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Title: Surgical Treatment for Congestive Heart Failure


1
Surgical Treatment for Congestive Heart Failure
  • LaDale Simpson
  • March 1, 2007

2
Statistics
  • Congestive Heart Failure is a common medical
    problem affecting over 5 million Americans
    annually
  • 1.5-2.0 of the U.S. population at any given time
    is inflicted with this disease
  • Over 500,000 cases are newly diagnosed annually
  • Leading cause of hospitalization (80) in
    patients over 65 years of age
  • The impact of heart failure on society is
    massive, as approximately 40 billion annually is
    spent on inpatient and outpatient visits.
  • An additional 500 million is estimated to be
    spent on medications each and every year

3
What is CHF?
  • Congestive heart failure arises when a persons
    heart is unable to keep up with its required
    workload.
  • The pumps in an affected heart are weakened, thus
    causing the blood to move throughout the
    circulatory system at a reduced speed.
  • As a result, the heart is unable to pump
    much-needed oxygen and nutrients to meet the
    bodys demand.

4
What is CHF?
  • The chambers in the heart thus respond by
    stretching to hold more blood or by hardening and
    becoming thick.
  • This allows the body, for a short time, to
    compensate for the inadequacy of the valves, but
    with time the muscle walls of the heart begin to
    weaken as well.
  • In response, the kidneys often cause the body to
    retain fluid, particularly water and sodium.
  • This fluid can accumulate in the arms, legs,
    ankles, feet or lungs, causing congestion
    throughout the body.

5
Risk Factors
  • CHF is closely associated with many major risk
    factors including
  • Age
  • Smoking
  • History of alcohol abuse
  • Metabolic syndrome
  • Coronary artery disease
  • Hypertension
  • Valve disease
  • Diabetes mellitus
  • Obesity
  • Family history of heart failure

6
Types of CHF
  • There are 2 main types of congestive heart
    failure systolic dysfunction and diastolic
    dysfunction.
  • Systolic dysfunction occurs when the heart is
    unable to empty completely with contraction, and
    therefore, inadequate amount of blood is sent out
    into circulation.
  • Testing for systolic dysfunction is done by
    measuring the ejection fraction.
  • A normal ejection fraction is more than 55 of
    the blood volume.
  • An ejection fraction 45 indicates systolic
    dysfunction.
  • If your ejection fraction is normal then you
    assume the patient has a diastolic dysfunction.
  • This occurs when the heart contracts normally,
    but the ventricles do not relax properly or are
    too stiff to fill completely.

7
Stages of CHF
  • In 2001, the American Heart Association developed
    four stages (A-D) to classify patients suffering
    from congestive heart failure, which were later
    revised in 2005.
  • Stage A patients that are high risk to develop
    CHF but have no structural damage or symptoms
    pertaining to the disease.
  • Stage B patients have some sort of structural
    damage to the heart, usually detected with an
    echocardiogram test, but are yet to experience
    any symptoms
  • Stage C patients are those patients who have
    structural damage and also have prior or current
    symptoms.
  • Stage D patients are patients who, even after
    receiving optimum medical care, still have
    advanced symptoms. These are the patients that
    become candidates for surgical procedures and/or
    mechanical assist devices, and often require
    hospitalization or hospice care.

8
Surgery
  • Surgery is not often used to treat patients with
    congestive heart failure.
  • However, it can be a logical method of treatment
    in cases in which traditional treatments are not
    working for whatever reason.
  • These such surgeries present a great risk, thus
    physicians seek to identify patients who have the
    greatest to gain from surgical intervention.

9
Heart Transplant
  • Perhaps the only current treatment that is
    capable of fully reversing the congestive heart
    failure is receiving a complete heart transplant,
    in which surgeons replace the damaged heart with
    a healthy one taken from a donor who has been
    pronounced brain dead.
  • Surgeons remove the healthy heart from the donor,
    keep it in a cooled environment, and then it is
    transported to the medical facility in which the
    recipient is waiting for it.
  • The back walls of the atrias in the recipients
    body are kept intact and the atrias of the new
    heart are sewn together at this point.
  • Blood vessels are then reconnected.
  • Timing is everything, as a healthy heart can only
    exist out of the human body for 4-6 hours.

10
Heart Transplant
  • There is a much greater number of patients who
    suffer from congestive heart failure and could
    potentially benefit from a heart transplant than
    there are healthy donated hearts.
  • Due to this fact, there is a strictly screened
    heart transplant list.
  • Possible patients are evaluated on many different
    levels including age, medical history, diagnostic
    test results, social history and psychosocial
    evaluation.
  • Only patients who are believed to be able to
    survive the surgery and who will comply with
    years of disciplined living afterwards are
    considered for the list.
  • This list is prioritized according to the
    severity of illness, blood type and geographic
    location.
  • Once a patient is added to the donor list it is a
    long, stressful wait before he or she might
    receive a healthy heart

11
Left Ventricular Assist Device
  • The left ventricular assist device (LVAD) serves
    as a bridge to transplantation for patients in
    whom medical therapy has not worked and are
    waiting for a heart transplant, or as a
    destination therapy for patients who are
    non-transplant candidates due to age or
    comorbidity
  • This device supplements the function of the left
    ventricle when its pumping ability is damaged
  • It is a portable, battery-powered pump which is
    implanted in the abdominal wall and is connected
    to the heart in two places.

12
Left Ventricular Assist Device
  • The pump pulls blood from the left ventricle and
    then sends it to the aorta, from which blood is
    pumped out into circulation.
  • Thus, this allows blood to keep pumping through
    the heart at the rate in which the body demands.
  • An additional tube extends from the LVAD to the
    outside of the body and transports wires to a
    controller which the patient typically wears on a
    belt.
  • The batteries are normally located on a shoulder
    holster which also connects to the controller.

13
Left Ventricular Assist Device
  • Left ventricular assist devices are typically
    worn for weeks to months and serve to buy time
    for the patient, regardless of whether he or she
    is a candidate for a heart transplant.
  • It allows the patient to return home and attempt
    to live a semi-normal life.

14
Coronary Artery Bypass Graft
  • The most common type of surgical procedure
    performed on a patient suffering from congestive
    heart failure is a coronary artery bypass graft
    (CABG).
  • During a bypass operation an artery or vein is
    removed from another healthy part of the
    patients body, such as a leg, arm or the chest
    wall.
  • This removed blood vessel is then surgically
    attached in a way that it allows blood to bypass,
    or go around, the affected portion of the
    pre-existing blood vessel and thus becomes a
    graft.

15
Coronary Artery Bypass Graft
  • A coronary artery bypass traditionally calls for
    an open-heart surgery and the use of a heart-lung
    bypass machine to circulate the blood while the
    patient is having the surgery.
  • Minimally invasive procedures have been developed
    in which multiple smaller openings, or
    keyholes, are made in the chest.
  • This procedure has many benefits
  • less scarring
  • shorter hospital stay
  • faster recovery
  • less bleeding during surgery
  • reduced chance of post-operative infection
  • less pain afterwards

16
Coronary Angioplasty
  • Coronary angioplasty is a medical surgery that is
    used to restore blood flow through a narrowed or
    blocked artery in the heart.
  • A narrow, hollow catheter with a balloon on the
    end is inserted into a blood vessel in the arm or
    upper thigh and is guided to the diseased portion
    of the artery.
  • It is then inflated, which forces any plaque that
    is responsible for the narrowing outward against
    the wall of the artery, thus widening the artery
    and restoring the blood flow.
  • After the widening of the artery takes place, the
    balloon and catheter are removed.

17
Coronary Angioplasty
  • Since its development in 1977 the stent has
    decreased the risk by 50 of an artery closing
    again after an angioplasty.
  • Stents are tiny structures made of wire mesh that
    surgeons insert to prop open arteries that have
    been dangerously narrowed or clogged with fatty
    plaque.
  • The first stents were made with a bare metal but
    now most of them are coated with medications that
    aid the recovery of the artery from the surgery.
  • The usage of plaque removers and lasers have also
    provided beneficial tools to aid angioplasty.
  • Plaque removers are used to cut away the plaque
    while lasers dissolve plaque in the arteries
    while performing the angioplasty.

18
Electrical Signaling
  • The pumping of a normal, healthy heart is
    achieved from impulses sent through the organ by
    its very own electrical system.
  • It is vital that this rhythm of squeezing blood
    through the heart is done at a steady rate, for
    if not, the heart will ultimately lose its
    functioning capability.
  • Some patients have an abnormality of this
    electrical system in the heart
  • bradycardia
  • tachycardia
  • The majority of congestive heart failure patients
    suffer from an additional abnormality of this
    rhythm, in which the two ventricles do not
    contract simultaneously.
  • Treatment of all three of these conditions may be
    done surgically, with implantation of some sort
    of electrical device.

19
Electrical Signaling
  • A pacemaker is a small device that aids a hearts
    SA node.
  • This device detects heart rate of a patient.
  • When the heart rate drops below a set rate (which
    is determined by a physician) it send an
    electrical impulse that passes through the
    hearts muscle, just as the SA node does.
  • Thus, the heart contracts and pumps as it is
    intended to, correcting the bradycardia.

20
Electrical Signaling
  • A pacemaker is implanted just below the skin of
    the chest of the patient in a minor procedure.
  • It is comprised of a pulse generator and the
    leads.
  • The generator houses the battery and a tiny
    computer that monitors the patients heart rate
    and determines when to send an electrical
    impulse.
  • The leads are wires that are threaded through the
    veins into the heart and implant in the heart
    muscle.
  • They are the connection that sends impulses from
    the generator as needed.

21
Implantable Cardiovascular Defibrillator
  • Tachycardia is repaired by a device known as an
    implantable cardiovascular defibrillator, or ICD.
  • It, also, is a pace-making device that is placed
    just below the skin of the patients heart which
    monitors its rate and rhythm.
  • When the ICD detects an abnormally fast heart
    rate, it delivers a series of small electrical
    impulses in a similar manner as the typical
    pacemaker.
  • This impulse causes the heart to beat in a
    normal, slower rhythm again.

22
Cardiac Resynchronization Therapy
  • The hearts of some congestive heart failure
    patients have a delay in electrical conduction
    through the left bundle branch, which transmits
    the hearts electrical impulses to the left
    ventricle from the left atrium.
  • This is termed a left bundle branch block, or
    LBBB, and causes a delay in left ventricular
    contraction compared to that of right ventricular
    contraction.
  • This results in an asynchronous contraction,
    which further weakens the hearts pumping
    efficiency.

23
Cardiac Resynchronization Therapy
  • The recommended treatment for LBBB is cardiac
    resynchronization therapy, or CRT, which requires
    a sort of biventricular pacemaker.
  • Tiny electrical impulses are sent via leads to
    the right atrium and then to the two ventricles
    concurrently, ensure their simultaneous
    contractions.
  • This method of surgical treatment eliminates the
    delay caused by the LBBB and is typically
    recommended for patients suffering from stage D
    congestive heart failure.

24
Heart Valve Repair
  • Heart valves are flaps of tissues that ensure
    that blood traveling through different chambers
    of the heart and into circulation moves in the
    proper direction and does not flow back from
    where it came from.
  • Heart valve disease can be caused by infection,
    congenital heart disease or aging, and may cause
    the valves to either not close properly,
    resulting in a leaky valve, or not open
    completely, resulting in a decrease in blood
    flow.
  • Both of these circumstances make the heart work
    harder than normal and may worsen the extent of
    congestive heart failure the patient is suffering
    from.
  • Depending on the severity of the condition,
    defective valves may need to be either repaired
    or completely replaced.

25
Heart Valve Repair
  • Complete valve replacement involves the removal
    of a damaged valve and insertion of a new valve
    in its place.
  • This new valve may be an artificial valve made of
    metal or plastic, or may be a donated valve from
    a human donor.
  • During this surgery a patient is connected to a
    heart-lung machine.
  • Following the surgery the patient must be placed
    on a regimen of anticoagulation therapy to
    prevent blood clots in the area of the new valve.

26
Heart Valve Repair
  • New developments over the years have developed a
    minimally invasive repair option for patients.
  • With this most advanced technology a damaged
    valve can be repaired with an incision between
    the ribs of approximately 2.5 cm in diameter,
    opposed to the traditional open-heart surgery.
  • This surgery, called a mini-thoracotomy, lessens
    a patients post-operative scarring, recovery
    time and discomfort.
  • The Bow Tie procedure uses a single stitch to
    join the valve leaflets when they do not properly
    come together, and can be done in a minimally
    invasive manner.

27
Heart Valve Repair
  • Mitral regurgitation is a condition in which the
    mitral valve the valve between the left atrium
    and the left ventricle allows backflow of the
    blood from the ventricle into the atrium after is
    has been pumped through the valve.
  • This condition is existent in virtually all
    patients with congestive heart failure and is due
    to remodeling of the left ventricle.
  • Mitral valve repair typically involves
    restructuring the leaflets of the valves and
    providing a sort of support with a ring.
  • Preservation of the mitral valve contributes to
    decreasing wall stress, improving systolic and
    diastolic function and enhances proper geometry
    of the left ventricle.

28
Left Ventricular Reconstruction
  • In a failing heart, the normal elliptical shape
    of the left ventricle is lost.
  • The ventricle dilates and remodels in response to
    its inability to pump efficiently, creating a
    spherical shape.
  • Ironically, this remodeled shape eventually turns
    from being compensatory and beneficial to a
    contributing cause of heart failure and mitral
    regurgitation.
  • As the ventricle walls pull apart the mitral
    valve is no longer able to close completely, thus
    regurgitation takes place.
  • In this instance it proves beneficial to
    reconstruct the shape of the left ventricle.

29
Left Ventricular Reconstruction
  • The leading procedure by todays standards is the
    Dor procedure.
  • With this technique a mannequin device is used to
    remove any scar tissue in the left ventricle that
    may be present from previous damage.
  • The surgeon enters the left ventricle through the
    anteroapical scar.
  • Once the dead tissue determined, a Dacron patch
    is sutured for the ventricle to close over.
  • This prevents destruction of the left ventricle.
  • Another leading surgery involves a polyester mesh
    cardiac support device, the Acorn CorCap.
  • The device wraps around the ventricle from
    posterior to anterior, using sutures, and girdles
    the heart, helping to retain its elliptical
    shape.
  • It provides more end diastolic support and
    reduces wall stress.

30
Post-Operative Recovery
  • Patients who receive a surgical measure of
    treatment for congestive heart failure often face
    a long road of recovery following the procedure.
  • These patients are given a strict set of
    guidelines in which they are responsible to
    follow for a period of weeks to months.
  • The patient should take proper care of any
    incisions in which he or she obtained with the
    procedure.
  • They should be kept clean and dry, using only a
    mild soap and water to clean them.
  • If there are any signs of an infection, such as
    drainage, opening of the incision line, redness
    or warmth around the area or an increase in body
    temperature then a physician should be contacted
    immediately.
  • If the patient underwent an open-heart procedure
    a physician should also be contacted if he or she
    feel as if the sternum has moved or feels like it
    has popped
  • Pain relievers are typically given to make a
    patient feel more comfortable, but the patient
    and/or his or her family should take care to make
    sure that no more than the prescribed dosage is
    taken.

31
Conclusion
  • Congestive heart failure has become an emerging
    epidemic the in the world today, affecting over 5
    million Americans in our country alone.
  • Pharmacologic treatments are considered a first
    option for its treatment, but a wave of new,
    surgical courses of treatments has began to
    develop.
  • It is essential for critical appraisal of these
    surgical therapies so that they can be offered to
    the growing population suffering from heart
    failure.
  • Although a complete heart transplant is
    considered to be the gold standard of treatment
    for a failing heart, there are far too few donor
    hearts to supply an ever-growing population who
    potentially could benefit from them.
  • This is why it is crucial to seek other
    approaches to correcting this problem.

32
Conclusion
  • All of the methods described have proven
    beneficial to expanding the duration and
    increasing the quality of the lives of congestive
    heart failure patients, and have allowed the
    majority of them who have received the operations
    to maintain a normal lifestyle.
  • Although these surgeries are currently considered
    to be a bridge to transplantation, prolonging
    life until a donor heart may come available in
    the future it is a great possibility that they
    will be considered an equally life-saving method.

33
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