Dynamic cardiomyoplasty: evaluation of an alternative treatment for end-stage heart failure

Dynamic cardiomyoplasty (DCMP) was developed as an alternative treatment fo r patients with end-stage heart failure. The first clinical application of this technique was in 1985 by Carpentier und Chachques. Since then, DCMP ha s been performed in more than 1000 patients world-wide. During the initial experience with DCMP, survival for NYHA class IV patients was clearly shown to be much worse than that for class III patients. By careful patient sele ction, operative mortality has decrease from 31 % in the past to less then 5 % today. The vast majority of patients have demonstrated significant impr ovement in NYHA class and overall quality of life with only minor effects o n systolic cardiac function. Clinical work, as well as recent animal work s upports the hypothesis that by a combination of long-term elastic constrain t and active dynamic assist, DCMP decreases myocardial wall stress. This pr ocess results in a "reverse remodeling" of the insufficient heart with an i mprovement of the "contractility reserve". To prove the effectiveness of DC MP versus medical therapy alone, the C-SMART study started in 1994, as the first and only randomized trial. Unfortunately the study was stopped in 199 8 due to slow patient recruitment after enrolling 103 patients. The study s howed that, from a symptoms standpoint, patients with DCMP were improved ov er those who were medically treated. However, there was no significant diff erence for survival between the two groups after 12 months. The lack of a c lear survival advantage and the relatively poor and inconsistent hemodynami c benefit of DCMP have hindered its acceptance to date as a treatment alter native for patients with endstage heart failure. The ultimate role of DCMP in the treatment of heart failure will depend on the outcome of future deve lopments to improve the contractility and the long-term durability.