Patients With Refractory End-Stage Heart Failure (Stage D)

CLASS I
(1) Meticulous identification and control of fluid retention is recommended in patients with refractory end-stage HF.

(2) Referral for cardiac transplantation in potentially eligible patients is recommended for patients with refractory end-stage HF.

(3) Referral of patients with refractory end-stage HF to a HF program with expertise in the management of refractory HF is useful.

(4) Options for end-of-life care should be discussed with the patient and family when severe symptoms in patients with refractory end-stage HF persist despite application of all recommended therapies.

(5) Patients with refractory end-stage HF and implantable defibrillators should receive information about the option to inactivate the defibrillator.

CLASS IIa
(1) Consideration of an LV assist device as permanent or “destination” therapy is reasonable in highly selected patients with refractory end-stage HF and an estimated 1-year mortality over 50% with medical therapy

CLASS IIb
(1) Pulmonary artery catheter placement may be reasonable to guide therapy in patients with refractory end-stage HF and persistently severe symptoms.

(2) The effectiveness of mitral valve repair or replacement is not well established for severe secondary mitral regurgitation in refractory end-stage HF.

(3) Continuous intravenous infusion of a positive inotropic agent may be considered for palliation of symptoms in patients with refractory end-stage HF.

CLASS III
(1) Partial left ventriculectomy is not recommended in patients with nonischemic cardiomyopathy and refractory end-stage HF.

(2) Routine intermittent infusions of vasoactive and positive inotropic agents are not recommended for patients with refractory end-stage HF.



JACC. 2009; 53; e1-e90