Heart Failure Surgery, Devices & Transplantation
When heart muscle is damaged, it can't pump enough blood to the rest of the body. A weak heart leads to sluggish circulation (congestion) and symptoms such as fatigue, shortness of breath, swelling in the feet and ankles, and irregular heart beats. Common causes of heart failure are coronary artery disease, heart attack, high blood pressure, valve problems, heart muscle disease (such as cardiomyopathy), and heart irregularities.
Medications and cardiac rehabilitation programs can reduce symptoms, but if you have advanced heart failure, your surgeon may recommend surgery.
The goals of surgery for heart failure are to relieve your symptoms (give you more energy), avoid serious complications (such as a heart attack or trips to the emergency room for difficulty breathing), and help you live longer.
You and your surgeon have many options to accomplish these goals. Some surgeries correct a reversible underlying cause of your heart failure. Other surgeries target a complication or specific symptom of the heart failure. In some cases, the surgeon will insert a mechanical or electronic device to correct the condition or relieve symptoms. Transplantation is available for patients suffering from end-stage heart failure that cannot be helped by other treatments.
Common Types of Surgery for Patients with Heart Failure
Based on your condition and symptoms, your surgeon may recommend one or more of the following surgeries or procedures:
Coronary Artery Bypass Graft (CABG)
- If your heart failure is caused or worsened by a blocked coronary artery, your surgeon can use a healthy artery from elsewhere in your body to create a new pathway around the blockage. This is called coronary artery bypass graft (CABG) surgery.
- CABG brings more oxygen-rich blood to the heart muscle, helping it pump more strongly, and giving you more energy and a better quality of life.
- In many cases, our heart surgeons use minimally invasive valve approaches on patients with heart failure who need CABG surgery.
- Some types of coronary artery blockage can now be treated with a catheter procedure or a hybrid procedure that combines minimally invasive surgery with a catheter intervention.
Learn more about interventional procedures and hybrid revascularization procedures in Angioplasty and Other Interventional Cardiac Procedures.
Heart Valve Surgery
- Valve problems can be a cause or a result of heart failure. Depending on your situation, your surgeon may recommend heart valve surgery to repair or replace a valve. One of the two valves on the larger and more powerful left side of the heart—the aortic valve and the mitral valve—is usually the source of the problem.
- A stiffened aortic valve can force the heart to work harder to pump blood through the narrowed opening. Over years, all this extra work can take a toll on the heart. If aortic stenosis is causing or aggravating heart failure, your surgeon may recommend repair or replacement to reduce the strain on your heart.
- Heart failure can change the heart's shape and weaken the cord-like tendons inside the heart that attach to the mitral valve flaps. These changes may cause a leaky mitral valve (regurgitation) and produce symptoms. Your surgeon can restore the normal shape and function of the mitral valve. This stops the leakiness and decreases your symptoms.
- In many cases, our heart surgeons use minimally invasive valve approaches on patients with heart failure who need valve repairs. Many minimally invasive valve approaches still require putting you on a heart-lung machine (cardiopulmonary bypass), but they also tend to cause less trauma than open heart valve surgery and thus may be more appropriate for patients with a failing heart.
- Some types of heart valve disease can now be treated with a catheter procedure or a hybrid procedure that combines minimally invasive surgery with a catheter intervention. Learn more about hybrid procedures and interventional procedures such as valvuloplasty, mitral clips, and transaortic valve repair in Angioplasty and Other Interventional Cardiac Procedures.
Left Ventricular Reconstruction
- A heart attack often damages muscle in the left ventricle (the main pumping chamber). This damaged patch of tissue is permanently weakened. Sometimes a scar forms and the whole “dead zone” becomes thin and nonfunctional.
- The heart works harder to make up for the lost muscle—but over time this extra work leads to a lopsided enlargement of the heart, less effective pumping, and heart failure.
- Your surgeon can remove or isolate the dead tissue and pull together the healthy edges of tissue. Sometimes a synthetic patch is added. This surgery—called left ventricular reconstruction—eliminates the dead zone, returns the heart to a more normal shape, and improves heart function.
- Other names for this surgery include: the Dor procedure, left ventricular aneurysm repair, left ventricular infarct exclusion, and left ventricular reduction.
- Other procedures often performed at the same time include Coronary Artery Bypass (CABG) and heart valve surgery.
- This a major open-chest procedure that requires the use of heart-lung machine; it is not appropriate for all patients with heart failure.
- Some patients with cardiomyopathy who have heart walls that have grown abnormally thick (hypertrophic) may benefit from a variation of this surgery called septal wall myectomy, where the surgeon removes a wedge of the overgrown heart muscle between the left and right chambers (the septum) in order to improve the heart’s pumping ability.
Procedures for Devices and Pacemakers
- The heart's electrical signals can go haywire when the overworked heart changes shape or when heart tissue is damaged or has a "dead zone." This is why heart failure often leads to abnormal heart rhythms. These out-of-sync heartbeats—or atrial fibrillations—can cause inefficient pumping of blood or, sometimes, a dangerously erratic rhythm.
- To improve the timing of electrical signals in your heart, your surgeon can insert a device called a biventricular cardiac pacemaker. This unit, about the size of an old-fashioned pocket watch, has a generator (battery) and computer chip. It is inserted just under the skin in the upper chest near the shoulder. Wires (leads) go from the pacemaker through a vein into the heart's lower chambers.
- The biventricular pacemaker sends low-energy electrical pulses to keep the right and left chambers (ventricles) of the heart pumping together in unison. The coordination helps the heart pump more blood with each beat.
- This is sometimes called cardiac resynchronization therapy (CRT).
- Pacemaker batteries last about eight years and are easily replaced in a minor procedure.
- Most patients get pacemakers that can automatically speed up the heart rate during activities.
- Some biventricular pacemakers can also work as an implantable cardio-defibrillator (ICD), which can send a high-energy electrical zap to stop any dangerous arrhythmias.
- Inserting a pacemaker is a minor procedure that takes about an hour or two; it can be done by your surgeon or by a heart arrhythmia specialist known as an electrophysiologist.
- Some patients with heart failure have atrial fibrillations that require the MAZE procedure, a surgery that cuts lightly across the heart's surface in order to block erratic electrical signals from spreading. See the section on Atrial Fibrillation Surgery (MAZE) for more details.
- Some patients with certain types of arrhythmias may require catheter ablation or another electrophysiologic intervention; your surgeon or a Temple electrophysiologist can often provide these special procedures using minimally invasive techniques.
Ventricular Assist Devices
- Today, one of the best new options for patients with end-stage heart failure is the ventricular assist device (VAD). Temple surgeons specialize in inserting the newest generation of VADs (also called mechanical heart pumps or circulatory assist devices).
- The newest pumps are small, powerful, and reliable. They can help patients with heart failure live longer and feel better. Some of the devices duplicate the natural once-a-second pumping action of the heart. Other VADs pump blood continuously through a rotary tube. See the section on Mechanical Circulatory Support Devices for more details.
- In many cases, the purpose of the VAD is to help a patient on the waiting list for a heart transplant (this is called “bridge therapy”). In other cases, for example in patients who do not qualify for a transplant, the VAD is intended to remain permanently (this is called “destination therapy”).
- In recent years, many surgeons have started to consider VAD insertion as a temporary assist for a heart that is deemed likely to recover its own strength—perhaps with the help of new drug or a novel stem cell therapy. Temple heart researchers are working on these types of regenerative therapies and partnering with Temple surgeons to use the VAD for this new short-term purpose (which we call “rest and regeneration therapy” or “R&R therapy”).
Total Artificial Heart
- For extremely sick patients waiting for a heart transplant, the SynCardia Total Artificial Heart may be an option. It is used as a temporary replacement for wait-listed patients with signs of severe damage in both heart chambers (biventricular failure). These are patients who cannot wait any longer for a donor heart.
- The SynCardia mechanical heart replaces both ventricles and all four heart valves. The plastic device takes over completely for the patient’s own dying heart, which is removed when the artificial heart is implanted. It is powered by pulses of air delivered from a small portable pump that is worn like a shoulder bag.
- Temple is one of just a few dozen heart centers in the U.S. certified to implant the SynCardia total artificial heart. It is common after surgery to see patients respond quickly as blood flow is restored throughout their body.
- After the surgery to implant the artificial heart, many patients can return home to a more active lifestyle as they wait for a permanent donor heart. Clinical trials have shown that nearly 8 of 10 patients receiving the artificial heart survive the wait for a heart transplant. See the section on Mechanical Circulatory Support Devices for more details.
- For patients with end-stage heart failure, a heart transplant may be an option. “End-stage” means that the heart is severely damaged and cannot be helped with other standard procedures or surgeries. Older patients or those with serious medical conditions may not be good candidates for transplant; they may need a special treatment such as a VAD.
- In transplantation, the failing heart is removed and replaced with a healthy heart from a deceased donor. This operation requires a median sternotomy (splitting of the breastbone) and cardiopulmonary bypass (heart-lung machine) and lasts four to five hours or more.
- In addition to the risks of the surgery itself, patients considering transplantation must also know that this option requires a careful selection process, a pre-transplant “wait list” period, a long post-transplant recovery (a week or two in the hospital followed by months of frequent tests and biopsies), and a lifetime commitment to cardiac rehabilitation, lifestyle changes, and follow-up counseling, monitoring, and ongoing treatment (eg, powerful immunosuppressants to prevent rejection).
- The good news is that many patients who receive a transplant can eventually start enjoying many of their favorite activities again—walking, sports, family outings, vacations, or even a resumption of their career. Transplantation can be truly life-saving—leading to a longer life and a better quality of daily living.
- Patients who are eligible and ready to commit to the hard work of transplantation need to find an experienced transplant team of doctors, nurses, and specialists who can educate and guide them through the entire process.
- Temple’s heart transplant program, started in 1984, was the first in the region. Our surgeons have done over 1000 heart transplants, one of the largest totals in the world.
- Temple cardiovascular surgeons and heart failure specialists can explain the exact eligibility requirements, risks, and potential benefits of heart transplantation for someone in your situation.
Things to Know about Heart Failure Surgery, Devices, and Transplantation
- Patients with heart failure are often considered a high risk for surgery. However, Temple cardiovascular surgeons are experienced in advanced surgical options that may be appropriate even for elderly patients with advanced heart disease and other medical conditions. These new options include minimally invasive and robotic-assisted procedures as well as “hybrid” surgeries that combine minimally invasive surgery with a catheter-based treatment.
- Temple surgeons employ a variety of temporary assist devices to help high-risk or critically ill patients maintain good blood flow during surgery or a complex hybrid procedure. Dr. Howard Cohen of Temple helped develop one such left ventricular support device, called the TandemHeart®, which is a temporary external device that can maintain blood circulation during a procedure or stabilize critically ill patients before surgery. Other assistive devices used at Temple are the Impella 2.5 and the intraaortic balloon pump.
- Enrollment in one of Temple's clinical trials of new therapies may be another option for those with advanced heart failure. Trials involving new drugs, special surgical procedures, new transplantation techniques, novel devices, and stem cell therapies (to regrow healthy heart muscle) are now underway at Temple.
- Temple surgeons are experienced in surgery for patients with all forms and severities of heart failure. We treat patients with end-stage heart failure who have additional medical conditions as well as those with milder symptoms or who are in the early stages of deteriorating heart function.
- For patients with no other options, Temple surgeons and heart failure specialists can evaluate and prepare patients for heart transplantation. Our heart transplant team is one of the most experienced in the region. For those who need biventricular support as they wait for a suitable donor heart, we can provide the SynCardia total artificial heart. Our team offers all the latest techniques in surgical and post-op care as well as extensive protocols and support teams for lifelong follow-up care.
- Your surgeon can discuss with you the exact tests and guidelines for deciding when and why surgery or transplantation is recommended.
- Your surgeon can tell you about the risks and benefits of your specific procedure.
To schedule an appointment with a Temple Heart Surgeon, click here or call 1-800-TEMPLE MED (1-800-836-7536).