The armamentarium for treating end-stage heart failure has evolved significantly in recent years. Although cardiac transplantation remains the gold standard treatment for this disease, the increasing disease prevalence and limited donor organ supply limit the applicability of this strategy as an across-the-board solution. Several different medical therapies have been established through prospective randomized trials as a means for improving ventricular function, symptoms, and clinical outcomes. These include the use of β-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, and aldosterone antagonists.1 Biventricular pacing has emerged as a method for improving symptoms and survival and limiting complications in patients with heart failure and cardiac dyssynchrony.2 However, these treatments are all limited in their efficacy, with mortality rates as high as 18% at 6 months.3 Accordingly, surgical management of heart failure continues to represent one of the fastest growing aspects of adult cardiothoracic surgery.
The heart failure state may be the result of ischemic changes causing myocardial dysfunction (and thus dilatation and often valvular dysfunction) or may begin first with ventricular chamber distension and remodeling causing increased wall tension and subendocardial ischemia. Thus, apart from ventricular assist devices (described later), the major surgical approaches to heart failure can be categorized by their mode of therapeutic benefit: (1) coronary revascularization, (2) repair of valvular defects resulting in pressure and volume overload, and (3) anatomic ventricular restoration. In all cases, it is imperative to determine preoperatively whether the given patient is also a transplantation candidate, so as to prepare for the possible eventuality of postcardiotomy assist device bridging to transplantation.
Although several nonrandomized studies have documented the utility of various surgical approaches to heart failure, there is currently no Level 1 evidence to establish the role of coronary artery bypass graft (CABG) w ventricular remodeling procedures in these patients. The Surgical Treatment for Ischemic Heart Failure (STICH) trial was designed specifically to address these questions.4 In this ongoing trial, patients were included if they had an ejection fraction (EF) ≤35%, coronary anatomy suitable for revascularization, and age ≥18 years. Exclusion criteria included the need for an aortic valve procedure, cardiogenic shock or intra-aortic balloon pump support, percutaneous coronary intervention planned for coronary artery disease treatment, acute myocardial infarction as the cause of left ventricle (LV) dysfunction, more than one prior CABG, and noncardiac illness that either imposed a substantial operative mortality or was associated with a life expectancy of <3 years. Based on these selection criteria, patients were randomized according to the protocol illustrated in Fig. 30–1. Patients were treated with medical therapy, CABG, or CABG with surgical ventricular restoration (SVR). The study was designed to address two separate hypotheses:
Randomization on the Surgical Treatment for Ischemic Heart Failure (STICH) trial. CABG, coronary artery bypass graft; CAD, coronary artery disease; EF, ejection fraction; MED, medical therapy; SVR, surgical ventricular restoration. Reproduced with permission from Joyce et al.4
- Hypothesis 1 (coronary revascularization hypothesis): Improvement in myocardial ...