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High Risk Heart Surgery Procedures
Coronary revascularization, also known as coronary artery bypass grafting (CABG), is a procedure in which blood is rerouted around one or more clogged coronary arteries in order to improve blood flow to the heart muscle. The new connections are established using arteries and/or vein grafts taken from the patient's body.
Coronary revascularization is typically recommended for heart failure patients who have left main coronary artery disease; narrowing of at least three of the major coronary arteries, including the left anterior descending artery; decreased ventricular function (as indicated by the size of the heart or ejection fraction); or diabetes mellitus.
In many cases, cardiac function will improve dramatically after CABG. In patients with blockages in at least two major vessels, CABG has been shown to be more effective than angioplasty in reducing symptoms, long-term mortality, need for re-intervention, and long-term health-care costs.
Many hospitals do not perform CABG on patients with severely compromised left ventricular function, considering the risks too high. However, many of the risks can be significantly reduced by using off-pump and minimally invasive surgical techniques, which are available at NYU.
Some cases of heart failure are due to hypertrophic obstructive cardiomyopathy, a disease of unknown origin that causes the heart muscle to thicken and the septum (the muscular wall separating the right and left ventricles) to stiffen, limiting the heart's ability to pump blood. Treatment usually begins with calcium-channel blockers or beta-blockers, which slow the heart rate and relax blood vessels, thereby improving blood flow. A surgical procedure called septal myomectomy should be considered for patients who do not respond to medical therapy or who have left ventricular outflow tract obstruction, a blockage of the blood exiting from the heart. In a septal myotomy, the surgeon removes a portion of the septum. This eases the obstruction, which relieves symptoms and often slows the progression of disease
Surgical Ventricular Restoration
Surgical ventricular restoration (the Dor procedure) is a treatment option for patients with ischemic cardiomyopathy - heart failure caused by a heart attack. After a heart attack, portions of the left ventricle may become scarred, causing the muscle to thin and bulge out, a condition known as a ventricular aneurysm. Once an aneurysm forms, the heart must work harder in order to pump enough blood throughout the body. Eventually, the heart weakens and enlarges, resulting in heart failure.
In ventricular restoration surgery, the surgeon removes the dysfunctional areas of the left ventricle and "remodels" the heart, restoring its normal size and shape. The procedure is often performed in combination with coronary revascularization or mitral valve repair.
Surgical ventricular restoration has been shown to slow the progression of heart failure, reduce clinical symptoms, delay the need for transplantation, and improve long-term survival in many patients. Furthermore, the combination of ventricular restoration and CABG (coronary artery bypass grafting) has been shown to have better outcomes than CABG alone.
Ventricular Assist Devices
Ventricular assist devices (VADs) are mechanical pumps that assist, or take over, the function of a weakened heart. VADs are used for emergency as well as short-, intermediate-, and long-term support.
VADs are commonly used to sustain patients for a brief period, from days to weeks, allowing time for the heart, and other vital organs, to recover. This is called a "bridge to recovery." Most often, VADs are used as a life-support system for patients who need a heart transplant but who are unlikely survive the wait for a donor heart (which averages almost six months). This is referred to as a "bridge to transplant." More and more, VADs are being used as a "destination therapy," a permanent solution for patients with end-stage heart failure who have exhausted all other therapies but are not considered candidates for transplant.
The newest application of VADs is as an emergency support for patients undergoing high-risk catheterization procedures. In the case of an emergency, such as acute heart failure (see below), an assist device can be quickly inserted via a catheter, allowing enough time for the patient to be brought to the operating room for a more definitive operation or for placement of a longer-term assist device.
The Heart Failure Program at NYU currently offers a complete selection of FDA-approved VADs for all patients and clinical scenarios. Our team has extensive experience in the management of patients with VADs, including both inpatient and outpatient care.
Thoracic Aortic Dissection Repair
Aortic dissection occurs when the innermost layer of the aorta tears, allowing blood to leak through and separate (dissect) the inner and middle layers of the blood vessel. Aortic dissection can trigger several different potentially life-threatening events, such as stroke, sudden heart failure, and failure of one or more vital organs. If left untreated, aortic dissection can eventually lead to a fatal rupture of the aorta.
Aortic dissection usually requires immediate treatment. Patients diagnosed with this condition are admitted to the intensive care unit, where their vital signs can be closely monitored. Various drugs may be administered, which lower blood pressure and slow the heart rate.
Whether further treatment is recommended depends on the location of the dissection, the presence of bleeding from the dissection, and the patient's overall condition. Some patients are treated with medication only. However, immediate surgery may be necessary. To repair an aortic dissection, the surgeon removes the area of dissected aorta and rebuilds the blood vessel with a synthetic graft.