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................................................................................................................ (Figure 4).376 Patients with contraindications to MCS or heart transplantation should be considered for palliative care (see section 10.2.4).

Despite many prognostic parameters (Supplementary Table 13), predicting outcomes remains difficult and patients are often referred to advanced HF centres too late. Identifying warning signs in patients with non-advanced symptoms may allow early referral so that MCS and heart transplantation may be offered before the development of end-organ failure (Figure 5; Supplementary Table 14).376,386 An organizational model between centres with different levels of care complexity, based on a ‘Hub and Spoke’ network is the key to good patient management.376

10.2 Management

In patients with advanced HF, pharmacological therapy and shortterm MCS may be needed until the implantation of long-term MCS or heart transplantation becomes available.

10.2.1 Pharmacological therapy and renal replacement Inotropes may improve haemodynamic parameters, reducing congestion, augmenting cardiac output, and aiding peripheral perfusion. Although not proven, this may help to prevent worsening end-organ function. Conversely, traditional inotropes may favor myocardial ischaemia and/or tachyarrhythmias and worsen the clinical course.387,388 They can be used as palliative therapy for the relief of symptoms in patients without other treatment options. Intermittent long-term use of inotropes may be considered in outpatients to improve functional class and QOL.389,390 Kidney dysfunction and loop diuretic resistance often characterize the clinical course of patients with advanced HF. Doubling of the loop diuretic dose is proposed, in the first instance, followed by concomitant administration of thiazides or metolazone (see section 11.3.3).145 In patients who fail to respond to diuretic-based strategies, renal replacement therapies should be considered. Ultrafiltration is one of the most common approaches. It may be considered in those with diuretic resistance even if data about its effects on outcomes are unsettled.391,392

10.2.2 Mechanical circulatory support MCS can improve survival and symptoms of patients with advanced HF.376,393 The use of MCS should be considered for the different scenarios listed in Table 15. Indications for short- and long-term MCS should be based on the INTERMACS profiles (Table 14, Figure 4).

Short-term mechanical circulatory support Short-term MCS devices are indicated to reverse critical endorgan hypoperfusion and hypoxia in the setting of cardiogenic shock. They can be used for a short, limited, period of time, from a few days up to several weeks. The aim is to support the central nervous system and organ perfusion, to reverse acidosis and multi-organ failure until the patient’s outcome becomes clearer be that of cardiac recovery, transition to durable MCS or heart transplantation, or, in some cases, towards a more palliative approach. The care of patients on short-term MCS is complex and requires dedicated expertise including having specific plans for stopping support when neither cardiac nor brain injury recovers. Short-term MCS should be used in patients with INTERMACS profiles 1 or 2 as a bridge to decision (BTD), bridge to recovery (BTR), bridge to bridge (BTB) for either long-term MCS or urgent heart transplantation (Figure 4).394 Further details about shortterm MCS are reported in the Supplementary text 11.4.

Long-term mechanical circulatory support Long-term MCS is indicated in selected patients when MT is insufficient or when short-term MCS has not led to cardiac recovery or clinical improvement, to prolong life and improve QOL, or to keep the patient alive until transplantation (bridge to transplantation, BTT) or to reverse contraindications to heart transplantation (bridge to candidacy, BTC), or as destination therapy (DT) (Table 15). Long-term MCS should be considered in patients with INTERMACS profiles 2 to 4 and also in patients with INTERMACS

Table 14 Continued

Profile Time frame for intervention Profile 7. Advanced NYHA class III symptoms Patient without current or recent episodes of unstable fluid balance, living comfortably with meaningful activity limited to mild physical exertion. Heart transplantation or MCS may not be currently

indicated.

Modifiers for profiles Possible profiles that can be modified Temporary MCS can modify profile only in hospitalized patients. They include IABP, ECMO, TandemHeart, LVAD, Impella. 1, 2, 3 Arrhythmia can modify any profile. They include recurrent ventricular tachyarrhythmias that have recently contributed substantially to clinical compromise, frequent ICD shocks or requirement for external defibrillation, usually more than twice weekly. 17 Frequent episodes of HF decompensation characterize patients requiring frequent emergency visits or hospitalizations for diuretics, ultrafiltration, or temporary i.v. vasoactive therapy. Frequent episodes may be considered as at least two emergency visits/ admissions in the past 3 months or three in the past 6 months. 3 if at home, 4, 5, 6. Rarely for profile 7. ECMO = extracorporeal membrane oxygenation; HF = heart failure; IABP = intra-aortic balloon pump; ICD = implantable cardioverter-defibrillator; INTERMACS = Interagency Registry for Mechanically Assisted Circulatory Support; i.v. = intravenous; LVAD = left ventricular assist device; MCS = mechanical circulatory support; NYHA = New York Heart Association. Modified from 381. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026