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Table 24. Recommendations for Inotropic Support, MCS,
and Cardiac Transplantation
Recommendations COR LOE
Inotropic Support
Cardiogenic shock pending definitive therapy or resolution I C
BTT or MCS in stage D HF refractory to GDMT IIa B
Short-term support for threatened end-organ dysfunction in
hospitalized patients with stage D and severe HFrEF
IIb B
Long-term support with continuous infusion palliative therapy
in select stage D HF patients
IIb B
Routine intravenous use, either continuous or intermittent, is
potentially harmful in stage D HF
III:
Harm
B
Short-term, intravenous use in hospitalized patients without
evidence of shock or threatened end-organ performance is
potentially harmful
III:
Harm
B
MCS
MCS is beneficial in carefully selected
a
patients with
stage D HF in whom definitive management, eg, cardiac
transplantation, is anticipated or planned
IIa B
Nondurable MCS is reasonable as a "bridge to recovery" or a
"bridge to decision" for carefully selected
a
patients with stage
D HF and acute profound disease
IIa B
Durable MCS is reasonable to prolong survival for carefully
selected
a
patients with stage D HFrEF
IIa B
Cardiac Transplantation
Evaluation for cardiac transplantation is indicated for carefully
selected patients with stage D end-stage heart disease despite
GDMT, device, and surgical management
I C
a
Although optimal patient selection for MCS remains an active area of investigation, general
indications for referral for MCS therapy include patients with LVEF <25% and NYHA
class III–IV functional status despite GDMT including, when indicated, CRT, with either
high predicted 1–2-year mortality (eg, as suggested by markedly reduced peak VO
2
, clinical
prognostic scores) or dependence on continuous parenteral inotropic support. Patient selection
requires a multidisciplinary team of experienced advanced HF and transplantation cardiologists,
cardiothoracic surgeons, nurses, and, ideally, social workers and palliative care clinicians.
