Heart failure in the young and old: insights into various therapies.

Cardiovasc Diagn Ther 2021;11(1):336-338 | http://dx.doi. org/10.21037/cdt-20-297 Nowadays, chronic heart failure is the most important field in cardiology and cardiovascular surgery. Whereas management o f a cu te s e r ious hear t d i s ea se s o f atherosclerotic, ischemic, infectious, toxic or inflammatory origins, have much improved through the years leading to a successful primary treatment, these patients, after overcoming such acute bouts of disease may ultimately have recurrence and veer into phases of chronic heart failure. This has become even more prevalent, since these patients become older and sicker, thus, have more chance to develop chronic heart failure. Veritably, chronic heart failure is now the most frequent cause of death in those more than 80 years old, both in men and women (1). This data clearly illustrates the heart failure scenery in developed countries which is in broad contrast to the underprivileged and larger part of the globe. This vast difference in socio-economic facets must be then taken into consideration. Consequently, broad interest and enthusiasm have been invested into diagnosis and treatment of heart failure during the recent decades, which has resulted in the emergence of a number of novel pharmaceutical concepts, new rhythm stabilizing procedures and better understanding of the value and limits of organ-saving surgical procedures. These included the wide acceptance of revascularization procedures in even highly reduced left ventricular function assuming that the “hibernating”, i.e., not functioning, but still vital myocardium might be revitalized next to dead tissues, scars or fibrosis, where no such measures could be successful. Recently, only indirect signs of hibernation such as preserved thickness of otherwise adynamic heart muscle are discernible on echocardiograms. The relationship of fibrotic to hibernating myocardium thus determines the amount of improvement in revascularization. Fibrosis and hibernation are also responsible for ischemic mitral insufficiency through dysfunction of papillary muscle-bearing ventricular areas and their reversibility. Moreover, in left ventricular aneurysmectomy, the amount of functional improvement resulting from reduction of the ventricular diameter and thus decrease in myocardial strain, is determined by the quality of the remaining myocardial tissues. With cardiovascular magnetic resonance imaging using delayed gadolinium enhancement, replacing endomyocardial biopsy as gold standard for human cardiac fibrosis identification and quantification, introduced by Iles and colleagues (2) and extensively elaborated by others (3-5), it is possible to noninvasively assess interstitial myocardial fibrosis and visualize scar tissue in patients with clinically evident cardiomyopathy. This may well be a promising tool to answer important issues in clinical intervention and improve morbidity and mortality of patients with heart failure. We have formulated a complex of components of ischemic cardiac failure which accounts for the majority of patients with long-standing coronary artery disease most remarkable in the elderly. LOCIMAN stands for Left Ventricular failure in Obstruction of Coronary arteries, Ischemic Mitral incompetence and Aneurysm. There is a lack of studies analyzing which degree these components contribute to the clinical picture of heart failure and how much influence can be achieved by revascularization, mitral valve repair and aneurysmectomy. Heart transplantation has endowed us a dramatic treatment modality and is now a well-developed and fascinating method to reverse chronic otherwise untreatable heart failure to a sudden normal life capacity. This means prolonging the supposedly very short life span of patients with advanced heart failure by an average of 10 to 11 years (6) and, as in my own experience, could be up to 35 years in Editorial Commentary