Risk factors and surgical treatment
The second treatment principle is to minimize the common risk factors for heart failure, such as alleviating hypertension [4]. Coronary revascularization [coronary artery bypass grafting (CABG)] for ischaemic heart disease preserves cardiac function [5] and improves outcome in combination with guideline-recommended medical therapy with excellent long-term overall mortality rates (all-cause mortality at 10 years with CABG versus optimal medical treatment: 58.9% vs 66.1%, hazard ratio 0.84, 95% confidence interval 0.73–0.97; P = 0.02; NNT = 14), as was recently demonstrated from STICH (Surgical Treatment for Ischaemic Heart Failure) and STICHES (Surgical Treatment for Ischaemic Heart Failure Extension Study) investigators [19]. The latest coronary revascularization guideline favours CABG as the preferable choice of revascularization in multivessel disease and reduced ventricular function, whereas comparable data for percutaneous coronary intervention are missing [20].
Beneficial reverse remodelling effects induced by pharmacological heart failure treatment in ischaemic heart failure led to the development of a surgical procedure to reduce left ventricular volume and wall tension, with the expectation of a similar mortality benefit [21]. Post hoc analyses from the STICH trial added further insight to this idea: CABG with additional surgical ventricular reconstruction (SVR) in cases with postinfarction dilation proved effective. So, these data revealed that SVR continues to be important in the treatment of ischaemic cardiomyopathy, with convincing results and survival benefits whenever SVR was performed in a way that reduced the ventricular geometric parameters to an almost normal size (postoperative left ventricular systolic volume index of 70 ml/m2 or less) [22].
Several interventional treatments are being investigated to address coexisting lesions, especially the treatment option using interventional edge-to-edge repair for functional mitral regurgitation associated with heart failure. The latest evidence on interventional edge-to-edge repair in this patient cohort indicates that in patients whose condition is stable and in high volume centres, this therapy can lead to survival benefits and symptomatic relief from dyspnoea [23]. However, in a more open all-comers trial on functional regurgitation, including severely impaired patients who can also be considered for a heart transplant or MCS, interventional edge-to-edge repair failed to provide a clinical benefit [24].