Non-transplant surgery for heart failure and severe left ventricular dysfunction. Opportunities and limitations

The need of alternatives to transplantation has lead to routinely reconsidering conventional surgery for selected patients with advanced heart failure. Although the recovery of ventricular contractility with revascularization sometimes restores ventricular function almost to normality while dramatically enhancing the quality of life, only a few patients with ischemic left ventricular dysfunction exhibit the amount of hibernating myocardium required for such a spectacular outcome taking place. Advanced remodeling is a further obstacle and is currently being addressed by means of operations designed to reduce ventricular volume and restore geometry. Hemodynamic measurements raise concerns, however, as to the diastolic function and the competence of the mitral valve late after reconstructive surgery. Finally, the repair of mitral valve regurgitation has produced interesting short-to-medium term results both in terms of survival and heart failure relief. Yet, their durability is uncertain, if not disappointing when the valvular disease has an ischemic etiology. Expectations of patients undergoing one of the aforementioned procedures, or a combination thereof, should not be averaged as they heavily depend on the specific patient profile under evaluation.