HEART FAILURE AND HEART REPLACEMENT
The final stage in almost any type of heart disease is heart failure, also known as congestive heart failure, in which the heart muscle weakens and is unable to pump enough blood to the body. In the early stages of heart failure, the muscle may enlarge in an attempt to contract more vigorously, but after a time this enlargement of the muscle simply makes the heart inefficient and unable to deliver enough blood to the tissues. In response to this shortfall, the kidneys conserve water in an attempt to increase blood volume, and the heart is stimulated to pump harder. Eventually excess fluid seeps through the walls of tiny blood vessels and into the tissues. Fluid may collect in the lungs, making breathing difficult, especially when a patient is lying down at night. Many patients with heart failure must sleep propped up on pillows to be able to breathe. Fluid may also build up in the ankles, legs, or abdomen. In the later stages of heart failure, any type of physical activity becomes next to impossible.

Almost any condition that overworks or damages the heart muscle can eventually result in heart failure. The most common cause of heart failure is coronary heart disease. Heart failure may develop when the death of heart muscle in a heart attack leaves the heart with less strength to pump blood, or simply as a result of long-term oxygen deprivation due to narrowed coronary arteries. Hypertension or malfunctioning valves that force the heart to work harder over extended periods of time may also lead to heart failure. Viral or bacterial infections, alcohol abuse, and certain chemicals (including some lifesaving drugs used in cancer chemotherapy), can all damage the heart muscle and result in heart failure.

Despite its ominous name, heart failure can sometimes be reversed and can often be effectively treated for long periods with a combination of drugs. Medications such as digitalis are often prescribed to increase the heart’s pumping efficiency, while beta blockers may be used to decrease the heart’s workload. Drugs known as vasodilators relax the arteries and veins so that blood encounters less resistance as it flows. Diuretics stimulate the kidneys to excrete excess fluid. About 4.6 million people with heart failure are alive in the United States today.

A last resort in the treatment of heart failure is heart transplantation, in which a patient’s diseased heart is replaced with a healthy heart from a person who has died of other causes. Heart transplantation enables some patients with heart failure to lead active, healthy lives once again. However, a person who has received a heart transplant must take medications to suppress the immune system for the rest of his or her life in order to prevent rejection of the new heart. These drugs can have serious side effects, making a person more vulnerable to infections and certain types of cancer.

The first heart transplant was performed in 1967 by South African surgeon Christiaan Barnard. However, the procedure did not become widespread until the early 1980s, when the immune-suppressing drug cyclosporine became available. This drug helps prevent rejection without making patients as vulnerable to infection as they had been with older immune-suppressing drugs. About 3,500 heart transplants are performed worldwide each year, about 2,500 of them in the United States. Today, about 83 percent of heart transplant recipients survive at least one year, and 71 percent survive for four years.

A shortage of donor hearts is the main limitation on the number of transplants performed today. Some scientists are looking for alternatives to transplantation that would help alleviate this shortage of donor hearts. One possibility is to replace a human heart with a mechanical one. A permanent artificial heart was first implanted in a patient in 1982. Artificial hearts have had been used experimentally with mixed success. They are not widely used today because of the risk of infection and bleeding and concerns about their reliability. In addition, the synthetic materials used to fashion artificial hearts can cause blood clots to form in the heart. These blood clots may travel to a vessel in the neck or head, resulting in a stroke. Perhaps a more promising option is the left ventricular assist device (LVAD). This device is implanted inside a person’s chest or abdomen to help the patient’s own heart pump blood. LVADs are used in many people waiting for heart transplants, and could one day become a permanent alternative to transplantation.

Some scientists are working to develop xenotransplantation, in which a patient’s diseased heart would be replaced with a heart from a pig or another species. However, this strategy still requires a great deal of research to prevent the human immune system from rejecting a heart from a different species. Some experts have also raised concerns about the possibility of harmful viruses from other species being transmitted to humans as a result of a transplant.