[Refractory heart failure. Surgery of the left ventricle and mitral insufficiency]

The high number of patients with advanced heart failure despite optimal medical therapy and the limited availability of radical therapeutic solutions (including heart transplantation) increase the interest in alternative surgical procedures. In this paper, the correction of secondary mitral valve regurgitation, left ventriculectomy, and aneurysmectomy/ventriculoplasty will be reviewed. Secondary mitral valve regurgitation worsens both symptoms and prognosis in patients with left ventricular dysfunction of ischemic and non-ischemic etiology. Its correction, mostly by conservative repair, can be performed with an acceptable perioperative risk in patients with compensated heart failure. Concomitant correction of mitral insufficiency is advisable in patients with significant regurgitation undergoing revascularization surgery. On the other hand, data regarding the improvement in clinical and objective parameters after mitral valve surgery in patients with severe mitral regurgitation and idiopathic or ischemic cardiomyopathy who are unsuitable for revascularization are discordant. In view of its feasibility and presumed efficacy, partial left ventriculectomy or the Batista operation seemed attractive but the expectations were not met: success cannot be predicted in individual patients, the initial improvement may be of short duration, and the peri and postoperative mortalities are relevant. Postinfarction surgical reconstruction and reshaping of the left ventricle is performed mostly together with revascularization surgery; the surgical experience, indications and results reported in various studies are however discordant. In conclusion, multicenter cooperation including randomized studies or registries is worthwhile in order to define the role of surgery of the mitral valve and left ventricle in patients with advanced heart failure.