Non-transplant surgery for heart failure.

hrombolysis and PTCA save lives during acute myocardial infarction, but incomplete or delayed reperfusion results in akinesia or dyskinesia. If more than 20% of the left ventricular circumference is dyskinetic, the remaining contractile cavity dilates to increase stroke volume. When more than 50% of the myocardium is impaired, increased wall tension (LaPlace's law) triggers progressive left ventricular failure with regression to myocyte fetal genetics and apoptosis. 1 2 In Britain, most heart failure is caused by coronary artery disease, particularly in patients over 60 years old. There are now hundreds of thousands of patients with debili-tating symptoms despite maximal medical treatment. Less than 300 cardiac transplants per year are undertaken in a labour intensive way by 10 separate units. In a short time, more palliated young patients with congenital heart disease will require these organs. Consequently , the treatment of older patients with coronary disease and idiopathic dilated cardio-myopathy requires a radical rethink. The following account of current and emerging surgical strategies for heart failure concentrates on those patients with left ven-tricular ejection fraction (LVEF) < 30%, mean pulmonary artery pressure > 25 mm Hg, left ventricular circumferential akinesia or dyski-nesia > 60%, and left ventricular end diastolic volume (LVEDV) > 250 ml (LVEDV index (LVEDVI) > 140 ml). Most of these patients are New York Heart Association (NYHA) functional class III or IV with medical treatment. In coronary disease the relation between infarct size and mortality has been well defined (table 1). 3 From the coronary artery surgery study registry, five year survival for patients with LVEF < 25% was 41% with medical treatment and 62% with surgery. 4 For patients with dilated cardiomyopathy, mortality untreated is directly related to the severity of systolic dysfunction. Increased chamber sphericity and the presence of mitral regurgita-tion are markers of worse prognosis (one year mortality 54–70%). In the failing heart, mitral regurgitation occurs secondary to annular dila-tation, altered left ventricular geometry or pap-illary muscle dysfunction (fig 1). Volume overload causes progressive left ventricular and annular dilatation, worsened mitral regurgita-tion, and decreased survival. Coronary revascularisation in heart failure patients High risk coronary bypass is the most frequent conventional operation in heart failure patients. Incomplete myocardial infarction leaves viable but ischaemic myocardium within involved segments (flow/metabolism mismatch). Hibernating myocardium is an unstable sub-strate for postinfarction dysrhythmic events and mortality, independent of age or LVEF (event rate 43% v 8% for scar). 5 Hibernating myocardium …