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Management of patients with advanced heart failurea

Weaning from MCS support LVAD-DT (Class IIa) List for HT or de-listing with

very close follow-up in case of meaningful improvement

(Class I)

Withdrawal of MCS support Advanced HF

therapies (HT/LVAD) can

be deferred. Very close follow-up

Contraindications

for HT

N

Cardiac, neurological and end-organ

recovered Neurological and end-organ

recovered but no cardiac

recovery

Persistence of severe brain damage and severe irreversible end-organ damage

Potentially reversible High riskb

Contraindication

reversed

LVAD-BTC (Class IIa)

Short-term MCS BTD/BTR/BTB/BTT

(Class IIa) INTERMACS >4 “Stable ambulatory” INTERMACS

3–4 INTERMACS

2 INTERMACS

1

Y

N Y

Y

Y N N

Figure 4 Algorithm for the treatment of patients with advanced heart failure. BTB = bridge to bridge; BTC= bridge to candidacy; BTD= bridge to decision; BTR= bridge to recovery; BTT= bridge to transplantation; CA= cardiac amyloidosis; DT= destination therapy; ESC= European Society of Cardiology; HCM=hypertrophic cardiomyopathy; HF= heart failure; HFA= Heart Failure Association; HT =heart transplantation; INTERMACS = Interagency Registry for Mechanically Assisted Circulatory Support; LVAD= left ventricular assist device; LVAD-BTC= left ventricular assist device  bridge to candidacy; LVAD-DT= left ventricular assist device  destination therapy; MCS= mechanical circulatory support. aThis algorithm can be applied to all patients with advanced HF defined according to the ESC/HFA criteria,376 with exception of HCM, CA, arrhythmic storm, adult congenital heart disease, refractory angina. bRecurrent hospitalization, progressive end-organ failure, refractory congestion, inability to perform cardiopulmonary exercise test or peak oxygen consumption <12 mL/min/kg or <50% of expected value.385 Colour code for classes of recommendation: Green for Class of recommendation I and Yellow for Class of recommendation IIa (see Table 1 for further details on classes of recommendation). Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026