THE ROLE OF SURGERY IN HEART FAILURE - part 2 pps

Congress in 1956. Dr. DeBakey has continued
a life-long involvement with the library, serving
first as a board member and later as its chairman.
Being especially sensitive to the medical needs
of soldiers, Dr. DeBakey also proposed the
creation of medical centers designed exclusively
for veterans. The first Veterans Administration
Hospital was established in Houston in 1949 on
the recommendation of Dr. DeBakey. In recogni-
tion of his contributions to the welfare of vet-
erans, in 2003 the Michael E. DeBakey Veteran’s
Administration Medical Center at Houston was
named in his honor.
Career at Baylor College of Medicine
In 1948, Dr. DeBakey accepted the position of
chairman of the department of Surgery at Baylor
University College of Medicine, now Baylor
College of Medicine. There, his talent for organi-
zational innovation led to numerous develop-
ments. Dr. DeBakey’s protean interest and
abilities were applied in many areas. As a result
of his administrative talents and leadership, by the
early 1950s, Baylor had become one of the leading
medical schools for surgical innovation. A seminal
contribution to this field was Dr. DeBakey’s
pioneering work in repairing arterial aneurysms
with Dacron grafts [3–14]. Nearly every aspect of
cardiovascular surgery was influenced by his tire-
less work ethic and innovative mind. To address
the subject of this monograph, however, the re-
maining comments are confined to Dr. DeBakey’s

role in the development of mechanical circulatory
support devices for advanced heart failure.
Partial and total artificial hearts
The first observation that the work of the heart
could be temporarily replaced by a pump, such as
the DeBakey roller pump, established the ground-
work for mechanical circulatory assistance. An-
other important observation reported by Dr.
DeBakey [15] was the potential for recovery of
the failed heart by simple prolongation of cardio-
pulmonary bypass. These two observations advo-
cated by Dr. DeBakey (ie, the ability of
circulatory support to replace heart function and
the ability of the heart to recover following ‘‘car-
diac rest’’ by mechanical assistance) formed the
basis of all subsequent developments in the field.
At Baylor, Dr. DeBakey energetically created
a team of the most talented physicians and
researchers to aid in the developmental work of
cardiac-assist devices. Two of the leading
researchers in this field were Dr. William Hall
and Dr. Domingo Liotta. As a Baylor student, I
had the privilege of working with Dr. Hall and
Dr. Liotta, and, in 1965, I wrote a student re-
search paper on cardiac support devices, which
was based on my work with these two leaders.
Significant research in this field would have
been impossible, however, without government
funding, which sustained the development of
future cardiac-assist devices. Recognizing this,

Dr. DeBakey [16–18] took his message to Wash-
ington. In 1963, he spoke before Congress about
the need for a total artificial heart, and his testi-
mony was instrumental in persuading the Na-
tional Institutes of Health to establish the
Artificial Heart Program (1964) to support the de-
velopment of such a device (Fig. 1).
Throughout the 1960s, researchers in the
Baylor Surgical Laboratories were known for
their leadership in the field of mechanical circula-
tory support, which was due in part to funding
received from the National Institutes of Health.
On July 18, 1963, after years of research with
animal models, Dr. DeBakey performed the first
successful clinical implant of a left ventricular
Fig. 1. Michael E. Debakey, MD, circa 1963. (Courtesy
of O.H. Frazier, MD, Houston, TX.)
118
FRAZIER
Expectations of Surgeons from an Imager
Hind Rahmouni, MD, Martin St. John Sutton, MD, FRCP
*
University of Pennsylvania Medical Center, Philadelphia, PA, USA
Congestive heart failure is a clinical syndrome
characterized by fatigue, shortness of breath,
exercise intolerance, and fluid retention with lower
extremity and/or pulmonary edema. There is an
estimated 25 to 30 million patients who have heart
failure worldwide. Heart failure is primarily
a disease of the elderly, and the prevalence of

chronic heart failure increases with advancing age.
Currently, chronic heart failure is the most
common hospital discharge diagnosis in patients
over the age of 65 years. Thus, as the population
ages, the management of heart failure will become
more frequent and of even greater importance.
The management of patients who have heart
failure is challenging, and the mortality with
medical therapy alone is high. Although the ideal
treatment for heart failure is cardiac transplanta-
tion, this therapy is limited by a chronic shortage
of donor hearts. Currently, the mainstay of heart
failure treatment is pharmacologic and includes
angiotensin converting enzyme inhibitors, angio-
tensin receptor blockers, b-adrenergic receptor
blockers, aldosterone receptor antagonists, di-
uretics, and digitalis. However, surgery is becom-
ing increasingly important with valve repair/
replacement, ventricular assist devices, and epi-
cardial restraints.
Systolic versus diastolic heart failure
Heart failure may be systolic due to abnormal
myocardial excitation–contraction coupling or di-
astolic due to abnormal relaxation and increased
myocardial passive stiffness. Between 30% and
50% of all patients presenting with heart failure
have diastolic heart failure (left ventricle [LV] ejec-
tion fractionR50%). Diastolic heart failure was
initially believed to be a rare and benign condition,
but the annual mortality from diastolic heart fail-

ure ranges from 5% to 15%, and admission rate
for recurrent heart failure is 50% within the first
6 months [1–4]. The remaining 50% to 70% of pa-
tients present with systolic heart failure that is
clinically indistinguishable from diastolic heart
failure. It is important to identify patients who
have systolic heart failure because they may be el-
igible for surgical therapy. The important informa-
tion in systolic heart failure for the surgeon from
an imaging perspective is the reliable and repro-
ducible assessment of LV size, architecture, and
function, because these are the strongest predictors
of clinical outcome following cardiac surgery. We
therefore focus attention on systolic heart failure
and how imaging modalities can optimize the
type and timing of surgical treatment.
Assessment of left ventricle function
There are several different imaging modalities
available for qualitative and quantitative assess-
ment of LV function: echocardiography, nuclear
imaging, contrast angiography, cardiac magnetic
resonance (CMR) imaging, and CT. CMR is
considered the gold standard for estimation of
LV volumes, mass, and function (LV ejection
fraction [LVEF]), because of its high spatial and
temporal resolution and its ability to quantify
LV volume from tomographic slices without geo-
metric assumptions regarding LV cavity shape
(Fig. 1). However, echocardiography is more
commonly used than CMR in clinical practice

for assessment of LV volumes and function be-
cause of its wider availability. Echocardiography
* Corresponding author. Division of Cardiology,
University of Pennsylvania Medical Center, 3400 Spruce
Street, Philadelphia, PA 19104.
E-mail address:
(M. St. John Sutton).
1551-7136/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.hfc.2007.04.002 heartfailure.theclinics.com
Heart Failure Clin 3 (2007) 121–137