.A. Nolan P.E. Sethi G.K. Tsau P.H. et al.Cardiac replacement with a total artificial heart as a bridge to transplantation.N Engl J Med. 2004; 351: 859-867Crossref PubMed Scopus (417) Google Scholar A totally contained artificial heart has recently been studied as a bridge-to-transplant device.20Copeland J.G. Smith R.G. Arabia F.A. Nolan P.E. Sethi G.K. Tsau P.H. et al.Cardiac replacement with a total artificial heart as a bridge to transplantation.N Engl J Med. 2004; 351: 859-867Crossref PubMed Scopus (417) Google Scholar The Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial randomized 129 patients with end-stage HF ineligible for cardiac transplantation to implantation of an LVAD or optimal medical management.21Rose E.A. Gelijns A.C. Moskowitz A.J. Heitjan D.F. Stevenson L.W. Dembitsky W. et al.Long-term mechanical left ventricular assistance for end-stage heart failure.N Engl J Med. 2001; 345: 1435-1443Crossref PubMed Scopus (3372) Google Scholar The primary end point was all-cause mortality. Patients enrolled had New York Heart Association class IV HF for at least 90 days despite optimal medical therapy. At 1 year, survival in the LVAD group was significantly greater than in the medical therapy group (52% vs 25%, P = .001). However, at 2 years, only 23% in the LVAD group were alive, compared with 8% in the medical group. Serious adverse events were more frequent in the LVAD group, predominately caused by infection, bleeding, neurologic dysfunction, and device malfunction. A subsequent analysis of the trial data reported that the majority of the benefit in this trial was restricted to the group receiving or dependent on intravenous inotropic therapy at time of enrollment. REMATCH provides support for the consideration of LVAD therapy as an alternative to cardiac transplantation in highly selected patients. Emerging Surgical Techniques Infarct Exclusion Surgery. Primary indications for surgical treatment of LV aneurysm consist of LV failure, angina pectoris, thromboembolism, and tachyarrhythmias. It has been well recognized for decades that, after ventricular aneurysmectomy, patients can experience improved HF symptoms.22Ohara K. Current surgical strategy for post-infarction left ventricular aneurysm—from linear aneurysmecomy to Dor's operation.Ann Thorac Cardiovasc Surg. 2000; 6: 289-294PubMed Google Scholar This concept recently has been expanded from dyskinetic (aneurysmal) ventricles to include akinetic ventricles, which previously were thought to not improve following ventricular reconstruction. Linear aneurysmectomy has been widely performed as a standard procedure for postinfarction LV aneurysm. However, this technique remains unsatisfactory because LV distortion occurs postoperatively and an akinetic or dyskinetic area persists in the ventricular septum, resulting in limited improvement of cardiac function.23Christenson J.T. Bloch A. Maurice J. Simonet F. Velebit V. Schmuziger M. Jatene correction of the ventricular geometry in postinfarction left ventricular aneurysm. Results of 62 operations.Scand J Thorac Cardiovasc Surg. 1995; 29: 53-57Crossref PubMed Scopus (3) Google Scholar To overcome these problems, Dor and associates excluded all akinetic or dyskinetic myocardium from the left ventricle, including the septum, and placed a tight circumferential suture around the aneurysmal base to reduce the LV volume and return the LV contour to near normal (endoventricular circular patch plasty, or EVCPP). Recently, EVCPP has attracted interest as a treatment for postinfarction large akinetic scars. Dor's group has reported on the use of this technique on more than 750 patients.24Dor V. Saab M. Coste P. Sabatier M. Montiglio F. Endoventricular patch plasties with septal exclusion for repair of ischemic left ventricle: technique, results and indications from a series of 781 cases.Jpn J Thorac Cardiovasc Surg. 1998; 46: 389-398Crossref PubMed Scopus (27) Google Scholar Results were clinically satisfactory and in more than 90% of cases with ventricular aneurysm, the 1-year LVEF was superior to the preoperative function. More recently, the same group has reported on 44 patients treated with EVCPP with previous transmural anterior myocardial infarction.25Di Donato M. Sabatier M. Dor V. Gensini G.F. Toso A. Maioli M. et al.Effects of the Dor procedure on left ventricular dimension and shape and geometric correlates of mitral regurgitation one year after surgery.J Thorac Cardiovasc Surg. 2001; 121: 91-96Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar They found that LV shape became more elliptical in systole than it was in diastole (eccentricity index closer to 1), but new onset mitral regurgitation occurred in 25% of patients. A minor modification of the procedure described by Dor is referred to as the surgical anterior ventricular endocardial restoration (SAVER) operation. A large, multicenter prospective registry reported on 439 consecutive patients who received this operation with impressive medium-term survival. Based on this, the STICH trial, a large, National Institutes of Health–funded study of both coronary artery bypass grafting and ventricular reconstruction has been initiated. Still, the limited experience with this procedure and the concern that mitral valvular disease could be worsened leaves insufficient grounds for a recommendation of this technique at this time. Passive Restraint. Another technique uses passive containment of the cardiac ventricles with a surgically placed epicardial prosthetic wrap constructed of preformed knitted material.26Sabbah H.N. Sharov V.G. Chaudhry P.A. Suzuki G. Todor A. Morita H. Chronic therapy with the acorn cardiac support device in dogs with chronic heart failure: three and six months hemodynamic, histologic and ultrastructural findings.J Heart Lung Transplant. 2001; 20: 189Abstract Full Text Full Text PDF PubMed Google Scholar A randomized controlled trial has been presented but not published describing outcomes in 300 patients in either a mitral surgery stratum or no mitral surgery stratum randomized to receive a cardiac restraint device.27Mann DL. Results of a multicenter randomized clinical trial for the assessment of a cardiac support device (CSD) in patients with heart failure. In: American Heart Association Scientific Sessions 2004. New Orleans, LA; 2004.Google Scholar Improvements in LV remodeling indices were noted, but no improvement in functional class. The primary endpoint was a combination of patients classified as improved, same, or worsened, based upon the occurrence of death, a major cardiac procedure indicative of HF progression and a change in NYHA class. The composite endpoint was positve, an effect driven principally by the use of additional procedures within the control group. There were no differences in mortality.