Dilated cardiomyopathy surgery
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Sachin Shah, M.D.; Abdelrahman Ibrahim Abushouk, MD[2]
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Overview
This section covers device-based, surgical, and procedural interventions for dilated cardiomyopathy (DCM). These therapies complement guideline-directed medical therapy (GDMT) and are considered when pharmacologic optimization alone is insufficient. Key interventions include implantable cardioverter-defibrillators (ICDs) for prevention of sudden cardiac death, cardiac resynchronization therapy (CRT) for electrical dyssynchrony, durable mechanical circulatory support (MCS) for advanced heart failure, and cardiac transplantation for end-stage disease. Temporary MCS devices serve as bridges to recovery, decision, or definitive therapy in cardiogenic shock. Device and surgical decisions should be made after adequate GDMT optimization and reassessment of left ventricular ejection fraction (LVEF), typically at least 3 months after initiation of therapy.
Implantable cardioverter-defibrillators
Primary prevention
ICD therapy is recommended for primary prevention of sudden cardiac death (SCD) in patients with DCM and persistent LV dysfunction despite GDMT.[1]
2022 AHA/ACC/HFSA guideline recommendations:[1]
| Class I |
| "1. In patients with nonischemic DCM or ischemic heart disease ≥40 days post-MI with LVEF ≤35% and NYHA class II–III symptoms on chronic GDMT, who have reasonable expectation of meaningful survival >1 year, ICD therapy is recommended for primary prevention of SCD to reduce total mortality. (Level of Evidence: A)" |
| "2. In patients ≥40 days post-MI with LVEF ≤30% and NYHA class I symptoms on GDMT, who have reasonable expectation of meaningful survival >1 year, ICD therapy is recommended. (Level of Evidence: B-R)" |
Important timing considerations:[2]
- In newly diagnosed nonischemic DCM, ICD implantation should be deferred until at least 3 months of optimized GDMT, as LVEF may improve substantially with medical therapy.
- There are no data supporting benefit of early ICD implantation in hemodynamically stable patients with newly diagnosed cardiomyopathy.
- A wearable cardioverter-defibrillator may be considered during the optimization period in selected high-risk patients.
The DANISH trial and its implications
The DANISH trial (2016) enrolled 1,116 patients with nonischemic HFrEF and found that ICD implantation did not significantly reduce all-cause mortality over a median follow-up of 5.6 years, although it did reduce sudden cardiovascular death.[3]
Key considerations:
- Extended follow-up of DANISH (median 9.5 years) confirmed no overall survival benefit (HR 0.89; 95% CI 0.74–1.08) but a significant 40% reduction in sudden cardiovascular death (HR 0.60; 95% CI 0.40–0.92).[3]
- Prespecified subgroup analysis demonstrated a significant survival benefit in patients ≤70 years of age; no benefit was observed in older patients due to a higher proportion of nonarrhythmic deaths.[4]
- The AHA/ACC guideline maintains a Class I recommendation for ICD in nonischemic DCM, while the 2022 ESC guideline provides a weaker Class IIa recommendation.[5]
- Modern GDMT (including ARNI and SGLT2 inhibitors) was not used in the DANISH trial, raising the question of whether contemporary medical therapy further reduces arrhythmic risk and attenuates ICD benefit.
Secondary prevention
ICD implantation is indicated (Class I) in survivors of sustained ventricular tachycardia or ventricular fibrillation not due to a completely reversible cause, who are receiving chronic optimal medical therapy and have reasonable expectation of meaningful survival >1 year.[1]
Subcutaneous versus transvenous ICD
The subcutaneous ICD (S-ICD) is an alternative to transvenous systems that avoids intravascular lead-related complications. The PRAETORIAN trial (849 patients) demonstrated noninferiority of S-ICD compared with transvenous ICD for the composite of device-related complications and inappropriate shocks over a median follow-up of 49 months.[6] The ATLAS trial (544 patients ≤60 years with risk factors for lead complications, mean follow-up 2.5 years) showed a significant reduction in perioperative lead-related complications with S-ICD compared with transvenous ICD (0.4% vs 4.8%; P=0.001).[7] The PRAETORIAN-XL extended follow-up (median 87.5 months) confirmed no significant difference in all device-related complications between S-ICD and TV-ICD in the intention-to-treat analysis, but TV-ICD was associated with significantly more major complications and lead-related complications.[8]
S-ICD limitations:[6]
- Cannot provide antitachycardia pacing.
- Cannot provide bradycardia pacing or CRT.
- Higher rate of inappropriate shocks from T-wave oversensing.
Genetic considerations
Both AHA/ACC and ESC guidelines recommend ICD implantation in patients with DCM due to LMNA mutations who have additional risk factors for SCD, even if LVEF is >35%.[1]
Cardiac resynchronization therapy
CRT is indicated in patients with HFrEF and electrical dyssynchrony who remain symptomatic despite optimized GDMT.[9]
2022 AHA/ACC/HFSA guideline recommendation:[1]
| Class I |
| "1. LVEF ≤35%, sinus rhythm, LBBB with QRS ≥150 ms, NYHA class II, III, or ambulatory IV on GDMT (Level of Evidence: B-R)" |
| Class IIa |
| "1. LVEF ≤35%, sinus rhythm, non-LBBB with QRS ≥150 ms, NYHA class III or ambulatory IV on GDMT (Level of Evidence: B-NR)" |
| "2. LVEF ≤35%, sinus rhythm, LBBB with QRS 120–149 ms, NYHA class II, III, or ambulatory IV on GDMT (Level of Evidence: B-NR)" |
| "3. LVEF ≤35%, atrial fibrillation, if ventricular pacing required or CRT criteria otherwise met, and rate control allows near 100% pacing (Level of Evidence: B-NR)" |
| "4. LVEF ≤35%, anticipated requirement for significant (>40%) ventricular pacing (new or replacement device) (Level of Evidence: B-NR)" |
| Class IIb |
| "1. LVEF ≤35%, sinus rhythm, non-LBBB with QRS 120–149 ms, NYHA class III or ambulatory IV on GDMT (Level of Evidence: B-NR)" |
| "2. LVEF ≤30%, ischemic cause of HF, sinus rhythm, LBBB with QRS ≥150 ms, NYHA class I on GDMT (Level of Evidence: B-NR)" |
- A patient-level meta-analysis of 7 RCTs confirmed comparable CRT benefit in nonischemic and ischemic cardiomyopathy for the composite of HF hospitalization or all-cause death.[10]
- Patients with LBBB, wider QRS duration (≥150 ms), and female sex derive the greatest benefit from CRT.[9]
Conduction system pacing
Conduction system pacing (CSP), including His bundle pacing and left bundle branch area pacing (LBBAP), is an emerging alternative to conventional biventricular pacing for CRT delivery.[11]
- A meta-analysis of 7 small RCTs (408 patients with LVEF ≤40%) found that CSP was associated with greater QRS narrowing (mean difference −13.34 ms) and greater LVEF improvement (mean difference 2.06%) compared with biventricular pacing.
- A meta-analysis of 4 RCTs and 17 observational studies (4,327 patients) reported that CSP was associated with lower all-cause mortality (10% vs 13%; OR 0.68) and reduced HF hospitalization (11% vs 20%; OR 0.52) compared with biventricular pacing.
- The 2023 HRS Guideline on Cardiac Physiologic Pacing proposes CSP as a reasonable alternative to biventricular pacing in CRT-indicated patients.
- LBBAP offers a technically simpler and more reliable approach than His bundle pacing, though large-scale RCT data comparing CSP with biventricular pacing for hard clinical endpoints remain limited.[11]
Durable mechanical circulatory support
Indications
Durable left ventricular assist device (LVAD) implantation is indicated in selected patients with advanced HFrEF refractory to GDMT.[12]
2022 AHA/ACC/HFSA guideline recommendation:[1]
| Class I |
| "1. In select patients with advanced HFrEF with NYHA class IV symptoms who are deemed dependent on continuous IV inotropes or temporary MCS, durable LVAD implantation is effective to improve functional status, quality of life, and survival. (Level of Evidence: A)" |
| Class IIa |
| "1. In select patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT, durable MCS can be beneficial to improve symptoms, functional class, and reduce mortality. (Level of Evidence: B-R)" |
Support strategies
Traditional LVAD indications include:[12]
- Bridge to transplantation (BTT): For patients listed or being evaluated for cardiac transplantation.
- Bridge to decision/candidacy: For patients whose transplant eligibility is uncertain.
- Destination therapy (DT): For patients not eligible for cardiac transplantation.
Following the 2018 US donor allocation policy change, LVAD implantation for destination therapy has increased to approximately 81% of all MCS implants, while BTT has decreased to approximately 5%.
Contemporary outcomes
The HeartMate 3 (fully magnetically levitated centrifugal-flow LVAD) is the predominant durable device in current use.
- In the MOMENTUM 3 trial, 1-year and 5-year overall survival rates for HeartMate 3 were 84% and 52%, respectively. Two-year overall survival was approximately 79–81% across the pivotal and continued access protocol cohorts.[12][13]
- The risk of death exceeds survival benefit between 3 and 4 years on LVAD support, regardless of implant strategy.[1]
- Pump thrombosis rates are markedly reduced with HeartMate 3 (1.4% in MOMENTUM 3 long-term follow-up) compared with prior-generation devices (8–10% at 1 year).[14]
Complications
Major complications of durable LVAD therapy include:[12]
- Gastrointestinal bleeding: Affects 25–30% of patients within 1 year; related to acquired von Willebrand disease from continuous-flow physiology.
- Stroke: Ischemic and hemorrhagic; stroke and infection confer the highest mortality risk among LVAD complications.
- Driveline infection: Related to the percutaneous power cable.
- Right ventricular failure: May occur after LV unloading.
- Aortic insufficiency: Moderate or greater severity develops in approximately 20% of patients within 1 year.
- Pump thrombosis: Markedly reduced with HeartMate 3 but not eliminated.
Only approximately 30% of patients remain free of hospital readmission within 1 year of LVAD implantation.[14] Patient selection should involve a multidisciplinary team including heart failure cardiologists, cardiac surgeons, social workers, palliative medicine specialists, and allied health professionals.
Temporary mechanical circulatory support
Temporary MCS devices are used in patients with cardiogenic shock as a bridge to recovery, bridge to decision, or bridge to durable MCS or transplantation.[15]
Available devices include:
- Intra-aortic balloon pump (IABP): Provides modest hemodynamic augmentation; most widely used temporary MCS device.
- Impella (percutaneous microaxial flow pump): Provides greater hemodynamic support than IABP; available in multiple configurations for left-sided (Impella CP, 5.5) and right-sided (Impella RP) support.
- TandemHeart: Percutaneous left atrial-to-femoral artery bypass; requires transseptal cannulation.
- Venoarterial extracorporeal membrane oxygenation (VA-ECMO): Provides full cardiopulmonary support; increases LV afterload and may require LV venting.
Randomized trials comparing percutaneous MCS devices have not demonstrated a consistent survival advantage of one device over another, though hemodynamic improvements are greater with Impella and TandemHeart compared with IABP.[15]
2022 AHA/ACC/HFSA guideline recommendation:[1]
| Class IIa |
| "1. In patients with advanced HFrEF and hemodynamic compromise and shock, temporary MCS is reasonable as a bridge to recovery or bridge to decision. (Level of Evidence: B-NR)" |
Cardiac transplantation
Cardiac transplantation remains the definitive therapy for eligible patients with end-stage heart failure refractory to GDMT, device, and surgical optimization.
2022 AHA/ACC/HFSA guideline recommendation:[1]
| Class I |
| "1. For selected patients with advanced HF despite GDMT, cardiac transplantation is indicated to improve survival and quality of life. (Level of Evidence: C-LD)" |
Key outcomes:
- Median survival of adult heart transplant recipients now exceeds 12 years.
- 1-, 3-, and 5-year survival rates for recipients transplanted between 2011 and 2013 are 90.3%, 84.7%, and 79.6%, respectively.
- Median survival of patients with stage D HF without advanced therapies is <2 years.[1]
- Treated rejection rates in the first year after transplantation are now <15%.[1]
The 2018 US donor allocation policy change prioritized critically ill patients on temporary MCS devices, resulting in decreased waitlist mortality but increased use of temporary support devices and longer graft ischemic times.
ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Dilated Cardiomyopathy (Nonischemic) (DO NOT EDIT) [16]
| Class I |
| "1. EP testing is useful to diagnose bundle-branch reentrant tachycardia and to guide ablation in patients with nonischemic DCM. (Level of Evidence: C)" |
| "2. EP testing is useful for diagnostic evaluation in patients with nonischemic DCM with sustained palpitations, wide-QRS-complex tachycardia, presyncope, or syncope. (Level of Evidence: C)" |
| "3. An ICD should be implanted in patients with nonischemic DCM and significant LV dysfunction who have sustained VT or VF, are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: A)" |
| "4. ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in SCD in patients with nonischemic DCM who have an LVEF less than or equal to 30% to 35%, are NYHA functional class II or III, who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: B) (See Section 1.2.)" |
| Class IIa |
| "1. ICD implantation can be beneficial for patients with unexplained syncope, significant LV dysfunction, and nonischemic DCM who are receiving chronic optimal medical therapy and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C)" |
| "2. ICD implantation can be effective for termination of sustained VT in patients with normal or near normal ventricular function and nonischemic DCM who are receiving chronic optimal medical therapy and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C)" |
| Class IIb |
| "1. Amiodarone may be considered for sustained VT or VF in patients with nonischemic DCM. (Level of Evidence: C)" |
| "2. Placement of an ICD might be considered in patients who have nonischemic DCM, LVEF of less than or equal to 30% to 35%, who are NYHA functional class I receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C) " |
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Heidenreich PA, Bozkurt B, Aguilar D; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (17): e263–e421. doi:10.1016/j.jacc.2021.12.012.
- ↑ Russo AM, Desai MY, Do MM; et al. (2025). "ACC/AHA/ASE/HFSA/HRS/SCAI/SCCT/SCMR 2025 Appropriate Use Criteria for Implantable Cardioverter-Defibrillators, Cardiac Resynchronization Therapy, and Pacing". J Am Coll Cardiol. 85 (11): 1213–1285. doi:10.1016/j.jacc.2024.11.023.
- ↑ 3.0 3.1 Butt JH, Doi SN, Thune JJ; et al. (2025). "Long-Term Effect of ICDs in Nonischemic Heart Failure With Reduced Ejection Fraction: Extended Follow-Up Analysis of DANISH". J Am Coll Cardiol. 86 (24): 2402–2414. doi:10.1016/j.jacc.2025.08.089.
- ↑ Chrispin J, Merchant FM, Lakdawala NK; et al. (2023). "Risk of Arrhythmic Death in Patients With Nonischemic Cardiomyopathy: JACC Review Topic of the Week". J Am Coll Cardiol. 82 (8): 735–747. doi:10.1016/j.jacc.2023.05.064.
- ↑ Könemann H, Ellermann C, Zeppenfeld K, Eckardt L (2023). "Management of Ventricular Arrhythmias Worldwide: Comparison of the Latest ESC, AHA/ACC/HRS, and CCS/CHRS Guidelines". JACC Clin Electrophysiol. 9 (5): 715–728. doi:10.1016/j.jacep.2022.12.008.
- ↑ 6.0 6.1 Knops RE, Olde Nordkamp LRA, Delnoy PHM; et al. (2020). "Subcutaneous or Transvenous Defibrillator Therapy". N Engl J Med. 383 (6): 526–536. doi:10.1056/NEJMoa1915932.
- ↑ Al-Khatib SM (2024). "Cardiac Implantable Electronic Devices". N Engl J Med. 390 (5): 442–454. doi:10.1056/NEJMra2308353.
- ↑ Olde Nordkamp LRA, de Veld JA, Ghani A; et al. (2025). "Device-Related Complications in Transvenous Versus Subcutaneous Defibrillator Therapy During Long-Term Follow-Up: The PRAETORIAN-XL Trial". Circulation. 152 (3): 172–182. doi:10.1161/CIRCULATIONAHA.125.074576.
- ↑ 9.0 9.1 Ternes CM, Kim JA, Basu A; et al. (2026). "Cardiac Resynchronization Therapy". JAMA. doi:10.1001/jama.2026.4893.
- ↑ Sudesh S, Abraham WT, Cleland JGF; et al. (2024). "Cardiac Resynchronization Therapy In Ischemic Versus Nonischemic Cardiomyopathy: Patient-Level Meta-Analysis of 7 Randomized Clinical Trials". JACC Heart Fail. 12 (11): 1915–1924. doi:10.1016/j.jchf.2024.08.010.
- ↑ 11.0 11.1 Glikson M, Burri H, Abdin A; et al. (2025). "European Society of Cardiology (ESC) Clinical Consensus Statement on Indications for Conduction System Pacing...". Europace. 27 (4): euaf050. doi:10.1093/europace/euaf050.
- ↑ 12.0 12.1 12.2 12.3 Tedford RJ, Leacche M, Lorts A; et al. (2023). "Durable Mechanical Circulatory Support: JACC Scientific Statement". J Am Coll Cardiol. 82 (14): 1464–1481. doi:10.1016/j.jacc.2023.07.019.
- ↑ Mehra MR, Goldstein DJ, Cleveland JC; et al. (2022). "Five-Year Outcomes in Patients With Fully Magnetically Levitated vs Axial-Flow Left Ventricular Assist Devices in the MOMENTUM 3 Randomized Trial". JAMA. 328 (12): 1233–1242. doi:10.1001/jama.2022.16197.
- ↑ 14.0 14.1 Varshney AS, DeFilippis EM, Cowger JA; et al. (2022). "Trends and Outcomes of Left Ventricular Assist Device Therapy: JACC Focus Seminar". J Am Coll Cardiol. 79 (11): 1092–1107. doi:10.1016/j.jacc.2022.01.017.
- ↑ 15.0 15.1 Geller BJ, Sinha SS, Kapur NK; et al. (2022). "Escalating and De-Escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association". Circulation. 146 (6): e50–e68. doi:10.1161/CIR.0000000000001076.
- ↑ Zipes DP, Camm AJ, Borggrefe M, BuxtonAE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.