Surgical approaches to arresting or reversing chronic remodeling of the failing heart.

Chronic ventricular remodeling is a central feature of heart failure that strongly correlates with a poor prognosis. Several recent surgical treatments for heart failure may derive benefit by their ability to arrest or substantially reverse this remodeling process. Dynamic cardiomyoplasty involves wrapping the heart with the latissimus dorsi muscle and stimulating the muscle to assist contraction. The wrap itself may provide a constraint helping to limit progressive cardiac dilation and/or assist in reversing this process. Left ventricular assist devices almost completely unload the heart and augment systemic circulation, thereby reducing neurohumoral activation. These combined effects seem to alter the chamber and cellular phenotype, and reversal of some molecular changes are associated with failure. Lastly, the partial ventriculectomy procedure directly reverses remodeling by acute removal of a portion of the lateral wall. Only preliminary nonrandomized trial data are currently available for each of these therapies with larger trials under way. However, early results are intriguing and are yielding insights into these mechanisms.