Surgery of the ventricle Left ventricular reconstructive surgery ( Dor Procedure)
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) 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 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. |
Saturday, October 6, 2007
When systolic heart failure is severe enough, a heart transplant may be suggested. 
High risk conventional surgeries
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Valve surgery
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
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.
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?
- 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.
Heart Failure Symptoms - When to Call the Doctor
The key to managing heart failure is to take your medications, make diet changes, live a healthy lifestyle and keep your doctor's appointments. Your heart doctor will tell you how often to visit.
If you are having any of the heart failure symptoms described in this handout, don't wait for your next appointment to call your doctor. If your symptoms are discovered early, your doctor may change your medications to relieve your heart failure symptoms. (Never change or stop taking your medications without first talking to your heart doctor).
When should I call my doctor?
Call your heart doctor if you have any of these heart failure symptoms:
- Unexplained weight gain -- 2 pounds in one day or 5 pounds in one week
- Swelling in your ankles, feet, legs or abdomen that has become worse
- Shortness of breath that has become worse or occurs more often, especially if you wake up short of breath
- A feeling of fullness (bloating) in your stomach with a loss of appetite or nausea
- Extreme fatigue or decreased ability to complete daily activities
- A respiratory infection or a cough that has become worse
- Fast heart rate around 120 beats per minute
- New irregular heart beat
- Chest pain or discomfort during activity that is relieved with rest
- Difficulty breathing during regular activities or at rest
- Changes in sleep patterns, including difficulty sleeping or feeling the need to sleep a lot more than usual
- Decreased urination
- Restlessness, confusion
- Constant dizziness or lightheadedness
- Nausea or poor appetite
What are the symptoms of heart failure?
Heart failure symptoms are related to the changes that occur to your heart and body.
Shortness of breath
Occurs with exercise or rest or when lying flat in bed.
Fluid backs up in the lungs,
causing shortness of breath and, often, a hacking cough.
Dizziness
Less blood to the brain causes dizziness.
Tiredness (fatigue) and weakness
Less blood to the major organs and muscles causes fatigue.
Rapid or irregular heartbeats
The heart beats faster to pump enough blood to the body. This causes a fast or irregular heartbeat.
Less blood to your kidneys causes the kidneys to retain fluid and water, resulting in edema (swelling) and water weight gain.
What is heart failure?
- Heart failure means the heart is unable to pump blood as well as it should. Heart failure does not mean the heart has stopped working.
- The "poor pump" is unable to keep up with the body’s constant need for oxygen and nutrients during heart falure. In response:
- the walls of the heart stretch to hold more blood
- the heart muscle walls thicken to pump more strongly.
- the kidneys cause the body to retain fluid and sodium. This increases the amount of blood circulating through the heart and blood vessels.
- your body tries to compensate by releasing hormones that make the heart work harder. Over time, these compensatory mechanisms fail and symptoms of heart failure begin to appear. Like an over-stretched rubber band, the heart’s ability to stretch and shrink back decreases. The heart muscle becomes over-stretched and is unable to pump blood effectively.
- Blood backs up into the arms, legs, ankles, feet, liver, lungs or other organs; the body becomes congested. This is called congestive heart failure.
- Heart failure is a progressive process, even if no new damage occurs to the heart.
Words related to heart failure:
- Ejection fraction (EF): a measurement of the amount of blood pumped out of the left ventricle with each heartbeat. In a normal person, the ejection fraction equals about 50 percent or more. If someone has systolic heart failure, the ejection fraction will equal about 20 to 40 percent, or even less.
- Ventricular remodeling: the changes that occur to the heart’s pumping chamber (ventricle) when someone has heart failure. The inside of the left ventricle gets bigger during heart failure, the walls become thicker and the heart changes shape (becoming more round rather than pear-shaped). These changes worsen the heart’s ability to pump blood, stress the heart and may cause the mitral valve to leak.
- Systolic heart failure (systolic dysfunction): occurs when the heart muscle does not contract with enough force, so there is not enough oxygen-rich blood pumped throughout the body. An ejection fraction less than 40 percent indicates systolic heart failure.
- Diastolic heart failure (diastolic dysfunction): occurs when the heart contracts normally (a normal ejection fraction) but the ventricle does not relax or fill properly, so less blood enters the heart.
CUT OF THE HEART
- Pioneers of Heart Surgery
Learn how military doctors working during World War II pioneered advances in antibiotics, anesthesia, and blood transfusions that ushered in the age of modern surgery. - Treating a Sick Heart
Read this overview of how the heart works, what heart failure is, and how to treat it, from noted physician Robert Soufer. - Troubled Hearts
Explore annotated photos of diseased hearts and find out what ails them. - Map of the Human Heart (Hot Science)
See exactly how blood flows through the amazing muscle called the human heart and learn fascinating heart facts.
Chest Pain
New onset chest pain always requires evaluation by your doctor. If the pain is severe, you should seek immediate medical care.
Even if the chest pain is not severe, emergency care is needed if the chest pain is crushing or squeezing or is accompanied by one or more of the following symptoms
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shortness of breath
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discomfort or tingling in the arms, especially the left arm
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pain in the back
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tightness or pain in the lower jaw
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profuse sweating
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lightheadedness or loss of consciousness.
Heart Attack Symptoms in Women
Heart attack symptoms are different for men and women. Dr. Weinrauch explains the warning signs women need to watch out for. Pass this along to someone you love.
Some warning signs for women. Very few pre-menopausal women have heart attacks, unless they smoke, have diabetes, or are on birth control pills for a long period of time. Smoking seems to be the biggest risk factor:
• Nausea and vomiting that won’t stop
• Breathlessness (but not sighing) with exertion or especially if it wakes you up at night
• Chest discomfort that starts behind the breast bone and radiates to either shoulder or arm, neck, or to the lower (but not upper) jaw
• Discomfort in the lower jaw especially if it occurs only with exertion or will not go away
Discomfort in the upper back especially if it occurs only with exertion or will not go away
• Discomfort in the chest or back that occurs when doing usual chores after a large meal
• Sudden onset of weakness that won’t go away
• Sudden racing heart sensation with a very fast pulse
• Sudden loss of consciousness
• Physical inability to perform usual household chores
Who is most at risk with these symptoms? The more of these factors that apply to you, the greater your risk:
• Menstruation has stopped
• Smoking
• Family history of arteriosclerotic heart disease before age 60
• High blood pressure (even treated)
• Diabetes (even mild, even treated)
• Obesity
• High cholesterol (even treated)
Heart Attack Symptoms and Warning Signs
A blockage in the heart's arteries may reduce or completely cut off the blood supply to a portion of the heart. This can cause a blood clot to form and totally stop blood flow in a coronary artery, resulting in a heart attack (also called an acute myocardial infarction or MI).
Irreversible injury to the heart muscle usually occurs if medical help is not received promptly. Unfortunately, it is common for people to dismiss heart attack symptoms.
What are the warning signs of a heart attack?
The American Heart Association and other medical experts say the body likely will send one or more of these warning signals of a heart attack:
- Uncomfortable pressure, fullness, squeezing or pain in the center of the chest lasting more than a few minutes.
- Pain spreading to the shoulders, neck or arms. The pain may be mild to intense. It may feel like pressure, tightness, burning, or heavy weight. It may be located in the chest, upper abdomen, neck, jaw, or inside the arms or shoulders.
- Chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath.
- Anxiety, nervousness and/or cold, sweaty skin.
- Paleness or pallor.
- Increased or irregular heart rate.
- Feeling of impending doom.
Not all of these signs occur in every attack. Sometimes they go away and return. If some occur, get help fast. IF YOU NOTICE ONE OR MORE OF THESE SIGNS IN YOURSELF OR OTHERS, DON'T WAIT. CALL EMERGENCY MEDICAL SERVICES (9-1-1) RIGHT AWAY! In the event of cardiopulmonary arrest (no breathing or pulse), call 9-1-1 and begin cardiopulmonary resuscitation (CPR) immediately.
How does the doctor know if I've had a heart attack?
The actual diagnosis of a heart attack must be made by a doctor who has studied the results of several tests. The doctor may:
- Review the patient's complete medical history.
- Give a physical examination.
- Use an electrocardiogram (or EKG) to discover any abnormalities caused by damage to the heart.
- Use a blood test to detect abnormal levels of certain enzymes in the bloodstream.
What does heart-related chest pain feel like?
If you suffer chest pain, particularly while exercising, you will almost certainly wonder whether it might be heart-related - and well you should. Heart muscle pain - angina - is likely to be the first warning of blocked coronary arteries, the cause of most heart attacks.
While there are no infallible guidelines about whether a chest pain is heart-related, it generally takes a particular form. Heart discomfort is rarely a sharp, stabbing pain. The textbook description of angina is a feeling of heaviness, pressure, tightness or aching in the chest, usually accompanied by shortness of breath. The pain generally goes away when you stop exerting yourself, and it frequently isn't especially severe, which is, perhaps, unfortunate.
Even a heart attack may not be unbearably painful at first, permitting its victim to delay seeking treatment for as much as four to six hours after its onset. By then, the heart may have suffered irreversible damage. It is not unknown for patients to drive themselves to emergency rooms with what proved to be very serious and even fatal heart attacks.
Angina is a protest from the heart muscle that it isn't getting enough oxygen because of diminished blood supply. A heart attack is simply the most extreme state of oxygen deprivation, in which whole regions of heart muscle cells begin to die for lack of oxygen. If the blockage in the arteries serving the heart muscle can be cleared quickly enough - within the first few hours of the onset of the attack - the permanent damage can be held to a minimum.
That's why it is so vital to seek medical attention quickly if you feel the sort of pressing pain or heaviness described above. There is a 90 percent probability that pain of this type is angina. And even if it goes away, the artery blockages that caused it are still there and will grow progressively worse.
Ignoring this sort of pain because it is not unbearable or because it goes away is the worst thing you can do. It is the only warning you are likely to get of a potentially lethal condition. Heed it! Consult a cardiologist immediately.
You can have a heart attack without knowing it
The nation's longest-running heart study suggests that about one heart attack in four produces no symptoms - or at least none that the victim associates with a heart problem.
These so-called "silent heart attacks," however, are only the most extreme case of a still more prevalent condition called "silent ischemia" - a chronic shortage of oxygen - and nutrient-bearing blood to a portion of the heart. Both conditions put their victims at significant risk.
The cause of ischemia, silent or otherwise, is almost always atherosclerosis - the progressive narrowing of the heart's arteries from accumulations of cholesterol plaque. In most instances, this reduction in blood supply generates a protest from the heart - the crushing pain called angina. But in perhaps 25 to 30 percent of heart attack victims, there were no previous symptoms of these gradually developing blockages. The Framingham Heart Study, which followed 4,000 Massachusetts men for more than 40 years, found that 25 percent of their subjects' heart attacks go unnoticed until their annual EKGs detect their after-effects.
The absence of pain, however, doesn't mean an absence of damage. The heart has a built-in reserve capacity, allowing it to suffer a certain amount of scarring and weakening from a heart attack and continue to meet the body's needs. But further ischemia or another heart attack, even a mild to moderate one, may prove fatal because that reserve capacity is no longer there. Even those who survive another heart attack are at increased risk of becoming cardiac cripples, disabled by congestive heart failure or arrhythmias heartbeat irregularities.
There is no way of predicting absolutely who is a candidate for silent ischemia, but statistically, the greater the number of risk factors for coronary artery disease that you have, the more likely you are to be a candidate. Those risk factors include some you can't control - your age, sex and genetic predisposition to atherosclerosis - and those you can influence, like diabetes, high blood pressure, high blood cholesterol, smoking, lack of exercise and obesity.
