Heart Failure Surgery: Valve Repair, LVADs and Transplant

Heart failure surgery begins when medicines are no longer enough, and it has three tiers: valve procedures such as balloon mitral valvotomy, valve repair and valve replacement; implantable devices, namely defibrillators to prevent sudden death and left ventricular assist devices to support the pump; and heart transplantation. The right choice depends on the cause, the patient's age and how long the result must last.

When heart failure outruns medicine, the next options are mechanical: open or catheter-based valve procedures, implantable devices, and ultimately a new heart. Dr. Biswarup Purkayastha, Consultant – Heart & Lung Transplant and Vascular Surgery, Artemis Hospitals, Gurugram, India, works across that entire range, and his views are shaped by a specific constraint. Many of his patients present young, with advanced rheumatic valve disease, from health systems where returning for a second operation is not realistic. Every choice below is made with durability in mind. For the drug therapy that precedes these decisions, see new heart failure drugs, from SGLT2 inhibitors to ARNIs.

Heart failure surgery for valve disease

Valve disease is best treated before it becomes intractable heart failure. Dr. Purkayastha's treatment strategy for valvular heart disease rests on early action: early valve repair or replacement, good-quality secondary antibiotic prophylaxis against recurrent group A streptococcal infection, heart failure medicines while the failure is still manageable, and, for intractable failure, the right implantable device for the right patient.

Balloon mitral valvotomy

Rheumatic heart disease remains a leading cause of heart failure in Africa and parts of Asia, and mitral stenosis, a narrowing of the mitral valve, is its signature lesion. For these patients, percutaneous balloon mitral valvotomy, in which a balloon passed through a vein is inflated inside the narrowed valve to widen it, relieves the stenosis without open surgery. Dr. Purkayastha describes it as a still very efficient therapy for heart failure caused by valvular disease.

Mechanical valves in young patients

When a valve has to be replaced, the patient's age frames the choice. Because heart failure from valvular disease presents so young in this population, options are limited, and a mechanical valve, which lasts a lifetime, is often the one that has to be chosen. Dr. Purkayastha accepts the known trade-offs: lifelong anticoagulation and the bleeding risk that comes with it.

Tricuspid valve: repair or replacement?

The tricuspid valve, in Dr. Purkayastha's practice, is more often repaired than replaced. His preferred options are a traditional DeVega repair, a suture technique that tightens the valve's ring, or an annuloplasty ring, a ring stitched around the valve to reshape it. The cost of tricuspid valve repair and replacement is set out separately.

When replacement is unavoidable, he favours a bioprosthetic valve, even in a moderately aged patient in the 50 to 60 age group, and in general for anyone older than 40. A mechanical valve in the tricuspid position is, in his words, highly unlikely. The reasoning is haemodynamic:

• Low wear. The right side of the heart is a low-pressure circuit, so wear and tear on a tissue valve is much less than on the left side.
• High thrombosis risk. With a low gradient across the valve, small local eddy currents form around a mechanical prosthesis, and clots develop.
• Serious consequences. A clot that slips into the lung can cause pulmonary hypertension or pulmonary embolism, which he describes as, in effect, a lung stroke. It can be deadly.

Mitral valve repair vs replacement

Where rheumatic mitral disease is concerned, Dr. Purkayastha favours a durable replacement over a repair that may need a second operation, and he is sceptical of catheter clip repairs.

Scepticism about transcatheter edge-to-edge repair (TEER)

Dr. Purkayastha is very wary of transcatheter edge-to-edge repair (TEER), in which a clip delivered through a blood vessel holds two valve leaflets together, whether the TriClip for the tricuspid valve or the MitraClip for the mitral. His reasoning comes from surgery. To surgeons, an edge-to-edge repair of the mitral valve, the Alfieri stitch, is the ultimate bailout. There are half a dozen established methods for repairing a mitral valve, including sliding annuloplasty and triangular or quadrangular resection. The edge-to-edge stitch is reserved for an extreme valve where no repair is possible and replacement is ruled out, by financial constraint or by an anatomical abnormality. For such a patient, he asks a pointed question: why intervene at all?

Planning removes the guesswork

He argues that modern imaging makes the bailout scenario largely avoidable. With multiplanar three-dimensional reconstruction, surgeons can assess the mitral annulus, annular calcification and mitral annular disjunction (MAD), a displacement of the valve's hinge point away from the heart muscle, before the operation. That level of preoperative planning allows the team to be nearly certain of the anatomy it will encounter and to decide the plan early.

Does mitral valve replacement last longer than repair?

Dr. Purkayastha's broader position is that replacement deserves more credit than it receives. Rheumatic valves do not hold well after repair. Most of the data favouring repair is Western, and even that is shifting. He cites a landmark paper by Marc Gillinov at the Cleveland Clinic, with whom he has discussed the question personally, and follow-up data from the same centre. In his reading, they show that in rheumatic and ischaemic mitral disease, replacement gives better freedom from recurrent regurgitation and re-operation, because a sizeable share of those repairs fail within the first decade. Durability depends heavily on the cause of the valve disease: repair of degenerative mitral valves at experienced centres is generally durable over the long term, whereas repairs of rheumatic and ischaemic valves fail more often.

The implication depends on the health system. Where insurance and unified healthcare allow a patient to return for a re-operation every sixth or seventh year, repair may be affordable. Where a valve operation has to be a lifelong fix, he considers replacement the better strategy, scientifically and haemodynamically.

Does an ICD treat heart failure?

An implantable cardioverter-defibrillator (ICD), a small implanted device that shocks a dangerous heart rhythm back to normal, does not treat heart failure. Dr. Purkayastha takes care to correct this common misunderstanding. It does not improve the pumping action of the heart. Its purpose is to prevent sudden cardiac death, which heart failure and irregular rhythms make more likely.

He illustrates the point with a widely reported case: a professional footballer who suffered a cardiac arrest on the pitch at the Euro 2020 tournament, was resuscitated with CPR and defibrillation, received an ICD, and went on to return to international football. For patients with dangerous arrhythmias, an ICD can be life-saving. The cost of ICD implantation is set out separately.

Left ventricular assist devices (LVADs)

A left ventricular assist device (LVAD) is a mechanical pump implanted alongside the heart to take over the work of the left ventricle. Dr. Purkayastha sees two roles for it: a bridge to transplant and a permanent destination therapy.

What an LVAD is for

The most intensive implantable device is the left ventricular assist device, specifically the HeartMate 3. Dr. Purkayastha is direct about its demands: it is expensive, it is intensive, and it requires the hospital to commit significant effort and resources to each patient. The two roles are:

• Bridge to transplant. Having heart failure and wanting a transplant does not by itself make a patient a transplant candidate. A patient in very poor condition may need to be bridged to that point.
• Destination therapy. An older patient who does not want a transplant can use the device as a permanent solution.

If heart failure is intractable and life-threatening even with an ICD in place, an LVAD may be the answer.

Destination therapy is replacing transplant for older patients

For patients above 55, Dr. Purkayastha says LVADs have replaced heart transplantation to a reasonable extent. In his view, for someone who expects to live no more than about 15 years, the device can serve as a long-term solution. Published results are more modest than that horizon: in the MOMENTUM 3 trial, about 58% of HeartMate 3 recipients were alive at five years. There is no immunosuppression; a simple antiplatelet and anticoagulant regimen is enough.

His unit currently follows a young man who has lived with an LVAD for about a decade. As the device nears the end of its working life and develops complications such as battery malfunction, the patient has been registered with the national organ transplant organisation and will remain on the LVAD for a few more months or years until a heart becomes available. The case shows a device supporting a young patient for years before transplantation.

Where the technology is heading

LVADs have evolved from first-generation pulsatile devices to continuous-flow axial pumps and now to fully magnetically levitated centrifugal designs with the HeartMate 3. That change has substantially reduced pump thrombosis and stroke, and he sees it making the LVAD a therapy of up to 15 years. A total artificial heart, the SynCardia, already exists, and research is under way on a fully magnetically levitated biventricular total artificial heart that could support both ventricles for years.

Dr. Purkayastha does not expect devices to make transplantation obsolete. He believes no device engineered by human beings will be as beautiful as the natural heart or replace it completely, and he expects heart transplantation to remain essential for at least the next 15 to 25 years.

The future of heart transplantation: expanding the donor pool

Heart transplantation remains, in his words, the holy grail of heart failure treatment. Unlike a kidney or part of a liver, a heart cannot come from a living donor. The binding constraint is the supply of deceased-donor organs, and he identifies three developments that will change it within the coming decade.

1. Donation after circulatory death

Most heart donation today follows brain death. Dr. Purkayastha argues the field must extend to donation after circulatory death (DCD). Consider a hospital patient with a catastrophic illness who is not brain dead, for whom the family and treating team have agreed to withdraw life support, while the heart itself is healthy. The family can be prepared in advance. After the heart stops and a five-minute no-touch period has passed, the heart can be reanimated, retrieved and implanted in a recipient.

The scale of the opportunity is large. DCD opens donation to many patients who will never meet brain-death criteria, and where it has been adopted it has increased adult heart transplant activity by about a quarter to a third.

2. Machine perfusion

Organ care systems such as the TransMedics OCS keep a donor heart beating outside the body, with blood pumped through it artificially, during transport. That extends preservation beyond the roughly four hours a heart tolerates in conventional cold storage, and with it the distance a heart can travel. Machine perfusion, too, expands the effective donor pool.

3. Xenotransplantation

The third development is the transplantation of hearts from genetically modified pigs into humans, which has now become a reality; Dr. Purkayastha is aware of at least two recipients. The first two pig-heart recipients, both treated at the University of Maryland in 2022 and 2023, survived about two months and about six weeks respectively. Success so far has been limited, but in his view xenotransplantation is only going to improve with time.

Taken together, donation after circulatory death, machine perfusion and xenotransplantation are the three forces he expects to transform the deceased-donor transplant landscape over the next ten years. For a region where the burden of late-presenting heart failure leaves many patients beyond the reach of medicine or valve surgery, the size of that donor pool will matter directly. Clinicians' questions on tricuspid valve choices, LVADs, donor hearts and xenotransplantation are answered in the Live Discussion from the masterclass.