Surgical management of heart failure

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Abstract
Over the past three decades mortality from cardiovascular disease has decreased in industrialised societies while the incidence and prevalence of heart failure has been increasing.1 Heart failure is now a major health problem, affecting up to 2% of the population and 10% of patients aged over 65 years.2 In 1990 heart failure accounted for 5% of all hospital admissions in Britain,3 at a cost to the NHS of £360m ($576m).4 In the United States, where 400 000 new cases are diagnosed annually, treatment costs in excess of $34bn (£21.2bn).5 The natural course of heart failure is progressive so that even with angiotensin converting enzyme inhibitors, the only medical treatment to have consistently improved prognosis, the annual mortality is 25-50%.5 This dismal outlook, particularly in severely symptomatic patients, often prompts surgical referral. A small proportion of patients may benefit from coronary revascularisation, albeit at a higher operative risk,6 while unsuspected or underestimated valvular disease may merit valve repair or replacement. For many, conventional cardiac surgery has little to offer and the only surgical option is transplantation. Newer surgical approaches include cardiomyoplasty, left ventricular volume reduction, and mechanical support. Cardiac transplantation is presently the optimum surgical treatment for heart failure. Allograft transplantation results in 90% survival at one year and 50% survival at five years with return to a near normal quality of life.7 However, the scarcity of donor organs …