Advanced cardiac failure. New surgical approaches]

Therapeutic options: Prognosis of advanced heart failure is ominous since survival rate is less than 65% one year after an acute and severe cardiac episode. Medical therapy has proven to be efficient in reducing fatal complications and in delaying critical evolution. Depending on the etiology and the myocardial status, new surgical approaches can also be proposed for repair or substitution. Surgical repair: The beneficial effect of myocardial revascularization on severe ischemic cardiomyopathy, the relevance of mitral valve repair in dilated cardiomyopathy, and the advantage of ventricular remodeling in patients with major Ventricular dyskinesia has been clearly demonstrated. All these surgical techniques improve ventricular function and enhance survival rate by about 70% after three years. Substitution procedures: The best therapeutic option to recover heart function for normal life and reduced mortality remains, when possible, cardiac transplantation. Ventricular cardiac assist devices are planned as a temporary option to bridge the waiting period to transplantation or for myocardial recovery but can also be proposed as a chronic implantation in an outpatient care scheme. Cardiomyoplasty for therapeutic management of advanced cardiac failure is still a controversial surgical approach. Other clinical strategies such as transmyocardial laser revascularization, myocardial angiogenesis and myocardial cell therapy are being investigated or developed. Adapted treatment: Optimal management of each patient with advanced heart failure requires an adequate treatment selected among a wide range of medical and/or surgical strategies.