Book Review

Heart Failure: A Combined Medical and Surgical Approach

N Engl J Med 2007; 357:99-100July 5, 2007

Article

Heart Failure: A Combined Medical and Surgical Approach
Edited by Patrick M. McCarthy and James B. Young. 314 pp., illustrated. Malden, MA, Blackwell Futura, 2007. $99.95. ISBN: 978-1-4051-2203-0

The many therapeutic options for patients with heart failure make it essential for physicians to understand the intricacies of both the medical and surgical aspects of these choices. Heart Failure is an attempt at the difficult feat of making these intricacies more understandable. It includes discussions of all options for the treatment of heart failure, but it could have done more. With the surgical and medical editors and the authors all having some connection to the Cleveland Clinic and, presumably, all of them having worked together, one would hope that the reader would see how surgeons and cardiologists interact to solve the problems presented in the book. But each author writes about his or her own specialty, and we never get to see how the cardiologist can work with the surgeon to identify the right candidates for procedures or to provide medical care that produces the best possible outcomes.

The lack of any meaningful discussion of the medical treatment of patients hospitalized with advanced heart failure is an obvious example of this deficit in the book. How should these patients be treated when they arrive at the hospital? Which patients will respond to medical treatment, and which will need mechanical support? What should be done about the patient who is not a candidate for a left ventricular assist device (or who, after informed consent, does not want the device)? Is there anything that will help such a patient?

Perhaps stronger medical input would have changed some of the chapters that were written from a surgical perspective. The authors of the chapter on ventricular reconstruction seem remorseful that the Batista procedure has been abandoned, stating that the results of the procedure “actually look favorable” in comparison to the results of the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) study, in which the use of a left ventricular assist device as destination therapy was examined. The author of the chapter on valve surgery finds fault with a retrospective, propensity-matched analysis that showed a poor outcome in patients with severe heart failure who underwent mitral-valve surgery. The author appears, instead, to believe anecdotal reports of the benefits of the surgery.

The book is probably most appropriate for cardiologists who want to understand the many options available to patients with heart failure. It provides a complete accounting of the impressive number of studies that underlie evidence-based guidelines for the treatment of chronic heart failure. Although details about failed treatments may be interesting only to heart-failure specialists, and there is some repetition of the many studies that have led to our present therapeutic regimen, a reader can see why the prognosis for patients with heart failure has improved so dramatically. The rapidity of the development of new options — particularly mechanical ones — and the necessity for these options to be rigorously evaluated are also apparent. In addition to information about the medical treatment of chronic heart failure, the book provides complete information about testing (notably, about newer imaging techniques and assessments of myocardial viability) and possible surgical interventions.

Some other limitations of the book should be noted. As in most discussions of heart failure, the distinction between systolic dysfunction and heart failure without systolic dysfunction is sometimes lost; the author of the chapter on epidemiology tends to discuss heart failure in general, but the authors of the chapters on therapeutic strategies focus on patients with the well-studied systolic dysfunction. The book does not focus on pathophysiology and is not designed to bring the reader up-to-date on what is known about the mechanisms of heart failure. Most regrettably, however, it misses the opportunity to provide insight on how the inevitable tension between medical and surgical treatments should be resolved. Addressing this issue might help physicians look at problems in different ways and reasonably consider all possibilities, thereby improving outcomes.

Stephen S. Gottlieb, M.D.
University of Maryland School of Medicine, Baltimore, MD 21201
sgottlie@medicine.umaryland.edu