End-stage Heart Failure: Surgical Therapy and Implantable Devices

Despite recent advances in medical therapy, mortality remains high following the diagnosis of heart failure (HF). Cardiac transplantation is still the standard surgical treatment option for highly selected patients with severe end-stage HF; however, it is available only to a small percentage of patients. The small number of available donor hearts is an inherent limitation on the ability of cardiac transplantation to greatly impact the management of advanced HF. The increased incidence and prevalence of HF in an ever aging and medically complex population has paved the way for alternative surgical and device treatment strategies. Some of these treatment options include ventricular reduction and remodeling surgery, mitral valve repair, mechanical ventricular assist device implantation, implantable cardioverter defibrillators, and cardiac resynchronization therapy. Several recent trials have demonstrated effectiveness of these therapies with regard to improvement in physiologic end points, HF symptoms, and survival. Surgical and device techniques are usually combined with optimal medical management of HF. The total cost and actual cost-effectiveness of employing these new therapeutic modalities in a growing population of HF patients remain to be determined.