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Ann Thorac Surg 2003;76:S2254-S2259
© 2003 The Society of Thoracic Surgeons

Supplement: Gibbon & His Heart-Lung Machine

Surgical treatment of congestive heart failure: evolving options

Bartley P. Griffith, MDa*

a Division of Cardiac Surgery, University of Maryland, Baltimore, Maryland, USA

* Address reprint requests to Dr Griffith, Division of Cardiac Surgery, University of Maryland, N4W94, 22 S Greene St, Baltimore, MD 21201, USA
e-mail: bgriffith{at}smail.umaryland.edu

Presented at the symposium, "Gibbon & His Heart-Lung Machine: 50 Years & Beyond," Philadelphia, PA, May 2, 2003.

I am most pleased to be included in this wonderful symposium to honor John Gibbon and his contributions to cardiopulmonary bypass. It is special to me as a graduate of Jefferson Medical College to discuss surgical treatment of congestive heart failure as I have formed much of my interest in the areas that intrigued Dr Gibbon. Since leaving this school I have had unbridled opportunities to research and clinically explore extracorporeal membrane oxygenation, heart and lung transplantation, and mechanical circulatory support. It is important to review the current trends in surgical management because congestive heart failure afflicts more than 4.9 million Americans and consumes more than 5% of the total US health care dollars ($40 billion) [1]. Our specialty's response to the need is critical for those suffering and for cardiac surgeons who adapt to nonsurgical advances in coronary artery disease. My discussion will include the role for myocardial revascularization, mitral valve repair, left ventricular remodeling, mechanical circulatory support, and transplantation for those with heart failure.

Patients are often referred for consideration of revascularization when they have considerable left ventricular dysfunction based on established trials [2–5]. In the past much attention has been focused on the factors that influence surgical mortality [6–16]. These include quality of surgical targets, symptomatic status of the patient, level of pulmonary artery pressure, acuteness of presentation, and overall state of the patient at presentation. Surgical mortality is now an acceptable 2.3% to 5.0%. However a number of patients have been referred to us for consideration of transplantation when they have severely depressed left ventricular function and with unclear viability. The assessment of myocardial viability has improved and now permits the differentiation of myocardial fibrosis from hibernation [17, 18]. In the latter, coronary revascularization results in improved systolic function but operative intervention when substantial zones of viable myocardium are absent in the target areas has consistently resulted in higher mortality [19–25]. Confusion often continues as many patients have a mixed pattern of scarring and hibernation. Our experience has included assessment of inotropic reserve by dobutamine stress, perfusion and metabolism by positron emission tomography (PET), and perfusion plus integrity of cell membrane by single photon-emission computed tomography (SPECT) with either thallium 201 or technetium 99mTc-sestamibi (Fig 1) [26–30]. We work hard to find a reason to offer surgical revascularization as we believe this to be our best first interventional choice.



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  		Fig 1. Example of positron emission tomography (PET) mismatch pattern in a patient with chronic ischemic left ventricular dysfunction demonstrating an irreversible perfusion defect on 99mTc-sestamibi single photon-emission computed tomography (SPECT). Stress myocardial perfusion SPECT images (left panel) show severely reduced defects in the apical, anteroapical, and septal regions that persist on the rest images (fixed defects). These findings are commonly interpreted to represent large myocardial infarction in the left anterior descending (LAD) vascular territory. Rest 13N-ammonia images (top, middle panel) show markedly decreased perfusion in the apical and anteroapical regions. However 18F-fluorodeoxyglucose (FDG) images (bottom, middle panel) acquired under glucose-loaded condition show preserved glucose utilization in the abnormally perfused myocardial regions at rest (perfusion-metabolism mismatch pattern), a scinitigraphic marker of hibernation. A coronary angiogram (right panel) shows 95% stenosis of the proximal LAD coronary artery (arrow) associated with akinesis of the apical and anteroseptal regions and a calculated left ventricular ejection fraction of 20%.

 
There has been an increase in the attention of the importance of left ventricular end systolic volume as an important prognostic indicator for congestive heart failure and death after myocardial infarction and coronary artery bypass [31–33]. Left ventricular remodeling defined by volume enlargement and geometric distortion occurs when segments of viable muscle dilate remote from scar [34]. This occurs in at least 40% of patients after transmural infarction. It has been demonstrated that normokinetic myocardium remodeling begins as early as 4 weeks after infinfarction and shrinkage fraction continues to reduce up to 3 years [32]. While these data have recently boosted aggressive treatment of patients with transmural infarcts with angiotensin-converting enzyme inhibition and beta blockade, surgical treatments have evolved to reshape the distorted left ventricle geometry by variation on aneurysmectomy or use of restraint devices.

Likoff and Bailey were first to excise a left ventricular aneurysm [35]. The "off pump" technique was employed using a large clamp and suture closure. As cardiopulmonary bypass was developed many centers performed direct closure. Cooley reported on the largest numbers of these procedures and is credited with having established the standard techniques [36]. In time investigators considered effects of the distortion of the left ventricle by the aneurysm that were not addressed by the standard repair [37]. Stoney developed the double-breasting modification in which lateral myocardium is advanced down onto the septum and secured at the junction of scar and viable muscle (Fig 2, A and B) [38]. Cooley evolved his original technique, Jatene reported on the use of a circular suture with or without a patch to close the ventriculotomy, and Dor perfected the endoventricular patch plasty that was a blend of septal exclusions and endoventricular closure with a patch (Fig 2, C) [39–43]. In clinical practice today the double-breasting technique is used when the anterior aneurysm is fibrotic and the involvement of the septum in scar is limited. The Dor procedure has special merit for those with large septal involvement. Buckberg studied the anatomy of the heart to learn further about how best to restore the normal left ventricular shape [44]. He popularized a modification of the Dor procedure and initiated a clinical trial to test its benefits (Fig 3) [45]. Currently the National Institutes of Health is also conducting a randomized evaluation of this repair based on his initial input.



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  		Fig 2. (A) Apicoanterolateral aneurysm with limited septal involvement. (B) The double-breasting technique includes advancement of the lateral myocardial wall onto the septum at the junction of scar and normal tissue. (C) Dor's technique: a Dacron patch lined with pericardium is sutured circumferentially at the junction of scar and normal muscle with a large septal involvement. (From Trehan N, et al. J Card Surg 2003;18:114–20. Reprinted with permission from Blackwell Publishing.)

 


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  		Fig 3. Buckberg modification of the Dor technique. A preformed circular patch is sized by ends of a cardiac encircling suture.

 
Left ventricular diastolic support appliances are being developed and tested as mechanical aids to prevent progressive remodeling [46–48]. This is achieved medically by reducing vascular resistance at the potential of reduced end-organ perfusion. These devices may make it possible to reduce the tension on the left ventricular wall without reducing blood pressure. We have experience with the ACORN cardiac support device, a "woven-of-yarn" device that slips over a dilated left ventricle like a sock and is designed to provide diastolic support while restraining further dilatation (Fig 4). This concept was perhaps stimulated by blended outcomes of earlier cardiac myoplasty and the now rare Batista-type partial left ventriculectomy [50]. Its basis is that reduced wall stress can mitigate and reverse remodeling by reducing stretch protein, hypertrophy, and extracellular matrix [51]. Preclinical experimental trials and clinical experience suggest that benefits in compliance and contractility occur without evidence of constrictive effects [52–54]. Data are now being acquired in a multicenter randomized evaluation of the CorCapTM, Cardiac Support Device (Acorn Cardiovascular Inc, St. Paul, MN) in ambulatory patients with ischemic or nonischemic dilated cardiomyopathy (left ventricular end-diastolic diameter >=60 mm).



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  		Fig 4. The ACORN cardiac restraint device.

 
Mitral coaptation requires a large leaflet area that is 2.5 times the area of the valve orifice. Functional mitral regurgitation from loss of leaflet coaptation is a frequent complication of end-stage cardiomyopathy. It is due to alteration in the annular-ventricular apparatus and ventricular geometry. As the annulus dilates the cordae are drawn away and the leaflet area is no longer sufficient. As a trainee I was taught there was little benefit and possibly unacceptable risk and harm to consider mitral valve replacement in the face of severe left ventricular dysfunction. The fear was that left ventricular afterload would increase by reducing the pop-off allowed by mitral insufficiency. As current approaches to mitral regurgitation stress valve repair that maintains the annulus-papillary muscle continuity [55], most series report a lower risk. Some medical series have shown significantly reduced survival of patients with mitral regurgitation in end-stage cardiomyopathy [56]. Bolling [57] reasoned that perhaps an evaluation of mitral valve repair for end-stage cardiomyopathy might have merit. The operative risk seemed appropriate in this needy class of patients as it was hoped with elimination of regurgitant volumes of as much as 50% of the stroke that forward output would improve. Knowing the relative lack of alternatives, except donor-limited transplantation, this approach has now been established to benefit ambulatory patients with chronic severe left ventricular dysfunction. Operative mortality has been 5% to 10% and most patients have improved several New York Heart Association classes [58]. While patients improve, 2-year survival continues to be reduced and is in the range of 70%. The use of repair by a tight no. 26 complete ring annuloplasty popularized by Bolling is based on restoration of leaflet coaptation lost through progressive left ventricular dilatation and associated stretch of the papillary muscle support (Fig 5). Systolic anterior motion of this anterior mitral leaflet that occurs from "overcorrection" has not been a problem owing to the widened aortomitral angle in these myopathic hearts.



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  		Fig 5. (A) Central insufficiency of mitral valve as tested intraoperatively in a patient with severe left ventricular dysfunction and enlargement. There is loss of coaptation of the leaflets. (B) Mitral annuloplasty has reestablished a smaller annulus and resulted in improved leaflet coaptation and competency.

 
Cardiac transplantation has been established as a reasonable treatment for end-stage heart disease and results confirm an excellent quality of life and an average greater than 7-year survival [59]. With progressive improvements in immunsuppression protocols aimed at reduced steroids and limited calcineurin inhibition (renal toxicity), prospects continue to be good for intermediate outcomes. Chronic progressive obstructive coronary artery disease is the major unsolved issue that limits longer-term benefit. It is likely this problem will only be solved by future protocols that result in a tolerant state between allograft and host.

The limited availability of donor organs spawned the development and clinical testing of various forms of mechanical ventricular assist devices (VAD). The Food and Drug Administration approved the paracorporeal pneumatic Thoratec and the HeartMate and WorldHeart electrical devices as bridges to transplant. This led to consideration of pumps for destination therapy in the form of the National Institutes of Health-sponsored Randomized Evaluation of Mechanical Ventricular Trial (REMATCH). In this study it was determined that survival and quality of life were superior in those patients supported with the HeartMate VAD compared with those treated with intense medical therapy alone. While survival differences were small at 1 and 2 years, surgical patients entered into the latter half of the trial performed better, suggesting a significant learning curve even in experienced centers. Thromboembolic problems with this device were rare but infection and premature failure of the porcine inlet valve limited late outcomes. The FDA approved the use of the HeartMate for permanent therapy and Medicare is deciding on coverage.

We are now clinically testing new types of pumps that are turbine-based and thus smaller than the older displacement sac-type VADs. These valveless turbines produce a continuous flow of blood and can, if adjusted to high speed, result in a near pulseless state by capturing all native left ventricular blood and eliminating aortic valve openings. Our recent work with the Jarvik 2000 (Fig 6) has taught us that many patients with some cardiac reserve do well with left ventricular assist rates of 3 to 4 L/min flow. Our hope is that these small, relatively less invasive pumps will be proven biocompatible and targeted for patients ill but not imminently dying with congestive heart failure. Late NYHA III patients would make for a lower risk but high impact population. Most interested in the field of cardiac replacement have watched with anticipation the reintroduction of the total artificial heart. The present AbioCor device (Abiomed, Danvers, MA) is powered by completely implanted coils and is being evaluated in candidates who are not capable of receiving a heart transplant due to age, associated diseases, or biventricular failure. To date 11 patients have received an implant and 1 survived 17 months. Early outcomes once again show high surgical risks in mortally ill patients and the difficult balance between bleeding from anticoagulation and stroke from inadequate suppression of clotting. Finally, a fully implantable ventricular assist device, the LionHeart (Arrow International, Arrow, PA), is also being tested and to date the transcutaneous systems for emergent transmission appear to function well.



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  		Fig 6. (A) Jarvik 2000. (B) Jarvik 2000: preimplant (left panel); 24 hours postimplant (right panel).

 
Much of the attention in the treatment of heart failure is directed at better understanding the process of myocardial remodeling. Fortunately, it appears that even fibrosis is reversing to an extent. The degree to which the various surgeries described might initiate reversible remodeling remains unknown. We will, I am sure, use these surgical procedures as platforms to better understand how the various influences on the myocyte extracellular matrix, fibroblast, and endothelial can affect positive change. The outlook for surgery playing an important role in the treatment of heart failure has never been greater. Doctor Gibbon would be pleased to know how important the surgeon continues to be in this field.[49]

Acknowledgments

The author wishes to thank Vasken Dilsizian, MD, of the University of Maryland School of Medicine, Baltimore, Maryland, for his assistance with the figures in this article.

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