across a prosthetic valve depends upon the type, size, and position of the prosthesis as well as the cardiac output; guidelines are available for the ac- ceptable range of Doppler gradients encountered in properly functioning valves. The ACC/AHA guidelines [7] actually do not recommend an an- nual routine echocardiography in patients who have mechanical valves or during the first 5 years with bioprosthetic valves unless there is a change in clinical status. However patients who have bio- prosthetic valves may be considered for annual echocardiography after the first 5 years in the ab- sence of a change in clinical status (IIb). An echo- cardiography should be performed anytime if there is a change in clinical status. The most common prosthesis complications are: extrinsic interference of function (pannus, thrombus, vegetation) resulting in obstruction or regurgitation, perivalvular leak, strut fracture and component escape, leaflet tear of bioprosthesis, and leaflet calcification/stenosis of bioprosthesis. Because of its more anterior position, aortic prosthesis can be imaged more efficiently by TTE than mitral prosthesis. Assessment of mechanical prosthetic malfunction is more difficult with TTE because acoustic shadowing caused by the pros- thetic material may limit transthoracic visualiza- tion of prosthetic leaflets, vegetations, abscesses, and thrombi. TEE should be performed when TTE does not clearly identify the site and/or Fig. 8. (A) Transesophageal echocardiogram of patient who had HeartMate vented electric LVAD showing volume un- loading of left atrium and LV, whereas right-sided chambers remain volume loaded. ( B) Ex vivo LV end-diastolic pres- sure–volume relations (EDPVR) measured from normal hearts, failing hearts, and end-stage failing hearts supported with LVAD explanted at time of transplantation. (C) With heart size indexed by V30, volume on EDPVR at which pres- sure is 30 mm Hg, it is seen that LV reverse structural remodeling occurs and is more prominent after than before 30 days of support. In contrast, there is no significant reverse remodeling of right ventricle. (D) Time course of regression of cel- lular hypertrophy during LVAD support. (From Mancini D, Burkhoff D. Mechanical device-based methods of manag- ing and treating heart failure. Circulation 2005;112:444; with permission.) 133 EXPECTATIONS OF SURGEONS FROM AN IMAGER Surgery for Heart Failure: Now Something for Everyone? Stephen Westaby, MS, PhD, FRCS * Oxford Heart Centre, John Radcliffe Hospital, Headington Oxford, UK The year 2007 marks the 50th anniversary of two major advances destined to become pivotal in the treatment of heart failure. In 1957 Charles Bailey reported a small series of left ventricular aneurysm resections performed by side clamping of the dyskinetic scar and suture without cardio- pulmonary bypass. Performed with low mortality, the operation provided immediate symptomatic relief from breathlessness [1]. The same year, Wal- ton Lillehei and Vincent Gott used direct electrical stimulation of the myocardium to save a 3-year- old child who had tetralogy of Fallot and surgically induced complete heart block [2]. This procedure was the landmark beginning of cardiac pacing (Fig. 1). For the past 50 years cardiac surgery has been in a continuous state of flux. In congenital heart disease palliative techniques have given way to corrective operations using cardiopulmonary by- pass. Rheumatic valve disease has virtually dis- appeared with the widespread use of antibiotics. Coronary artery bypass surgery (CABG) is in recession with the hugely successful refinement of percutaneous balloon angioplasty and stents. In turn coronary intervention rates will fall because of public health initiatives on diet and smoking together with the widespread use of statins. Stent graft technology now benefits many who would otherwise require extensive high-risk thoracoab- dominal aortic surgery. Total artificial hearts have given way to left ventricular assist devices, and pulsatile blood pumps are superceded by minia- turized continuous flow devices. In the same way that enthusiasm for prosthetic heart valves has waned in favor of valve repair techniques, re- construction of the failing heart is, for most patients, a more realistic alternative than commit- tal to a transplant waiting list. Nontransplant heart failure surgery is an ex- panding field at a time when medical treatment and cardiac resynchronization therapy have rec- ognized limits. Although donor hearts can be supplied to only to a tiny minority of patients who have heart failure, other surgical options may soon provide symptomatic relief for the majority. The demand for treatment emerges from an increasingly elderly heart failure population with greater expectations because of well-publicized medical advances and rapidly evolving technology [3]. The revolution in functional cardiac imaging by three-dimensional echocardiography, magnetic resonance, or contrast-enhanced computerized to- mography has provided a much better under- standing of the anatomy and pathophysiology of heart failure. The failing heart beats at more than 120,000 beats per day, pumping more than 6,000 L of blood against an increased systemic and pulmonary afterload. As the heart dilates, wall tension, myocardial energy, and oxygen con- sumption increase. Subendocardial blood flow is diminished in response. It is logical that a pharma- cologically or mechanically unloaded heart has the chance for recovery [4]. It is certain that the remodeled and unsupported heart does not. Left ventricular restoration surgery is predicated on the well-defined relationship between cardiac shape, volume, and function (Fig. 2) [5]. Equally, the recent remarkable developments in blood pump bioengineering provide an alternative ap- proach and a platform on which to base genetic or stem cell therapies [6]. * Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom. E-mail address: stephen.westaby@orh.nhs.uk 1551-7136/07/$ - see front matter Ó 2007 Published by Elsevier Inc. doi:10.1016/j.hfc.2007.04.003 heartfailure.theclinics.com Heart Failure Clin 3 (2007) 139–157 . superceded by minia- turized continuous flow devices. In the same way that enthusiasm for prosthetic heart valves has waned in favor of valve repair techniques, re- construction of the failing heart is,. normal hearts, failing hearts, and end-stage failing hearts supported with LVAD explanted at time of transplantation. (C) With heart size indexed by V30, volume on EDPVR at which pres- sure is 30 . hypertrophy during LVAD support. (From Mancini D, Burkhoff D. Mechanical device-based methods of manag- ing and treating heart failure. Circulation 2005;112:444; with permission.) 133 EXPECTATIONS OF SURGEONS