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PHYS THER
Vol. 80, No. 1, January 2000, pp. 61-69
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Updates

Surgical Innovations for Chronic Heart Failure in the Context of Cardiopulmonary Rehabilitation

Reed Humphrey and Ross Arena

R Humphrey, PT, PhD, FAACVPR, FACSM, is Assistant Professor, Department of Physical Therapy and Department of Physical Medicine and Rehabilitation, and Collateral Assistant Professor of Education, Virginia Commonwealth University, Medical College of Virginia Health Sciences Campus, 1200 E Broad St, PO Box 980224, Richmond, VA 23298 (USA) (rhumphre{at}hsc.vcu.edu).
R Arena, PT, is a doctoral student in the combined physical therapy/physiology program, Virginia Commonwealth University

Address all correspondence to Dr Humphrey


Key Words: Batista procedure • Congestive heart failure • Coronary revascularization • Dynamic cardiomyoplasty • Endoventricular circular patch plasty • Heart transplantation • Left ventricular assist device • Partial left ventriculectomy • Transmyocardial revascularization


   Introduction
 
According to 1998 data from the American Heart Association,1 approximately 4,900,000 Americans (2,500,000 men and 2,400,000 women) have been diagnosed with congestive heart failure (CHF), with approximately 400,000 new cases of CHF per year.1 The incidence of CHF approaches 10 cases per 1,000 people in the population after age 65 years, and CHF is the most frequent cause of hospitalization for people aged 65 years and older. Hospitalizations for CHF rose from 377,000 in 1979 to 872,000 in 1995. Approximately 20% of people who have sustained a myocardial infarction will be disabled with heart failure within 6 years of diagnosis.1 The reduction in mortality for people with other forms of cardiovascular disease, the increasing prevalence of CHF, and the rising median age of the US population suggest that the pool of patients who would require medical or surgical intervention will continue to expand well into the next century.

In recent years, pharmacological management of CHF has benefited from the addition of angiotensin-converting enzyme (ACE) inhibitors and adrenergic beta-blockers, providing major symptomatic improvement in people with mild to moderate heart failure.2 Physical activity is likewise gaining acceptance as an important intervention.3 Structured exercise programs for people with cardiovascular and pulmonary disease have existed in the United States for nearly 3 decades, and the outcomes are well documented in the literature.4,5 In recent years, the emphasis and direction of research have shifted to the beneficial effects of both endurance training and resistive exercise for clinical and behavioral outcomes for patients with CHF. Exercise for patients with CHF is safe3 and results in physiological and psychological changes that lead to improved functional status. These improvements include improvements in control of heart rate,6–10 measures of quality of life,11–15 exercise capacity,16–27 left ventricular function,28–33 skeletal muscle physiology,34,35 and peripheral blood flow and endothelial function.36–38 Squires39 has provided an extensive summary of the evidence-based benefits of endurance and resistive exercise training for people with CHF (Tab. 1).


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[in a new window] 		Table 1. Demonstrated Changes Due to Endurance or Resistive Exercise Training for Patients With Chronic Heart Failurea

 
The physiological adaptation to exercise training for people with CHF warrants attention because these individuals were historically exempted from exercise programs due to the presumption that poor left ventricular function prohibited improvement, increased the risk of an exercise-induced cardiovascular event, and might even be worsened by exercise. Although strongly associated with mortality, ejection fraction is poorly related to exercise performance as measured by oxygen consumption (VO2).40,41 Thus, increased exercise capacity appears to be influenced more by the peripheral adaptation of skeletal muscle than by improvement in cardiac output.42

Surgical alternatives to heart transplantation are being used. Aside from heart transplantation, recent interventions include: high-risk coronary artery bypass surgery (CABG), transmyocardial revascularization (TMR), dynamic cardiomyoplasty (DCM), partial left ventriculectomy (PLV), and the use of a left ventricular assist device (LVAD). Patients undergoing these procedures are potentially candidates for exercise rehabilitation. This update is not intended to review exercise treatment approaches for individuals with CHF, as these approaches have been described previously.43,44 The purposes of this update are to describe recent surgical and technological procedures in the treatment of people with CHF and to suggest exercise rehabilitation strategies.


   Heart Transplantation
Top
 Introduction
 Heart Transplantation
High-Risk Coronary Artery Bypass...
 Transmyocardial...
 Dynamic Cardiomyoplasty
 Partial Left Ventriculectomy
 Left Ventricular Assist Device
 Summary
 References
 
Heart transplantation remains the primary intervention for people with end-stage CHF. Although heterotopic transplants (the recipient's heart is not removed, and the donor heart is anastomosed in parallel) may be done in selected patients, orthotopic transplantation (removal of the recipient's heart and replacement with the donor heart) is associated with better survival and is most widely used.45 Approximately 50% of people who received heart transplants from 1980 through 1985 were alive at 60 months postoperatively.46 The survival rate improved to about 76% for people who received heart transplants from 1986 through 1990 and to about 78% for people who received heart transplants from 1991 through 1997.46 The 2 major complications and leading causes of death postoperatively are infection and rejection of the transplanted heart.45

Physical therapists have traditionally played an important role in the assessment and management of this population. Sadowsky47 has provided a relevant description of heart transplantation and review for physical therapy assessment and intervention. Postsurgical acute care for patients who have received heart transplants is similar to that for patients who have undergone a median sternotomy. Patients with heart transplantation frequently have a complex drug regimen due to immunosuppression. The major difference with respect to exercise remains the altered response of the heart to exercise. That is, in the denervated heart, the increase in heart rate to exercise is in response to the parallel increase in circulating catecholamines, and thus the initial rise in cardiac output is dependent on augmented preload and the Frank-Starling mechanism. As a result, abrupt increases in exercise demand are unusually fatiguing due to an increased need to meet the energy demand through anaerobic pathways. Given a more gradual warm-up and a lengthened cool-down period postexercise, patients who are stable following a heart transplant respond well to exercise therapy.47

Heart transplantation, however, has slowed in recent years due primarily to a lack of suitable donors, despite the use of older donors.46 A total of 3,471 heart transplants were performed in 1997, reflecting a progressive decline from a peak of 4,117 heart transplants in 1995.46 Given the estimated CHF prevalence of nearly 5 million and the rising numbers, alternatives to transplantation are crucial.


   High-Risk Coronary Artery Bypass Surgery
Top
 Introduction
 Heart Transplantation
 High-Risk Coronary Artery Bypass...
Transmyocardial...
 Dynamic Cardiomyoplasty
 Partial Left Ventriculectomy
 Left Ventricular Assist Device
 Summary
 References
 
Selected patients with poor left ventricular function, although at higher mortality risk, may benefit from coronary revascularization. The large magnitude of coronary artery disease and associated myocardial damage for many patients with CHF due to ischemia limits widespread use of CABG in this population. Historically, surgery was deferred for patients with severe CHF due to the poor benefit-to-risk ratio. Of those individuals who are appropriate candidates for coronary revascularization, 20% of patients with an ejection fraction of less than 30% experience operative mortality.48 Survivors are reported to have a 5-year survival rate of 80%.48 Shapira et al49 demonstrated a survival rate of 83.3% 7 years post-CABG, an improvement in CHF classification, and a 12.2% increase in left ventricular ejection fraction in a group of patients with left ventricular dysfunction. Hausmann and colleagues50 reported a 2-year survival rate of 87.8%, a 14.2% increase in ejection fraction, a 4.1-mm Hg decrease in left ventricular end-diastolic pressure, and a 5.4-mm Hg decrease in pulmonary wedge pressure.

Although the outcomes of patients with CHF undergoing CABG appear to be positive, there are indications that this group continues to be at increased risk of mortality postsurgery. Herlitz et al51 found that preoperative ejection fraction was an independent predictor of mortality 2 years after CABG. In another study by Herlitz and colleagues,52 a history of CHF prior to surgery was one of the factors that independently predicted mortality. Brandrup-Wognsen et al53 also found that a history of CHF independently predicted mortality after CABG. As data continue to emerge that better clarify the risks and benefits of bypass surgery for patients with poor left ventricular dysfunction, more patients with advanced CHF may be reconsidered for coronary revascularization.

Although physical therapists have been treating patients with coronary revascularization for years, it is unclear whether these patients present new challenges. These patients remain at higher postoperative risk, given their preoperative clinical status, and special attention to sternal healing and stability may be warranted in cases where there have been multiple sternotomies. Regardless, the proportion of patients who are at higher risk undergoing coronary revascularization and who are referred for exercise training can be expected.


   Transmyocardial Revascularization
Top
 Introduction
 Heart Transplantation
 High-Risk Coronary Artery Bypass...
 Transmyocardial...
Dynamic Cardiomyoplasty
 Partial Left Ventriculectomy
 Left Ventricular Assist Device
 Summary
 References
 
Transmyocardial revascularization is a procedure intended to improve chronic angina not amenable to bypass grafting or angioplasty.54 The TMR procedure is illustrated in Figure 1. A surgical laser creates a transmural channel in the area of the myocardium that has been identified as ischemic. The epicardial origin seals over once the laser has been removed, and oxygenated blood fills the newly created channel. The perfused channel supplies oxygenated blood to the surrounding myocardium.


Figure 1
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[in a new window] 		Figure 1. Transmyocardial revascularization. In this procedure, channels are created to provide microcirculatory blood flow. Reprinted by permission from Kantor B, McKenna CJ, Caccitolo JA, et al. Transmyocardial and percutaneous myocardial revascularization: current and future role in the treatment of coronary artery disease. Mayo Clin Proc.1999;74:585–592.

 
The theory is that symptoms are reduced due to an increased supply of oxygenated blood shunted directly to the myocardium via the transmural channels created by TMR.55 Angiogenesis is another proposed benefit of this procedure.56 Pelletier et al,56 using a rat model, reported an increase in vascular density following TMR. Mack et al55 also found evidence of neovascularization in 6 sheep undergoing TMR. Literature to date reveals that the procedure is safe and, although reported outcomes vary, that anginal symptoms are decreased and exercise tolerance is improved. Paradoxically, measurable improvements in left ventricular function or evidence of improved myocardial perfusion has not been found.54,56–58 Although data continue to emerge on the effectiveness of TMR, physical therapists may anticipate improved exercise performance with decreased angina but should be aware that risk status relative to left ventricular function or myocardial perfusion defects has not changed.


   Dynamic Cardiomyoplasty
Top
 Introduction
 Heart Transplantation
 High-Risk Coronary Artery Bypass...
 Transmyocardial...
 Dynamic Cardiomyoplasty
Partial Left Ventriculectomy
 Left Ventricular Assist Device
 Summary
 References
 
Dynamic cardiomyoplasty was first performed in 1985, and about 700 procedures have been performed to date.59 In this procedure, the latissimus dorsi muscle is typically detached distally (with preservation of the neurovascular supply), then brought forward through a resected second rib space, where it is surgically wrapped about the left ventricle. The DCM procedure is illustrated in Figure 2. The intent is to provide a muscular assist during ventricular systole. To do so, the latissimus dorsi muscle is paced by a cardiomyostimulator to gradually transform the muscle's contractile behavior from type II to type I characteristics. The stimulator is paced to myocardial contraction to provide an assist in conjunction with native left ventricular contraction. Due to the nature of the procedure and subsequent latissimus dorsi muscle transformation, estimated as a 12-week process, patients do not begin to receive hemodynamic or functional benefit for 2 to 3 months. Additionally, the repositioning of the latissimus dorsi muscle may promote atelectasis due to its restrictive presence in the thorax.


Figure 2
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[in a new window] 		Figure 2. Dynamic cardiomyoplasty. This illustration depicts the typical resection of the latissimus dorsi muscle, placement around the left ventricle, and pacing leads to retrain the muscle as an assist. Reprinted by permission of Medtronic. Available at: http://www.medtronic.co.ul/cardiomyoplasty/Images/cman.jpg.

 
Improvements in functional capacity and quality of life, as measured by change in New York Heart Association (NYHA) functional class (Tab. 2), have been documented.60 Lee et al61 found that cardiomyoplasty improved cardiac output and decreased myocardial oxygen demands in patients with dilated cardiomyopathy. Other research62,63 suggests that cardiomyoplasty reverses the deleterious myocardial remodeling process often seen in individuals with heart failure.


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[in a new window] 		Table 2. Functional and Therapeutic Classification of Heart Diseasea

 
Survival rates seem to depend on presurgical characteristics. Moreira et al64 found a 1-year survival rate of approximately 84% and a 5-year survival rate of approximately 45%. The severity of clinical status prior to surgery and the degree of cardiac impairment were both associated with survival rate. Patients who had NYHA class III functional status the majority of the time and lower pulmonary wedge pressures were found to have a 5-year survival rate of 64%. This survival rate is comparable to 5-year survival rates seen with heart transplantation.64 Furnary and colleagues65 found 1-year through 5-year survival rates to be 73%, 57%, 49%, 44%, and 40%. Predictors for poor survival rate were NYHA class IV functional status, high pulmonary wedge pressure, atrial fibrillation, and balloon pump use postsurgery.65 In another study by Moreira et al,66 survival rates in patients undergoing cardiomyoplasty were 86.6%, 78.7%, and 65.6% at 6 months, 1 year, and 2 years, as compared with survival rates of 58.8%, 41.1%, and 27.4% over the same time period in a group of patients receiving medical management for heart failure. Patients in both groups had either NYHA class III or IV functional status.66

Documented changes in VO2 are mixed in patients undergoing cardiomyoplasty. Furnary et al67 found no improvement in peak VO2 6 months postcardiomyoplasty. Moriera and colleagues,64 however, found an improvement of 3.6 mL O2/kg–1/min–1 in peak VO2 postcardiomyoplasty. Bocchi et al68 divided a group of patients undergoing cardiomyoplasty using a presurgery peak VO2 of 14 mL O2/kg–1/min–1 as a cutoff point. After cardiomyoplasty, the subgroup with a presurgery peak VO2 of less than 14 mL O2/kg–1/min–1 improved by 5.3 mL O2/kg–1/min–1 at the 6-month follow-up. The subgroup with presurgery peak VO2 values greater than 14 mL O2/kg–1/min–1, however, had only a 0.9-mL O2/kg–1/min–1 increase in peak VO2 over the same time period. Peak VO2 prior to cardiomyoplasty seems to have an influence on postsurgical peak VO2 improvements. Changes in peak VO2 past 6 months postcardiomyoplasty do not appear to be as thoroughly investigated.

Cardiomyoplasty appears to improve impairments in patients with chronic heart failure. The ability for certain presurgical variables to predict postsurgical survival rates, however, indicates that appropriate patient selection is important. This procedure is reserved for patients with end-stage heart failure whose treatment alternatives are limited. Malignant arrhythmia and sudden death with mortality rates as high as 33% have been reported postoperatively.69,70 Dynamic cardiomyoplasty, although promising, remains a limited viable option for patients with CHF.


   Partial Left Ventriculectomy
Top
 Introduction
 Heart Transplantation
 High-Risk Coronary Artery Bypass...
 Transmyocardial...
 Dynamic Cardiomyoplasty
 Partial Left Ventriculectomy
Left Ventricular Assist Device
 Summary
 References
 
Partial left ventriculectomy, also known as the Batista procedure, is a volume reduction procedure for improving left ventricular function.71 The rationale for the PLV is that a reduction in the left ventricular chamber radius, through surgical resection of a region of the myocardium, decreases wall tension and improves cardiac efficiency. The PLV procedure is illustrated in Figure 3. To minimize the dilatory effects of mitral regurgitation, the mitral valve is replaced or repaired. Coronary revascularization may be performed concomitantly in patients with ischemia. Although this procedure is fairly new, reported outcomes are promising. Suma et al72 studied 10 patients who underwent PLV. Eight of the patients had NYHA class IV functional status, and 6 patients required support with inotropic medications to maintain acceptable cardiac function. Eight of the subjects survived the procedure. Mean NYHA classification improved from 3.8 to 1.8, left ventricular end-diastolic volume decreased 18 mL, and ejection fraction increased 14.8%. Batista et al71 studied 120 patients who received a PLV. Most patients had NYHA class IV functional status at the time of surgery. The 30-day mortality rate was 22%, and the 2-year survival rate was 55%. Postsurgery, 57% of the patients improved to NYHA class I, and 33% improved to class II. Ten percent had no improvement in NYHA classification. McCarthy et al73 reported survival rates as high as 87% at 11 months.


Figure 3
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[in this window]
[in a new window] 		Figure 3. Partial left ventriculectomy. Top illustration reprinted by permission from McCarthy JF, McCarthy PM, Starling RC, et al. Partial left ventriculectomy and mitral valve repair for end-stage congestive heart failure. Eur J Cardiothorac Surg. 1998;13:337–343. Bottom illustration reprinted by permission from McCarthy PM, Starling RC, Wong LW, et al. Surgery for acquired heart disease. J Cardiovasc Surg. 1997;114:755–765.

 
Patients are generally discharged within 7 to 10 days, and although low-level activity may be initiated as soon as the patient is hemodynamically stable and cardiac rehabilitation can be initiated, vigorous exercise is deferred for 6 to 8 weeks, presumably to be consistent with other cardiac postoperative guidelines for vigorous exercise.59 Although PLV is another surgical option that holds promise for selected patients with CHF, experience with the PLV procedure and subsequent outcomes data are needed and will likely emerge over the next several years.

Endoventricular circular patch plasty is a variation of left ventricular reduction in which a patch, typically Dacron* or human tissue, is sewn into the left ventricle to connect viable myocardial tissue while excluding nonfunctional scar tissue. With time, the patch reshapes the left ventricle for optimized function. Dor and colleagues74 described their experience with over 750 patients, noting that 90% of the patients demonstrated improved left ventricular function, with mortality rates similar to those for patients with elective bypass surgery (~2%–3%).


   Left Ventricular Assist Device
Top
 Introduction
 Heart Transplantation
 High-Risk Coronary Artery Bypass...
 Transmyocardial...
 Dynamic Cardiomyoplasty
 Partial Left Ventriculectomy
 Left Ventricular Assist Device
Summary
 References
 
The best available surgical bridge to heart transplantation for patients with CHF who are unable to maintain essential cardiac function despite maximized inotropic therapy is an LVAD.75 Although the devices differ in design, the essential concept of the LVAD is illustrated in Figure 4. An implanted LVAD, with outflow at the cannulated left ventricular apex and aortic inflow, assists left ventricular cardiac output by diverting normal cardiac blood flow through a pump to augment blood flow exiting the heart. The blood chamber empties when full, triggered by an internal volume sensor. By operating in a "fill-to-empty" mode, the LVAD rate increases in proportion to venous return, allowing for a natural physiological response to varied physical effort. Because the chamber volume is fixed at 85 mL, the increased pumping rate during exercise provides for a normalized cardiac output with up to moderate workloads. The LVAD provides virtually all the resting cardiac output and the majority of cardiac output during exercise, upwards of 11 L/min, which is sufficient for most activities of daily living and moderate exercise. Depending on the degree of left ventricular dysfunction, the native left ventricle can augment the exercise cardiac output. As noted, there are variations of LVADs, depending on the manufacturer. Figure 4 illustrates one LVAD (HeartMate{dagger}). A pneumatic or vented electrical system is used to drive the pump. The pneumatic device requires the use of a mobile console, and the cart, although easily maneuvered, presents some mobility challenges. In the electrical device, the line that actuates the pump is connected to a small control unit worn in a shoulder harness The electrical version provides for greater mobility, an obvious advantage for exercise intervention.


Figure 4
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[in this window]
[in a new window] 		Figure 4. Left ventricular assist device. Reprinted by permission of Thermo Cardiosystems Inc, 470 Wildwood St, Woburn, MA 01888-2697.

 
Although the native heart rate and LVAD rate do not match perfectly, there is a parallel increase in response to exercise, as the native left ventricle augments cardiac output. Likewise, diminished preload, as experienced with orthostatic intolerance, slows the LVAD rate to permit chamber filling.

Left ventricular assist device implantation as a bridge to heart transplantation has provided an important benefit to patients with CHF who are critically ill and no longer responsive to maximized inotropic support. In addition, LVAD implantation may be used as a bridge to both the DCM and PLV procedures previously described, and the LVAD is undergoing investigation as a possible permanent device. Exercise testing and training for patients using an LVAD has proven to be safe, and available data indicate improved physiological and functional status.76–78 Once the patient is stabilized, usually within a few days after LVAD implantation, progressive ambulation and subsequent exercise training are initiated. Because the LVAD provides for an enhanced cardiac output, the intensity for endurance exercise can be increased to facilitate skeletal muscle adaptation at higher workloads. Monitoring of any signs and symptoms of exertional intolerance, such as hypotension, is important, and exercises that might stress the physical insertion of the line that actuates the pump should be avoided. Although peak VO2 values increase only slightly with endurance exercise training, submaximal workload tolerance is significantly increased.77–79 Given the increasing prevalence of LVAD use, positive exercise outcomes data, and the epidemiology of CHF, physical therapists should encounter greater numbers of patients with assist devices. Thus, an understanding of the exercise physiology and training guidelines is essential and available.80,81


   Summary
Top
 Introduction
 Heart Transplantation
 High-Risk Coronary Artery Bypass...
 Transmyocardial...
 Dynamic Cardiomyoplasty
 Partial Left Ventriculectomy
 Left Ventricular Assist Device
 Summary
References
 
The surgical alternatives to heart transplantation have expanded in recent years to include selected coronary revascularization,51 TMR,55 DCM,64 PLV,72 and LVAD implantation.76 The use of LVADs is currently considered a bridge to the other surgical interventions. Given the largely positive exercise testing and outcomes results to date, the use of LVADs will likely be increasingly prevalent in cardiopulmonary intervention programs.


   Footnotes
 
Writing was provided by Humphrey and Arena. Concept and research design, project management, and consultation (including review of manuscript before submission) were provided by Humphrey.

* EI du Pont de Nemours & Co Inc, 1007 Market St, Wilmington, DE 19898. Back

{dagger} Thermo Cardiosystems Inc, 470 Wildwood St, Woburn, MA 01888-2697. Back


   References
Top
 Introduction
 Heart Transplantation
 High-Risk Coronary Artery Bypass...
 Transmyocardial...
 Dynamic Cardiomyoplasty
 Partial Left Ventriculectomy
 Left Ventricular Assist Device
 Summary
 References
 

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