專題討論22:心臟衰竭治療新趨勢
Emerging Strategies in the Treatment of Heart Failure

程 序 表

S22-5
Surgical Management of Heart Failure
Shoei-Shen Wang, Nai-Kuan Chou, Nai-Hsin Chi, Shu-Chien Huang, I-Hui Wu, Chi-Hsung Wang, His-Yu Yu ,Wen-Je Ko, Yih-Sharng Chen,
Division of Cardiovascular Surgery, National Taiwan University Hospital

  When the patient is in stage D of heart failure, mechanical circulatory support, or cardiac transplantation may be required.

  Surgical management of heart failure includes 3V+RAT, i.e., vessel, valve, ventricle, rhythm, assist circulation or transplantation. Heart failure from ischemic cardiomyopathy can often be successfully treated with coronary artery bypass grafting (CABG) of viable myocardium. From the 5-year result of surgical treatment of ischemic heart failure (STICH) trial, CABG has lower mortality from any cause or cardiovascular-specific death. Surgical anterior ventricular endocardial restoration (SAVER) conjoined with CABG and mitral valve surgery is safe and effective to treat congestive heart failure from ischemic heart disease.
Assist circulation includes intraaortic balloon pumping (IABP), extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD). Application of ECMO in refractory heart failure includes bridge to recovery, transplantation or decision. Even in cardiopulmonary resuscitation (CPR) patients, a 20% increase in survival to discharge with ECMO support was noted at the National Taiwan University Hospital (NTUH). The effect ECMO assisted CPR improved survival of patients with refractory cardiac arrest up to more than 1 year. Longer CPR duration was associated with poor prognosis. Some VADs are used as a destination therapy for heart failure, not bridge to transplantation.

  Cardiac transplantation is currently the only established surgical approach to the treatment of refractory heart failure. About half of the Asian heart transplantations were performed in Taiwan. Unless tolerance, after transplantations all required immunosuppressants including calcineurin inhibitors (cyclosporine or tacrolimus), antiproliferation agent (mycophenolate) or mTOR inhibitor (everolimus), and steroid. With the formula of cyclosporine, everolimus and steroid, 1-year survival of 97.67% and 5-year survival of 80.23% were achieved at NTUH.