Surgery of the ventricle Left ventricular reconstructive surgery ( Dor Procedure) Incision line through dead scarred tissue Pursestring stitches around the dead tissue Pulling of pursestring and closing of left ventricle When a heart attack occurs in the left ventricle (left lower pumping chamber of the heart), a scar forms. The scarred area can become thin and bulge out with each beat. The bulging thin area is called an aneurysm. These changes, along with other heart damage you may have, may result in heart failure. Initially your heart is able to handle pumping harder, but over time, your left ventricle becomes larger than normal and pumps less effectively. Infarct exclusion surgery allows the surgeon to remove the infarcted (dead) area of the heart tissue and/or the aneurysm and return the left ventricle to a more normal shape. The goal of the heart failure treatment surgery is to improve heart failure and/or angina (chest pain) symptoms and possibly improve the pumping ability of your heart.

Implantable left ventriclar assist device (LVAD) The LVAD is known as the "bridge to transplantation" for those whose medical therapy has failed and are hospitalized with end-stage systolic heart failure. This device helps your heart pump blood throughout your body. CCF is one of the few institutions worldwide who have access to all clinically available mechanical ventricular assist systems including the Heartmate, Novacor, Thoratec, and Abiomed devices, allowing us to choose the machine which will best suit an individual patient's clinical needs. For selected individuals with severe, refractory heart failure, we can now offer the option of permanent LVAD therapy or "destination therapy." Cleveland Clinic surgeons are participating in two randomized trials comparing permanent support with an implantable (Novacor) and a continuous flow (Debakey) pump to the Heartmate device.

Heart transplant When systolic heart failure is severe enough, a heart transplant may be suggested. Heart (cardiac) transplant involves replacing a diseased heart or heart and lungs with a healthy donor organ or organs. The donor organ is completely removed from someone who has died, then kept cool in a special solution as it is transported. The disease heart is removed, leaving the back walls of the atria (heart's upper chambers). The hearts are sewn, atria to atria into the chest, the blood vessels are reconnected, and blood flows through the new heart into the body.

High risk conventional surgeries Coronary artery bypass surgery The most common surgery for heart failure treatment is bypass surgery. If a coronary artery becomes blocked, less oxygen-rich blood reaches the heart muscle. The heart muscle becomes "starved" for blood (ischemia) and is unable to pump normally; heart failure occurs. Your doctor will determine if your heart failure is caused by coronary artery disease and if you have blockages that can be "grafted" or bypassed. Although patients with heart failure are at an increased surgical risk, new strategies before, during and after surgery have decreased the risk and improved outcomes.

Reshape the mitral valve leaflets and provide support to the mitral valve with a ring Valve surgery As heart failure progresses, remodeling of the left ventricle causes the papillary muscles (which support the mitral valve leaflets) to stretch out of shape, causing the valve to leak. Mitral valve repair usually involves reshaping the leaflets and providing support to the mitral valve with a ring. Experience at the Cleveland Clinic Foundation has shown that repair of the mitral valve: Preserves the natural anatomy of the heart Improves cardiac function Decreases symptoms Improves survival Decreases complications and risks If the aortic valve leaks, aortic valve repair or replacement may be an option.

Surgical procedures to treat heart failure

Surgery is aimed at stopping further damage to the heart and improving the heart's function. Surgical procedures for heart failure treatment include:

• High risk conventional surgeries
  • Coronary artery bypass surgery
  • Valve surgery
• surgery of the ventricle
  • LV reconstruction surgery (Dor Procedure)
  • Implantable left ventricular assist device (LVAD)
  • Heart transplant
  • New innovations

Heart Transplant

When medications and surgery fail to manage heart failure symptoms and progression, cardiac transplant is considered as a treatment option. A heart transplant improves length and quality of life for patients with end-stage heart failure.

Screening
Before someone is placed on the heart transplant list, they are placed through a careful screening process. A multidisciplinary team of heart doctors, nurses, social workers, and bioethicists review the medical history, diagnostic test results, social history and psychosocial evaluation results to see if the patient is able to survive the heart transplant procedure and then, comply with the continuous care needed to live a long healthy life.

Waiting
Once the person is approved to be placed on the list, they must wait for a donor to become available. This process can be long and stressful. A supportive network of family and friends is needed to help the patient through this time. The health care team will monitor the patient closely to keep the patient's heart failure in control. Your transplant coordinator will discuss with you how you will be notified if a donor heart is available. The hospital must know where to contact the patient at all times should a heart become available.

The surgery
Once you are in the operating suite, the actual heart transplant procedure can take anywhere from 4 to 12 hours, or longer. Each person's case is different.

The donor heart
A surgeon from the heart transplant center goes to harvest the donor heart. The surgeon will make sure the donor heart is in good condition before beginning your surgery. The donor heart is removed by cutting the aorta and pulmonary artery in the mid-section. The atria are removed from the veins leading into the heart.

The transplant
When the donor heart arrives in the operating room, your surgeon will remove most of your heart and the donor heart will be placed in proper position and attached to your major blood vessels.

Recovery
How quick a patient recovers after heart transplant depends on many factors: age, general health, and response to the transplant. Most patients are up and about within a few days after surgery and home in about 7 to 16 days.

How the Heart Works

A healthy heart beats about 60 to 80 times per minute to pump blood throughout the body. The right and left sides of the heart work together. Blood that is low in oxygen first enters the right upper chamber (right atrium) of the heart. The blood flows from the right atrium to the lower chamber (right ventricle) through the open tricuspid valve. Blood passes through a valve before leaving each chamber of the heart. There are four valves in your heart; valves make sure blood flows in only one direction through your heart. The blood then travels through the pulmonary artery to the lungs where oxygen is added.

Oxygen-rich blood then returns to the left side of the heart. The blood flows from the left upper chamber (left atrium) to the lower chamber (left ventricle) through the open mitral valve.

From the left ventricle, the blood is pumped into a network of arteries (blood vessels) which carry the blood throughout the body.

With heart failure, the heart's pumping power is weaker than normal, causing less blood to move through the heart and to the body. Less blood flow throughout the body causes certain symptoms, as described above.

Understanding Heart Failure

What is heart failure?

Heart failure means that the heart's pumping power is weaker than normal. Heart failure does not mean that your heart has stopped working.

With heart failure, blood moves through the heart and body at a slower rate, and pressure in the heart increases. Therefore, the heart cannot pump enough oxygen and nutrients to meet the body's needs. The chambers of the heart respond by stretching to hold more blood to pump through the body. This helps to keep the blood moving for a short while, but then the heart muscle walls weaken and are not able to pump as strongly. The kidneys often respond by causing the body to retain fluid (water) and sodium.

If fluid builds up in the arms, legs, ankles, feet, lungs or other organs, the body becomes congested, and congestive heart failure is the term used to describe the condition.

What are the symptoms of heart failure?
The signs and symptoms of heart failure may be mild to severe, depending on how weak your heart is. The congestive heart failure symptoms are related to the changes that occur in your heart and body, including:

• Congested lungs (caused by fluid backing up in the lungs) -- cause shortness of breath with exercise or difficulty breathing at rest or when laying flat at night. Also cause dry, hacking cough or wheezing.
• Less blood to your kidneys causes fluid and water retention, resulting in swollen ankles, legs and abdomen (called edema) and weight gain. Symptoms may also include an increased need to urinate during the night.
• Less blood to your major organs and muscles causes fatigue (tiredness) and weakness when exercising. Less blood to the brain also causes dizziness or confusion.
• A feeling of fullness (bloating) in your stomach. A loss of appetite or nausea may also occur.
• Heart beating faster to pump enough blood to the body causes rapid or irregular heartbeats.

If you have heart failure or congestive heart failure, you may have one or all of these symptoms of heart failure. Sometimes, people with heart failure do not have any symptoms.

What are systolic and diastolic heart failure?
Systolic cardiac (heart) dysfunction (or systolic heart failure) occurs when the heart muscle doesn't contract with enough force, so there is not enough oxygen-rich blood to be pumped throughout the body.

Diastolic cardiac dysfunction (or diastolic heart failure) occurs when the heart contracts normally, but the ventricle doesn't relax properly so less blood can enter the heart.

A test called the ejection fraction (EF) is used measure how well your heart pumps with each beat to determine if systolic or diastolic dysfunction are present. Your doctor can discuss which condition is present in your heart.

How is heart failure diagnosed?

When diagnosing heart failure, your doctor first looks at three areas:

• Medical history: Your doctor will ask you many questions about your symptoms and medical history. Your doctor will want to know:
  • If you have any other health conditions such as diabetes, kidney disease, angina, high blood pressure or other heart problems
  • If you smoke
  • If you drink alcohol and how much you drink
  • What medications you are taking
• Physical exam: Your doctor will listen to your heart and give you a complete physical exam Your doctor will look for signs of heart failure as well as any other illnesses that may have caused your heart to weaken.
• Tests: Certain tests can help your doctor determine the extent of heart failure. Your doctor will tell you which of these tests you should have:
  • Blood tests — to evaluate kidney and thyroid function as well as to check cholesterol levels and presence of anemia. Anemia is a blood disorder that occurs when there is not enough hemoglobin (the substance in red blood cells that enables the blood to transport oxygen through the body) in a person's blood.
  • B-type Natriuretic Peptide (BNP) blood test - BNP is a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens. The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable. The BNP level in a person with heart failure - even someone whose condition is stable - is higher than in a person with normal heart function.
  • Chest X-ray — shows the size of your heart and whether there is fluid build-up around the heart and lungs.
  • Echocardiogram (or echo) — a graphic outline of the heart's movement. During an echo, a wand is placed on the surface of your chest. This wand sends ultrasound waves that provide pictures of the heart's valves and chambers so the pumping action of the heart can be studied. Echo is often combined with an ultrasound to find changes in the blood flow across the heart's valves and the pressure within the heart's chambers.
  • Ejection fraction (EF) — test that determines how well your heart pumps with each beat. This test measures how much blood is pumped out of the heart with each beat, and how much blood pumps through the heart with each beat. A normal EF is generally greater than 50 percent, which means that over half of the blood volume is pumped out of the heart with each beat.
    An EF of less than 40 percent usually confirms a diagnosis of systolic heart failure. An EF greater than 40 percent means that your heart failure is due to another cause, such as a valve disorder or diastolic dysfunction. Please note, however, that people with diastolic dysfunction can have a normal EF.
    Systolic dysfunction occurs when the heart muscle doesn't contract with enough force, so there is not enough oxygen-rich blood to be pumped throughout the body. Diastolic dysfunction occurs when the heart contracts normally, but the ventricle doesn't relax properly so less blood can enter the heart. Your doctor can discuss which condition is present in your heart.
  • Electrocardiogram (EKG or ECG) — records the electrical impulses traveling through the heart. During the test, small, flat, sticky patches called electrodes are placed on your chest. The electrodes are attached to an electrocardiograph monitor (EKG) that charts your heart's electrical activity on graph paper.