Medical Edge Newspaper Column

Treating Heart Failure: Noninvasive Methods Usually Suffice

Jan. 8, 2007
Dear Mayo Clinic:
I have heard that there are improved surgical therapies for heart failure being used at Mayo Clinic. My grandfather has heart failure, and it's a matter of time before he requires surgery. Please tell me about the latest advances. -- Dayton, Ohio

Answer:
Heart failure means the organ can't pump enough blood to meet the body's needs. Surgery for heart failure isn't inevitable. It's a preferred option to prevent progression of heart failure if there is an underlying correctable cause, such as a blocked coronary artery that can be cleared or bypassed or a faulty heart valve that can be repaired or replaced. Other procedures, such as ventricular reduction or remodeling, may help in certain circumstances, but the vast majority of patients can be treated quite successfully with medications and lifestyle changes.

Most commonly, heart failure develops over time as conditions such as high blood pressure or coronary artery disease gradually sap the heart of its strength, leaving it too weak or stiff to pump efficiently. Symptoms typically include weakness, shortness of breath, persistent wheezing, swelling and nausea.

Heart failure has multiple causes, many beyond the control of the individual patient, such as viral infection or even inherited conditions. Unhealthy behaviors can certainly worsen heart failure, however, so correcting them can significantly help. For example, sodium intake should be restricted, because too much of it contributes to fluid retention, which makes the heart work harder -- and weaken sooner. Excessive alcohol use can directly weaken the heart muscle or increase the risk of abnormal heart rhythms, which may worsen existing heart failure, so limiting alcohol consumption makes sense. And moderate exercise helps keep the entire body healthy, reducing demand on the heart.

Other desirable lifestyle changes include: maintaining a healthy weight; limiting intake of saturated fat, trans fat and cholesterol; reducing stress and getting enough sleep. Smoking damages blood vessels, reduces blood oxygen levels and makes the heart beat faster, so quitting is one of the best things a smoker can do.

Such behavioral changes often complement medications, resulting in lower dosages and, consequently, fewer side effects. Commonly used medications include angiotensin-converting enzyme inhibitors, which dilate blood vessels to lower blood pressure, improve blood flow, and decrease the heart's workload; digoxin, which increases the strength of heart-muscle contractions; beta blockers, which slow the heart rate and reduce blood pressure; and diuretics, which eliminate fluid from the body. Often, these medications are used in combination.

If drugs in conjunction with lifestyle changes prove insufficient, we consider implantable medical devices. A biventricular pacemaker can send timed electrical impulses to both of the heart's lower chambers so they pump in a more efficient and coordinated manner. An implantable cardioverter-defibrillator, which doesn't address heart failure per se, can prevent sudden death from a dangerous heart rhythm. And a mechanical pump called a "left ventricular-assist device" (LVAD) may be attached to a weakened heart to help it pump.

Originally used as "bridging" devices to help keep heart-transplant candidates alive while they waited for a donor heart, LVADs (which do some 90 percent of what an artificial heart would do) are now being considered as an alternative to transplantation. While LVADs, often called "heart pumps," are not yet reliable or low-maintenance enough for widespread use, their improved versions could make a major difference in the lives of many heart-failure patients.

Another option nearing general use is ventricular restoration surgery, which improves pumping function by repairing a ventricular aneurysm or removing scar tissue caused by a heart attack. This scar tissue makes the heart less efficient. Removing it permits the remaining healthy muscle to work optimally.

Heart transplantation is a last resort, since it requires the patient to take daily immunosuppressive medications. Most recipients resume normal activities within three to six months, and survival rates are nearly 86 percent after one year and 72 percent after five years. Unfortunately donor organs are in short supply, and not all potentially usable organs are offered for transplantation.

In most heart-failure cases, however, a combination of noninvasive therapies is all that's needed.

-- Thoralf M. Sundt III, M.D., Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.