What treatments are available if medications don't work?
Cardiac Resynchronization Therapy and Implantable Cardio-Defibrillators
Special pacemakers and Implantable Cardio-Defibrillators (ICDs) are FDA approved for patients with heart failure who would likely benefit from this therapy. Pacemakers and ICDs are small metal devices implanted beneath the skin connected to insulated wire(s) tunneled to the heart chamber. The insulated wires, called leads, transmit electrical impulses and stimulate the heart to beat or correct an abnormal heart rhythm. The leads carry electrical signals back and forth between your heart and the device.
Cardiac Resynchronization Therapy (CRT) is a pacemaker treatment for patients with enlarged hearts, who exhibit signs and symptoms of heart failure. When your heart is enlarged, a condition called cardiomyopathy, it often beats in an uncoordinated (dys-synchronized) way. “Resynchronization” simply means that the heart rhythm is put back in synch, or resynchronized, by a pacemaker so that it beats properly and efficiently. With CRT, the left and right ventricles are paced to contract in a coordinated (synchronized) manner. Because both the right and left ventricles of the heart are paced, this therapy is frequently referred to as “bi-ventricular pacing”. For many patients, cardiac resynchronization therapy improves heart function and decreases symptoms of heart failure.
Implantable Cardiac Defibrillators (ICD) are recommended for patients at high risk of developing a dangerous and life threatening abnormal heart rhythm. A defibrillator is a small device (same size as a pacemaker) implanted under the skin, like a pacemaker, to treat abnormal and potentially deadly heart rhythms. The device is small, fits into the palm of an average sized female hand, and contains small computerized parts that run on a battery. An ICD monitors heart rhythms and works as a pacemaker for slow heart rhythms in addition to delivering life-saving shocks for dangerously fast heart rhythms. If you have a low ejection fraction, with or without a past medical history of abnormal heart rhythms, your physician may recommend you have an ICD.
Surgical Options
Surgical options may be appropriate in select cases of heart failure, depending on the nature and severity of the problem. Some of the common surgeries are listed below:
- Coronary bypass surgery — This is a common heart surgery procedure used to increase blood flow to an area of the heart with reduced blood supply, caused by a blocked or significantly narrowed coronary artery. The surgeon uses blood vessels from the legs or chest to bypass the area of blockage and restore adequate blood flow through the arteries and to the heart. Adequate blood flow to the heart via the coronary arteries is important because these arteries provide oxygen and nutrients to the heart, helping it to remain viable and able to meet the needs of the body. Your cardiologist can tell you if this procedure is recommended for you.
- Modified DORProcedure (left ventricular reconstruction) — Patients with ischemic cardiomyopathy and an akinetic (loss of movement) or dyskinetic (abnormal movement) anterior wall may be candidates for hig-risk coronary bypass surgery with a modified DOR procedure. This procedure helps restore the normal geometry of the left ventricle thereby improving symptoms of left ventricular failure and chest pain.
- Heart valve repair or replacement — Mitral valve regurgitation and aortic valve regurgitation are conditions where the heart valves do not close completely and blood leaks backwards. Mitral valve stenosis and aortic valve stenosis are conditions where the heart valves don’t open properly and blood cannot move forward properly. Each condition can cause the heart muscle to pump harder, and can result in heart failure. In many cases, heart function significantly improves after the damaged heart valve has been repaired or replaced. Several surgical options for repair or replacement of damaged heart valves are available at Emory. Your cardiologists and cardiac surgeon can discuss the best options for you, based on the severity and location of your heart valve damage, and other existing medical conditions.
- Heart transplantation — Heart transplantation remains an excellent option for patients who have exhausted all medical and surgical therapies for heart failure. It continues to be limited by donor availability but short and long-term results are outstanding with an expected 60% survival at ten years.
- Mechanical Circulatory Support Device — There are several Mechanical Circulatory Support Devices available to treat heart failure conditions in certain circumstances. However, for long-term treatment of heart failure, a ventricular assist device can be used. Ventricular assist devices are mechanical devices that are surgically attached to the heart to assist with the workload of the heart. Most commonly, the devices are attached to the left ventricle, and are referred to as LVAD (Left-Ventricular-Assist-Device). If both ventricles need support, a device can be attached to the right ventricle, and separate device can be attached to the left ventricle, providing biventricular support. Afterwards, the devices are commonly referred to as Bi-VADs. Ventricular assist devices have been used primarily as a bridge to transplant or a bridge to recovery in patients who have acute decompensated heart failure. More recently, newer models of ventricular assist devices have been developed for utilization as permanent devices or “destination therapy.” These devices are utilized in patients who have progressive heart failure refractory to maximum medical therapy, and determined not to be candidates for heart transplantation.
- Research — Emory participates in many multi-center clinical research trials, including studies of surgical procedures used to treat heart failure. Ask your heart failure specialist about current studies related to surgical procedures for heart failure.
