Congestive Heart Failure and Transplantation

More than  5,000,000 patients suffer from congestive heart failure secondary to a number of problems including heart attacks and heart muscle wasting (cardiomyopathy). Each year, nearly 500,000 patients are newly diagnosed with congestive heart failure. While partly dependent on the patient’s functional classification, heart failure is associated with staggering costs to society (repeat hospital visits, loss of work potential, prescription medicines) and a dismal survival (1 year mortality, 10-75%). While medical therapy has greatly improved the outcomes for many of these patients, many will continue to decline and ultimately succumb to this disease. Heart transplantation can be a valuable option for these patients. Unfortunately, our donor supply limits this resource to less than 2500 patients each year. As such, a number of surgical options are available and routinely practiced here at UNC.

Transplantation

Heart transplantation remains the gold standard for patients with end-stage heart disease. Although recipients are required to take medicines to prevent rejection of their transplant, patients are able to return to excellent quality of life and have a survival over 50% at 10 years (markedly better than those patients not transplanted). At UNC, we have done over 250 heart and heart/lung transplants. In addition to the surgeons, the transplant team represents a comprehensive approach to these patients including The thoracic organ transplant team at UNC Hospitals includes three board-certified thoracic surgeons adult and pediatric cardiologists, adult and pediatric pulmonologists, anesthesiologists, transplant coordinators, social workers, physical therapists, infectious disease specialists, radiologists, and pathologists. Read more about the UNC transplantation program here.

Non-Transplant Surgical Alternatives

Because of the dearth of donor organs, we have adopted an aggressive strategy to try to maximize heart recovery in patients that potentially have reversible heart failure. At UNC, we routinely perform operations on patients with very poor heart function (<20-30%) with the expectation that patients will be able to regain function, quality of life, and lengthen life. In addition with optimal medical management, many of these patients can completely avoid heart transplantation. Typical procedures include but not restricted to low ejection fraction (EF) coronary artery bypass grafting, low EF aortic valve replacement, low EF mitral valve repair, ventricular reconstruction for akinetic and aneurysmal heart muscle, and biventricular lead placement.

Mechanical Circulatory Assist

Despite best medical and surgical therapy, a group of patients will continue to have symptomatic endstage heart disease. Many of these patients are candidates for artificial circulatory support. At UNC, we have a number of devices available that are routinely used to support both the acutely and chronically decompensated heart. Depending on the particular device used, both the right and left ventricles can be assisted (ie: LVAD=left ventricular assist device; RVAD=right ventricular assist device; BiVAD=biventricular assist device). Often these devices can be placed temporarily to allow myocardial recovery (ie: acute viral myocarditis).

The most common use of these devices is to bridge the acutely failing heart to eventual heart transplantation. Many patients will only require left ventricular support for heart failure. For these patients an LVAD is placed in the left upper quadrant of their abdomen. Blood flows into the device through an inflow conduit connected to the patient’s left ventricle. A one-way valve ensures unidirectional blood flow. The outflow cannula is connected to the aorta. From there oxygenated blood is delivered to the rest of the body’ organs. This method allows patients to recover end-organ damage, obtain rehabilitation, and possibly go home prior to definitive heart transplantation.

Finally, there are a group of patients with severe CHF who are not transplant candidates and who otherwise would succumb to their disease. These patients are candidates for destination therapy. With this method, devices would be implanted and remain in place for the remainder of the patient’s life.

At UNC, we actively use several devices including the Abiomed BVS5000, Thoratec paracorporeal devices, Heartmate XVE, and Novacor. We also have implanted the newer, smaller, axial flow pumps (Jarvik 2000). Having multiple options allows us to tailor our circulatory assistance depending on the particular patient’s problem.

While many cardiac surgery and heart transplant centers exist in the southeast, UNC is one of only two centers in North Carolina, South Carolina, Georgia, eastern Tennessee, and southern Virginia approved to provide destination therapy ventricular assist. In addition, we are involved with ongoing trials investigating devices for destination therapy.