Improving perioperative outcomes in patients with end-stage heart failure

In the United States alone, more than 4.5 million people are affected by heart failure, with more than 500,000 new cases diagnosed each year. Although cardiac transplantation remains the "gold-standard" surgical treatment for heart failure unresponsive to maximal medical therapy, the chronic shortage of donor hearts has necessitated clinical trials of other surgical options. Over the past two decades, research, technological progress, and extensive clinical experience have resulted in the application of ventricular assist device (VAD) technology to a broader population of heart-failure patients, as these devices have proven to be viable therapeutic alternatives for therapy of end-stage heart failure. All patients undergoing cardiac transplantation or VAD insertion have multiorgan dysfunction as a result of irreversible, severe ventricular dysfunction resulting in low cardiac output. Recently, fenoldopam has been described as a vasodilator that might be useful in patients with decompensated heart failure, particularly in the perioperative setting. As a selective dopamine-1 receptor agonist, fenoldopam causes vasodilation in the systemic, renal, mesenteric, coronary, and pulmonary vasculature. Potentially, the pharmacologic properties of fenoldopam could be successfully exploited in patients undergoing medical or surgical treatment of end-stage heart failure. Controlled randomized trials are needed to demonstrate improvement in cardiopulmonary or renal outcomes in such patients.