Reverse remodeling by surgery fact or fiction?

Mortality of chronic heart failure in industrial countries remains unaccept ably high despite advances in medical therapy. Heart transplantation, the g old standard in the treatment of end-stage heart failure is reserved for on ly a few patients because of the shortage of donor hearts. Surgical alterna tives to transplantation include dynamic cardiomyoplasty (CMP), mitral valv e reconstruction, left ventricular reduction surgery (PLVR) and ventricular assist devices (VAD). Improved survival and objective physiologic improvem ent have not been documented for CMP in the treatment of dilative cardiomyo pathy. Mitral valve reconstruction on the other hand shows promising result s. PLVR is an innovative procedure in which the heart is surgically reduced in size and cardiac function is dramatically improved immediately after su rgery. The presence of long-term effects is still unknown. VAD have been sh own to be extremely effective as a short- and long-term "bridge" to heart t ransplantation. They are not approved for permanent support. A randomized t rial in the U.S. is underway to compare the efficacy of these devices with the efficacy of medical therapy in NYHA functional class IV patients in qua lity of life, survival and costs.