So let's discuss surgical therapy options in congestive heart failure. There is a disease process that happens in congestive heart failure. It's called left ventricular remodeling. Heart transplantation has historically been the only option for congestive heart failure and end-stage congestive heart failure. But now, new surgical techniques exist to reverse the left ventricular remodeling or at least to slow it down in congestive heart failure. Could you please discuss the surgical treatment options for patients with congestive heart failure today?

Yeah, once you have patients with congestive heart failure, you have to consider the possible pathophysiological components of heart failure. For instance, you can have idiopathic cardiomyopathy when the heart doesn't contract properly. And this is one type of congestive heart failure. This is not so common compared with ischemic cardiomyopathy. Ischemic cardiomyopathy affects about two-thirds of patients with heart failure. The components of heart failure are different. You can have ischemia. You can have a hibernation of the myocardium. You can have a stunning myocardium. So the heart doesn't receive enough blood, and it reacts by a poor contraction. Then you can have other reasons. For instance, you have dilatation of the heart ventricle, some areas which are now akinetic or dyskinetic. So these factors can contribute to left ventricular dysfunction. You can also have arrhythmias, for instance, atrial fibrillation. It contributes significantly to poor left ventricular function. And you can also have malignant arrhythmias, for instance. They contribute to problems in this situation. And obviously, you have to consider all these pathophysiological components. You may have, for instance, a dyskinetic area and dilatation of the left ventricle. You can propose a kind of surgical restoration of the left ventricle. This can be very effective because you reduce remarkably the size of the left ventricle. You also achieve the physiological shape of the left ventricle, which is not a ball, but it's an elliptic shape. So the shape of the heart ventricle is very important for contraction. By offering this type of operation, so-called surgical restoration of the left ventricle, you will improve the quality of life. You improve the performance of the contractility of the left ventricle. You will have eliminated dyssynchrony of a contraction of the left ventricle. Also, you can eliminate the malignant arrhythmias, because you also resect the foci, which are responsible for the arrhythmia. So, there are many advantages of this type of operation [surgical restoration of left ventricle]. In addition, if mitral insufficiency is also present, you can treat the insufficiency of the mitral valve. Mitral regurgitation also contributes to heart failure. You can also eliminate this component of heart failure. You can also eliminate atrial fibrillation with an ablation procedure. Then you can, of course, take care of that cardiac arrhythmia. And you can also revascularize the patient. This will treat the hibernation of the ventricle or ischemia of the left ventricle. They produce this dysfunction of the contraction of the left ventricle. So putting together all these operations, you can really eliminate heart failure. When heart failure is too advanced, and you have a very, very low ejection fraction, almost the entire ventricle is fibrotic. Then you have options only of heart transplantation or left ventricular assist device or replacement of the heart or an artificial heart. But this, of course, is a more rare situation.

These surgical techniques are when you plan a heart failure surgery to stop advancement or even reverse the left ventricular remodeling. Do you do that in one surgery? Or do you do it in sequential surgical operations?

Many things. Yeah, many things you can do during the same surgery. For instance, you can make a restoration of the left ventricle together with correction of mitral insufficiency, ablation of atrial fibrillation, and revascularization of the heart. This eliminates the problem of hibernation [of the myocardium of the left ventricle].

Okay, that's very important. So you can do hybrid heart surgery. You can do coronary artery bypass grafting, and at the same time, you can solve the valvular problem. And that addresses heart failure, left ventricular remodeling.

You can do both surgical operations together. Or you can also use a hybrid type of approach. For instance, you can do the surgical remodeling of the left ventricle and use, a percutaneous coronary intervention to solve the ischemia problem of the left ventricle. You can also use, for instance, percutaneous ablation of atrial fibrillation in combination with the surgical left ventricle restoration. You can really decide [correct intervention] according to the surgical risk of the patient, to the clinical profile, to the age of the patient. So you can try to offer the best treatment for the patient.

So that's also important to emphasize the multidisciplinary approach.

Exactly! What you have noticed from what I said is that there are different specialties interacting in this treatment. And this is a typical example of the heart team. It is very important not only in the decision-making but also in performing the procedures.