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Heart Failure Preparation & Management

Daignosing Heart Failure Building a Team Optimal Medicine Therapy Minimally Invasive Surgery Invasive Surgery Recovery
Diagnosing A Heart Condition Building A Team Optimal Medicine Therapy Minimally Invasive Surgery Invasive Surgery Recovery

Invasive Surgery

Obviously, heart surgery is the biggest step in handling heart failure. The patient’s condition and their stage and classification of heart failure, determine the choices that have to be made when approaching surgery. There are two basic categories of heart surgery 1) minimally invasive and; 2) invasive. This section will cover invasive heart surgery options.

To determine whether a patient is a candidate for invasive surgery, a surgeon will evaluate and assess the patient’s medical and family history and the diagnostic tests including blood tests, urine tests, a Chest X-ray, an Echocardiogram, an Electrocardiogram, Coronary Catheterization (Angiogram), MRI, Nuclear Scan, and Ejection Fraction analysis (See Diagnosis).

There are many differences between invasive and minimally invasive heart surgery. One of the obvious differences is the incision that is made during the procedure. With invasive surgery the incision required is approximately 6 to 8 inches instead of the 3 to 5 inch incision made in minimally invasive heart surgery. In invasive procedures the surgical team will more than likely enter the body through the chest cavity (sternum).

There are two basic approaches to heart surgery-open and closed. Open-Heart Surgery requires surgically entering the heart to repair the problem. The heart will be shut down by the surgeon and the heart lung machine will be used so that blood and oxygen will continue to flow throughout the body sustaining circulation. In Closed-Heart Surgery the heart lung machine is not necessary, as the surgical team will not be entering the heart.

Invasive heart surgery may involve using one of many different specialized surgical instruments. These devices are used in aiding the surgeon in reaching into a very specific area of the heart.

Some basic types of invasive heart surgery include:

  • Aortic Surgery
  • Congenital Heart Surgery
  • DOR Procedure
  • Heart Transplant
  • Implantable Cardiac Defibrillator (ICD)
  • Stent Placement
  • Ventricular Assist Device (VAD)

AORTIC SURGERY

The Aorta is the largest artery in the body. Aorta conditions are serious, but through proper and expert diagnosis, medical attention, and necessary lifestyle changes (quitting smoking, proper diet and exercise), a patient may be able to enjoy a normal active life.

There are many different procedures that may be chosen approaching Aortic Surgery. Each patient’s individual assessment determines which procedure will be done. The Buttom Bentall, David Valve-Sparing Re-Implantation Procedure, Homograft Technique, the Ross Procedure, and the Yacoub Remodeling Procedure are a few of the procedures commonly performed.

Most all Aortic Surgeries involve either replacing the affected area (ascending aorta, arch, or root) with prosthesis, protecting the aortic valve with placement of a Dacron® tube graft around the valve, or removal of the affected area. Often aortic conditions affect more than one of these areas. Your surgical team may be able to determine a strategy, but may have to make final decisions once they have begun the procedure.

CONGENITAL HEART SURGERY

Congenital is defined as present at birth. Generally, Congenital Heart Surgery is performed during childhood, but some adult patients undergo the surgery. Pediatric cardiologists specialize in congenital heart birth defects, but perform surgery with a team of pediatric specialists.

As with adult surgeries, there are several different types of Congenital Heart Surgery, depending on the person’s diagnosis. These include, but are not limited to-Arterial Switch, Pulmonary artery banding, the Ross procedure, Shunt procedure, or a heart transplant in rare cases.

Congenital Heart Surgery can be performed with the Open-Heart or Closed-Heart approach (see above). These procedures have proven to have high success rates in the last years, but there may still be complications because a child’s organs are considered immature or underdeveloped.

DOR PROCEDURE

Left Ventricular Reconstructive Surgery, referred to as LVR, is a procedure for advanced Heart Failure patients. When a person experiences a heart attack in the Left Ventricle (the lower left pumping chamber of the heart that receives blood from the left atrium and pumps oxygen into the circulation), partial loss of the heart’s muscle movement occurs.

A Heart Attack may cause a scar on the Left Ventricle (LV) of the heart. If the scarred area becomes thin and begins to inflate with each heartbeat, an expansion of a blood vessel (aneurysm) may occur. Previous heart damage coupled with the aneurysm causes the heart to have to pump more rigorously.

The Dor Procedure, which was modernized by Vincent Dor, MD in 1985 is a practical method for restoring a dilated left ventricle to its normal dimensions. The LVR surgery not only restores the LV to its normal proportions, it involves removal of the dead tissue area and/or aneurysm.

Ideally, the Dor procedure may create complete recovery in the Left Ventricle allowing it to pump sufficient amounts of blood without being over worked. Research shows that the “five year survival matches or exceeds that of cardiac transplant, and freedom from Heart Failure post-operatively reaffirms the effectiveness (efficacy) and durability of LVR.”

Advanced Heart Failure patients often experience various heart problems before Left Ventricular issues occur. It is not unusual for a Heart Surgeon to perform concomitant or affiliated procedures while performing LVR. Because of the use of a heart lung machine LVR is considered a major open-heart surgery so therefore, other procedures may be performed concurrently.

A coronary bypass, which establishes a route past an obstruction and improves oxygen supply to the heart; or mitral valve repair, to close leaks, are common concomitants of the DOR Procedure.

LVR consists of the surgeon placing a small incision in the LV and locating the dead tissue and/or aneurysm. Depending on the size, part of the scar tissue may be removed before completing the procedure. Rows of stitches are placed around the circumference of the tissue to separate the frame from the healthy tissue. The stitches are then pulled together tightly, commonly referred to as a “purse string” procedure. One last row of stitches is placed outside of the LV to further strengthen the area.

HEART TRANSPLANT

A heart transplant might be an option if a patient is in the final stages and classifications of Heart Failure. A Heart Transplant is only performed if other treatments have not managed your heart failure properly.

A Heart Transplant is a major operation and has its complications, but new technology gives patients in the final stages of heart failure greater odds than ever before.
Heart Failure that results in a heart transplant my result from coronary artery disease, cardiomyopathy, heart valve disease, or sever congenital heart disease. Persons with life threatening diseases, diabetes, severe kidney, liver, or lung disease are not recommended for a heart transplant.

Once it has been determined that a person might benefit from a transplant they will be guided to a heart transplant evaluation center. Once a team of heart transplant specialists determines that a person qualifies for the transplant, they will then go on a donor list. The list is connected to a national database. There are about 4,000 people waiting for a transplant on any given day.

A patient should receive the “new” heart within four hours of it being removed from the donor. A new heart generally comes from a donor who is on life support. The transplant team and patient have little time to accept the transplant, so decisions have to be made quickly.

A Heart Transplant takes approximately four hours. It is an Open-Heart Surgery (see above) therefore a heart lung machine will be used. The failing heart will be removed and the donor’s heart will be sewn into place.

Complications after a heart transplant may include your body rejecting the new heart. Your immune system will recognize the new organ as foreign tissue and my fight it like an infection. There are drugs to help your immune system adjust to this.

IMPLANTABLE CARDIAC DEFIBRILLATOR (ICD)

Very simply, an implantable cardiac defibrillator (ICD) is a device that is designed to identify, monitor and remedy certain types of abnormal heart rhythms. It is similar to a conventional pacemaker.

Fibrillation causes the heart muscle to spasm or shudder. The twitching is not succinct with the regular heart rhythm or beat. The ICD is placed to prevent sudden death or cardiac arrest due to the fibrillation.

There are four chambers of the heart; the left and right atriums (upper chambers) and the left and right ventricles (lower chambers). Conventional pacemakers are used to correct slow heartbeats through wires (leads) that send electrical impulses to 1 or 2 chambers of the heart (generally the right atrium and the right ventricle). ICDs’ are used to correct an abnormally fast heart beat (tachycardia) or fibrillation.

Much like pacemaker installation, ICD placement involves placing wires (leads) through an artery to the right atrium (RA) and lodging them into the bottom of the right ventricle (RV) to transmit electrical impulses when necessary.

An ICD monitors an abnormally rapid heart beat (tachycardia) or the twitching caused by fibrillation. When a person’s heart is beating at a normal rate, the ICD will remain idle. If the ICD detects fibrillation or tachycardia, it will transmit battery powered electrical impulses to the right ventricle (RV) to make the heart beat at a normal rate.

STENT PLACEMENT

A Stent is a device that is used to hold tissue in place. It is generally a metallic mesh placed in the coronary artery to help keep blood vessels open so that blood may flow at a normal rate. Stent surgeries are the number one form of heart surgery in the United States.

Stent surgery is performed to unclog blocked arteries, commonly referred to as coronary artery disease. There are currently three types of stents on the market-metallic mesh, dissolvable, and drug-coated.

In stent surgery a catheter is generally inserted into an artery in the groin and is lead to an artery of the heart. The catheter has a small balloon on its tip. Once at the trouble spot in the artery, the balloon is inflated. This will widen the coronary artery and help compress the plaque, so that blood may flow more easily. The stent will be placed into the troubled area.

The traditional metallic mesh stent is placed in the coronary artery to help keep blood vessels open so that blood may flow normally. Once the stent is in place, a patient’s heart may then be able to pump blood much more efficiently. Ideally, tissue will eventually grow around the metal stent and maintain open arteries.

Dissolvable stents are new on the market and are designed to keep arteries open and eventually completely dissolve. This type of stent has proven to be effective for at least six months after placement. The study from Erasmus University Medical Center in Rotterdam, the Netherlands, reports “no deaths, blood clots or repeat artery-opening.”

The drug-coated stents are placed in the artery in the same manner as the others, but are coated with time-released medications that will hopefully keep the clogged artery from re-closing. These stents are still controversial because some studies have shown that they can raise the risk of blood clots forming months after the procedure and may only open the artery temporarily.

Your physician will help determine the right stent for you.

VENTRICULAR ASSIST DEVICE (VAD)

A ventricular assist device (VAD) is a device that has become increasingly used in patients awaiting a heart transplant. It is intended to either sustain life until a donor’s heart becomes available or to prolong a patient’s life that is in the final stages and classifications of Heart Failure.

The purpose of a VAD is to help a person’s weakened heart pump blood to sustain healthier circulation. The VAD will essentially help the Left Ventricle (LV) by alleviating the work that it normally does.
Depending on a patient’s medical and family history and their condition, the VAD will more than likely be surgically implanted into the abdomen. There are two types of VAD placement-Left Ventricle Assist Device (LVAD) and Right Ventricle Assist Device (RVAD).

In LVAD placement, the VAD will be placed through the left ventricle (LV) and the aorta. The VAD will then work with the LV. When the LV contracts blood that would normally flow into the left ventricle, it will instead flow into the VAD. When the heart relaxes, the blood from the VAD will pump into the aorta (the body’s largest artery), allowing the LV to fill with blood.
In RVAD placement, the VAD will be placed through the right ventricle (RV) and the artery that carries blood from the heart to the lungs (pulmonary artery). The VAD will then work with the RV.

In either case, there are wires (leads) attached to the VAD that will pass through the skin to the outside of the patients body. The patient will have a battery-operated controller that is attached to the wires. The controller is equipped with a display that will monitor the VAD and sound an alarm if it is not working properly. The controller may be worn on the patient’s body, attached by a belt, or me be plugged into a wall socket.

VAD placement is a serious step and may have it’s complications including, but not limited to, kidney or respiratory failure, blood clotting, or device failure. As with a heart transplant, persons with life threatening diseases, diabetes, severe kidney, liver, or lung disease are not recommended for a VAD.

New technology gives patients time and can help the heart and other organs. A successful VAD placement will allow a patient to live at home and will help alleviate shortness of breath and fatigue in later stage heart failure patients.

As with all heart conditions it is imperative to consult your physician and your surgeon to ensure that you receive the right treatment.



This information is not intended to replace the advice of a doctor. The Heart Failure Center does not provide medical advice, diagnosis or treatment. The contents of The Heart Failure Center Site ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or any symptoms you may have. If you think you may have a medical emergency, call your doctor or 911 immediately.

 

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