Surgical alternatives to heart transplantation

Cardiomyopathy is an expanding clinical problem, and is one of the leading causes of hospitalization worldwide. The use of heart transplantation is well established as the treatment of choice in appropriate patients. This in itself poses a problem, as the donor rate in many countries remains constant in spite of increasing numbers of potential recipients. There are many surgical options available to patients in this situation including high-risk coronary bypass surgery (i.e. Grade 4 LV, or LVEF≤30%) for those patients with ischemic cardiomyopathy and severe coronary artery disease with associated viability. High-risk valve repair or replacement is undertaken for valvular cardiomyopathy. Surgical ventricular restoration may be performed in conjunction with other forms of surgery, and all of the above should be accompanied by surgical implantation of LV epicardial leads for future biventricular pacing in the setting of widened QRS complex. Ventricular Assist Device implantation is better positioned as a precursor to cardiac transplantation, and is comprised of the 2 main categories of destination therapy or as a bridge to either recovery or transplantation. There is also a great deal of research and interest in cardiac splinting procedures and devices, although these are still only experimental in nature. In the future, surgical units that do not offer cardiac transplantation are likely to provide more surgical support to multidisciplinary heart failure clinics as the population ages, and the numbers of patients with cardiomyopathy increases.