How can I effectively manage patients with heart failure who may require surgical intervention?

Effective management of patients with heart failure who may require surgical intervention involves a multidisciplinary approach integrating medical optimisation, timely specialist referral, and appropriate surgical or percutaneous procedures based on individual risk and valve pathology. Initially, optimise heart failure pharmacotherapy including continuation or initiation of beta-blockers, angiotensin-converting enzyme inhibitors (or angiotensin receptor blockers if intolerant), and aldosterone antagonists, monitoring renal function, electrolytes, heart rate, and blood pressure closely to stabilise the patient before surgery ¹. Once stabilised, the specialist heart failure multidisciplinary team (MDT) should coordinate care, including detailed care planning and communication with primary care for ongoing management ³.

For patients with valvular heart disease contributing to heart failure, surgical intervention is indicated based on valve severity, symptoms, and surgical risk. For severe aortic stenosis or regurgitation in patients at low or intermediate surgical risk, surgical valve replacement via median sternotomy or minimally invasive surgery is first-line; transcatheter aortic valve implantation (TAVI) is reserved for those at high surgical risk or unsuitable for surgery ². In mitral valve disease, surgical repair is preferred for severe primary mitral regurgitation if the valve is suitable and the patient is fit for surgery; replacement is considered if repair is unsuitable. For secondary mitral regurgitation, surgery is considered if the patient is undergoing cardiac surgery for another indication; otherwise, medical management or transcatheter edge-to-edge repair may be appropriate if surgery is unsuitable ². Tricuspid valve repair should be considered during mitral or aortic valve surgery if tricuspid regurgitation is moderate to severe ².

Early involvement of specialist centres for mechanical circulatory support or transplantation assessment is recommended for patients with potentially reversible severe acute heart failure or those who may be transplant candidates ¹. This ensures timely consideration of advanced therapies beyond conventional surgery. Additionally, ongoing monitoring and follow-up by the heart failure MDT and primary care team are essential to manage symptoms, optimise therapy, and detect deterioration ³.

Recent literature in adult congenital heart disease highlights the importance of tailored advanced therapies and end-of-life care planning in complex heart failure cases, reinforcing the need for specialist input and individualised management plans (Crossland et al., 2019).