|When Is Surgery Necessary?
Surgery is only considered for patients who have severe CHF which is not responding to heart failure medications. It is performed to stop further damage to the heart and hopefully to restore at least some pumping action. To do so, it may involve treating the underlying cause. Surgical procedures for CHF include:
- Coronary (Heart) Angioplasty
- Heart Bypass Surgery
- Valve Surgery
- Left Ventricle Surgery
- Implantable Ventricular Assist Device (VAD)
- Heart Transplant
- Cardiac Resynchronization
Heart angioplasty (image) is a procedure used to open blocked or narrowed arteries caused by the buildup of fatty deposits (called atherosclerosis, image). Atherosclerosis is one of the main causes of coronary heart disease (CHD) which in turn is one of the leading causes of heart failure. By treating the underlying condition, the aim is to prevent further damage to the heart. Angioplasty involves using the heart catheterization method, which means placing a long thin tube called a catheter (cath) into the blocked artery. When the cath is placed at the point of blockage a small balloon inflates which squeezes the fatty deposits against the artery wall, allowing blood to flow freely again. For a more permanent solution a small metal stent might be inserted to keep the artery permanently open. This is known as stenting.
Heart Bypass Surgery
In more serious cases where the coronary arteries are severely blocked a heart bypass (image), also called coronary artery bypass surgery, may be performed. This is one of the most common surgeries for treating the symptoms of heart failure. It involves taking a blood vessel from another part of the body, such as the thigh and grafting it onto a blocked coronary artery. This creates a new route for blood to flow (the blockage is bypassed) and adequate blood flow can be restored to the heart. The operation is sometimes referred to as CABG (coronary artery bypass grafting pronounced cabbage), or CAB (coronary artery bypass). It is a serious procedure - but fortunately newer techniques have improved the overall outcome for patients. See also, what is the prognosis for heart failure? For more questions on female health, see our section Womens Health Questions.
Some patients with a diagnosis of heart failure learn that the main cause of their condition is disease of one or both heart valves. The valves are little flaps of tissue which open and close, controlling blood flow through the heart. Disease of these valves can result in a variety of problems, including reduced pumping action. As heart failure progresses, it can cause the valves to stretch out of shape, allowing leakages. Valve surgery usually involves reshaping the valve and supporting it with a ring. This surgery may also be referred to as mitral valve repair or aortic valve repair (depending on which valve needs repairing).
Left Ventricle Surgery (Dor Procedure)
This may be a necessary option for patients suffering CHF as a result of a heart attack (see heart attacks in women). When a heart attack occurs in the left side of the heart (left ventricle or pumping chamber), scar tissue can form. The scarred area may become thin and start to bulge out with each heartbeat. Initially your heart can cope with this but eventually the ventricle becomes larger than normal and less effective at pumping blood. This leads to heart failure. Surgery on the ventricle, called infarct exclusion surgery (most surgeons use the dor procedure method) allows the cardiologist to remove the dead scar tissue and to reshape the ventricle so that it looks more normal. This improves the pumping ability of the heart. It is also sometimes used to improve symptoms of angina in people with debilitating chest pain. Surgery requires a hospital stay of about 8 days, about a day longer than those having heart bypass surgery.
Implantable Ventricular Assist Device (VAD)
A VAD is a small mechanical device which can be fitted into the left ventricle of the heart to help it pump better. Initially they were used to buy time for patients whose heart failure treatment failed and who were waiting for a heart transplant (a sort of 'bridge to transplantation'). These patients have what is termed 'end-stage' heart failure. However due to the limited availability of donor hearts, as well as the number of patients who are not eligible for a heart transplant VADs are now also being used for long-term use. This is known as destination therapy. Given the high risks (and costs) associated with this operation, it is only usually offered to patients who would otherwise die from their condition.
Despite the millions of Americans who suffer from heart failure, very few progress to the point where they need to replace the heart itself. Only about two thousand heart transplants are performed every year in America, it really is considered a treatment of last resort. The limited availability of donor hearts and the fact that many patients do not qualify for surgery due to other medical problems or advanced age, are restricting factors. Currently it is only offered to patients if their disease is likely to be fatal within 3 years. The route to transplantation is a long one and requires the guidance and care of a specialized transplant center. A transplant involves completely replacing the diseased heart with a healthy one removed from someone who has just died. The heart is inserted into the patient, the blood vessels are reconnected and blood continues to flow. The life expectancy rates of heart transplant patients are generally very good.
Also called biventricular pacing, cardiac resynchronization is a relatively new treatment for heart failure. As the heart becomes more diseased it develops abnormalities in its electrical system (known as a heart arrhythmia). A healthy heart uses electrical impulses to control its pumping action (image). If these impulses become disturbed they can cause life threatening heart arrhythmias which can lead to sudden cardiac arrest. Cardiac resynchronization involves inserting a particular type of artificial pacemaker called a cardiac resynchronization therapy device, or CRT pacemaker to correct the problem. The commercial names of these devices include Heartmate, Novacor, Thoratec and Abiomed. However some patients may be better candidates for an implantable cardioverter defibrillator (ICD), which can shock the heart back into a correct rhythm if it needs it. Eligible patients may also consider buying a home defibrillator for cases of emergency.