Crespo-Leiro Et Al-2018-European Journal of Heart Failure

European Journal of Heart Failure (2018) 20, 1505–1535 HFA POSITION STATEMENT
doi:10.1002/ejhf.1236
Advanced heart failure: a position statement

of the Heart Failure Association of the
European Society of Cardiology
Maria G. Crespo-Leiro1*, Marco Metra2, Lars H. Lund3, Davor Milicic4,
Maria Rosa Costanzo5, Gerasimos Filippatos6, Finn Gustafsson7, Steven Tsui8,
Eduardo Barge-Caballero1, Nicolaas De Jonge9, Maria Frigerio10, Righab Hamdan11,
Tal Hasin12, Martin Hülsmann13, Sanem Nalbantgil14, Luciano Potena15,
Johann Bauersachs16, Aggeliki Gkouziouta17, Arjang Ruhparwar18, Arsen D. Ristic19,
Ewa Straburzynska-Migaj20, Theresa McDonagh21, Petar Seferovic22,
and Frank Ruschitzka23
1 Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain; 2 Cardiology,
University of Brescia, Brescia, Italy; 3 Department of Medicine, Unit of Cardiology, Karolinska Institute, Stockholm, Sweden; 4 Department for Cardiovascular Diseases, University
Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia; 5 Advocate Heart Institute, Naperville, IL, USA; 6 Athens University Hospital Attikon, Athens, Greece;
7 Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; 8 Transplant Unit, Royal Papworth Hospital, Cambridge, UK; 9 Department of Cardiology, University Medical
Center Utrecht, Utrecht, The Netherlands; 10 Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy; 11 Department of Cardiology, Beirut Cardiac
Institute, Beirut, Lebanon; 12 Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel; 13 Department of Internal Medicine II, Medical University of
Vienna, Vienna, Austria; 14 Department of Cardiology, Ege University Hospital, Izmir, Turkey; 15 Heart and Lung Transplant Program, Bologna University Hospital, Bologna, Italy;
16 Department of Cardiology and Angiology, Medical School Hannover, Hannover, Germany; 17 Heart Failure and Transplant Unit, Onassis Cardiac Surgery Centre, Athens,
Greece; 18 Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; 19 Department of Cardiology of the Clinical Center of Serbia, Belgrade University
School of Medicine, Belgrade, Serbia; 20 Department of Cardiology, University of Medical Sciences, Poznań, Poland; 21 Department of Cardiology, King’s College Hospital, London,
UK; 22 Department of Internal Medicine, Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center, Belgrade, Serbia; and 23 University
Heart Center, University Hospital Zurich, Zurich, Switzerland
Received 4 May 2018; revised 17 May 2018; accepted 21 May 2018 ; online publish-ahead-of-print 17 July 2018
This article updates the Heart Failure Association of the European Society of Cardiology (ESC) 2007 classification of advanced heart
failure and describes new diagnostic and treatment options for these patients. Recognizing the patient with advanced heart failure is critical
to facilitate timely referral to advanced heart failure centres. Unplanned visits for heart failure decompensation, malignant arrhythmias,
co-morbidities, and the 2016 ESC guidelines criteria for the diagnosis of heart failure with preserved ejection fraction are included in this
updated definition. Standard treatment is, by definition, insufficient in these patients. Inotropic therapy may be used as a bridge strategy, but
it is only a palliative measure when used on its own, because of the lack of outcomes data. Major progress has occurred with short-term
mechanical circulatory support devices for immediate management of cardiogenic shock and long-term mechanical circulatory support for
either a bridge to transplantation or as destination therapy. Heart transplantation remains the treatment of choice for patients without
contraindications. Some patients will not be candidates for advanced heart failure therapies. For these patients, who are often elderly with
multiple co-morbidities, management of advanced heart failure to reduce symptoms and improve quality of life should be emphasized. Robust
evidence from prospective studies is lacking for most therapies for advanced heart failure. There is an urgent need to develop evidence-based
treatment algorithms to prolong life when possible and in accordance with patient preferences, increase life quality, and reduce the burden
of hospitalization in this vulnerable patient population.
..........................................................................................................
Keywords Heart failure • Heart transplantation • Heart-assist devices • Extracorporeal membrane
oxygenation
*Corresponding author. Heart Failure and Heart Transplant Program, Complexo Hospitalario Universitario A Coruña (CHUAC), CIBERCV, 15006 La Coruña, Spain. Tel: +34 981
178304, Fax +34 981 178299, Email: [email protected]
© 2018 The Authors

European Journal of Heart Failure © 2018 European Society of Cardiology
1506 M.G. Crespo-Leiro et al.
Introduction purpose of this document, we consider ‘advanced’, ‘refractory’,
........................................................................................................................................................................
and ‘end-stage’ heart failure interchangeable terms, all reflecting
Although patients with chronic heart failure have improved outpatients who should be evaluated for advanced heart failure ther-
comes with implementation of evidence-based therapies, ulti- apies. The Interagency Registry for Mechanically Assisted Circu-
mately, they still progress to an advanced stage of the disease. latory Support (INTERMACS) profiles are also useful to further
Patients with advanced heart failure comprise an estimated 1% to describe clinical parameters and characteristics consistent with a
10% of the overall heart failure population,1 – 3 and the prevalence need for advanced therapies (Table 2).7 – 9 However, it must be
is increasing due to the growing number of patients with heart noted that the INTERMACS profiles were developed to classify
failure and their better treatment and survival. A thorough defini- patients to being considered for long-term MCS device implan-
tion of advanced heart failure is mandatory to facilitate appropriate tation based on symptoms and haemodynamic compromise and,
application of treatment such as heart transplantation or long-term more important, is specific for heart failure with reduced ejec-
mechanical circulatory support (MCS) devices. tion fraction (HFrEF), whereas our classification and, in general,
It is often a general cardiologist who is responsible for directing the term of advanced heart failure can be applied also to patients
patients to advanced heart failure resources and helping patients with heart failure with preserved ejection fraction (HFpEF).
navigate next steps in care. Thus, clinicians need to be appropri-
ately equipped to identify patients that might be candidates for
advanced heart failure therapies and to recognize the optimal time Limitations of the 2007 Heart Failure
for referral. Of equal importance, physicians should be prepared Association position statement
to address the needs of patients who are clearly not eligible for
advanced heart failure therapies, engage in discussions about chang-
for advanced chronic heart failure
ing goals of care, and optimize management strategies to lessen the Advanced heart failure encompasses patients who remain severely
symptomatic burden of advanced heart failure and improve quality symptomatic despite optimal guideline-directed management
of life. regardless of left ventricular ejection fraction (LVEF), including
The management of patients with heart failure to improve their patients with advanced heart failure who remain ambulatory but
quality of life and longevity is a mission of the Heart Failure Asso- are essentially New York Heart Association (NYHA) class IV.
ciation (HFA) of the European Society of Cardiology (ESC). In The first HFA position statement acknowledged the importance
this context, the HFA has prepared this position document to (i) of HFpEF and included a provision to diagnose advanced heart
describe the clinical characteristics of patients with advanced heart failure on the basis of high B-type natriuretic peptide (BNP)
failure, (ii) inform physicians about markers of poor prognosis that or N-terminal pro-BNP (NT-proBNP) levels independently of
indicate an advanced stage of disease, (iii) educate physicians on LVEF values.4 Despite this recognition, advanced symptoms in
optimal short-term management strategies for these patients in the setting of HFpEF were not emphasized sufficiently to meet
order to improve their candidacy for heart transplantation or MCS, current clinical practice needs. It is important to raise awareness
(iv) enable physicians to recognize the optimal time and processes that advanced heart failure does not depend on ejection fraction,
for referring patients to advanced heart failure centres, and (v) but on the patient’s symptoms, prognostic markers, presence of
ensure collaboration between advanced heart failure, palliative or end-organ damage, and goals for therapy.
symptom-focused care including end-of-life care teams. This posi- The treatment armamentarium has improved for HFrEF since
tion statement summarizes the best available evidence, practice the 2007 HFA document, with clearer indications for cardiac resyn-
standards, and expert opinions on the management of patients with chronization therapy (CRT) and the availability of new drugs, such
advanced heart failure. This article is intended to guide general as ivabradine and sacubitril/valsartan, although to date, no trial
cardiologists, heart failure cardiologists and other professionals has specifically addressed patients with advanced heart failure. The
involved in the care of these patients such as internists, primary need to optimize such therapies should be reflected in definitions
care physicians, and nurses through transitions in care. of advanced heart failure, and patients must be treated according to
the best available medical and device therapies (unless contraindi-
cated) before advanced therapies are considered.9,10
Definition of advanced heart Further criteria must also be considered. First, outpatient vis-
its with intravenous administration of loop diuretics and/or other
failure vasoactive medications are increasingly replacing hospitalizations
Prior definitions for patients with advanced heart failure are shown for heart failure.11 Thus, both unplanned outpatient visits and hos-
in Table 1.3 – 6 The criteria suggested in the 2007 HFA position pitalizations for worsening symptoms of heart failure must be con-
statement identified a stage where conventional treatments (i.e. sidered amongst criteria for the diagnosis of advanced heart failure
guideline-directed drugs, devices, conventional surgery) are insuf- to reflect evolving clinical practice. Second, recurrent malignant
ficient to control the patient’s symptoms, and advanced thera- arrhythmias are now well recognized contributors to and can be
pies (e.g. cardiac transplantation, MCS) or palliative therapies (e.g. consequences of advanced heart failure.12 – 14 Third, co-morbidities
inotropic infusions, ultrafiltration or peritoneal dialysis to con- can complicate the evaluation of patients with advanced heart
trol volume, or end-of-life comfort care) are needed. Overlap- failure, and sometimes influence candidacy for MCS or heart
ping terminology can be used to describe these patients; for the transplantation, although it should be recognized that in some
© 2018 The Authors

Advanced heart failure: HFA position statement 1507
Table 1 Prior definitions and indicators of advanced heart failure
Heart Failure Association4 American College of Cardiology/ Heart Failure Society of America3
American Heart Association 5,6
...........................................................................................................................................
1. Severe symptoms of HF with dyspnoea 1. Repeated (≥2) hospitalizations or ED The presence of progressive and/or
and/or fatigue at rest or with minimal visits for HF in the past year persistent severe signs and symptoms of
exertion (NYHA functional class 2. Progressive deterioration in renal HF despite optimized medical, surgical,
III or IV) function (e.g. rise in BUN and and device therapy. It is generally
2. Episodes of fluid retention (pulmonary creatinine) accompanied by frequent hospitalization,
and/or systemic congestion, peripheral 3. Weight loss without other cause (e.g. severely limited exertional tolerance, and
oedema) and/or of reduced cardiac cardiac cachexia) poor quality of life and is associated with
output at rest (peripheral 4. Intolerance to ACE inhibitors due to high morbidity and mortality. Importantly,
hypoperfusion) hypotension and/or worsening renal the progressive decline should be
3. Objective evidence of severe cardiac function primarily driven by the HF syndrome.
dysfunction, shown by at least one of 5. Intolerance to beta-blockers due to Indicators of advanced HF in the setting of
the following: worsening HF or hypotension optimal medical and electrical therapies
(a) A low LVEF (<30%) 6. Frequent systolic blood pressure <90 that should trigger consideration of
(b) A severe abnormality of cardiac mmHg referral for evaluation of advanced
function on Doppler 7. Persistent dyspnoea with dressing or therapies include:
echocardiography with a bathing requiring rest
pseudonormal or restrictive 8. Inability to walk 1 block on the level • Need for intravenous inotropic therapy
mitral inflow pattern ground due to dyspnoea or fatigue for symptomatic relief or to maintain
(c) High LV filing pressures (mean 9. Recent need to escalate diuretics to end-organ function
PCWP >16 mmHg, and/or mean maintain volume status, often reaching • Peak VO2 <14 mL/kg/min or <50% of
RAP >12 mmHg by pulmonary daily furosemide equivalent dose predicted
artery catheterization) >160 mg/day and/or use of • 6MWT distance <300 m
(d) High BNP or NT-proBNP plasma supplemental metolazone therapy • ≥2 HF admissions in the last 12 months
levels, in the absence of non- 10. Progressive decline in serum sodium, • >2 unscheduled visits (e.g. ED or clinic)
cardiac causes usually to <133 mEq/L in the last 12 months
4. Severe impairment of functional capacity 11. Frequent ICD shocks • Worsening right HF and secondary
shown by one of the following: pulmonary hypertension
• Diuretic refractoriness associated with
(a) Inability to exercise
worsening renal function
(b) 6MWT distance <300 m or less in
• Circulatory–renal limitation to RAAS
females and/or patients aged ≥75
inhibition or beta-blocker therapy
years
• Progressive/persistent NYHA functional
(c) Peak VO2 <12 to 14 mL/kg/min
class III–IV symptoms
5. History of ≥1 HF hospitalization in the • Increased 1-year mortality (e.g.
past 6 months 20–25%) predicted by HF survival
6. Presence of all the previous features models (e.g. SHFS, HFSS, etc.)
despite ‘attempts to optimize’ therapy • Progressive renal or hepatic end-organ
including diuretics, inhibitors of the dysfunction
renin–angiotensin–aldosterone system, • Persistent hyponatraemia (serum
and beta-blockers, unless these are sodium <134 mEq/L)
poorly tolerated or contraindicated, and • Recurrent refractory ventricular
CRT, when indicated tachyarrhythmias; frequent ICD shocks
• Cardiac cachexia
• Inability to perform ADL
6MWT, 6-minute walk test; ACE, angiotensin-converting enzyme; ADL, activities of daily living; BNP, B-type natriuretic peptide; BUN, blood urea nitrogen; CRT, cardiac
resynchronization therapy; ED, emergency department; HF, heart failure; HFSS, Heart Failure Survival Score; ICD, implantable cardioverter-defibrillator; LV, left ventricular;
LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; PCWP, pulmonary capillary wedge
pressure; RAAS, renin–angiotensin–aldosterone system; RAP, right atrial pressure; SHFS, Seattle Heart Failure Score; VO2 , oxygen consumption.
© 2018 The Authors

Table 2 Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile descriptions in
patients with advanced heart failure
Profile Time frame for intervention

...........................................................................................................................................
Profile 1: Critical cardiogenic shock Definitive intervention needed within hours.
Patient with life-threatening hypotension despite rapidly escalating inotropic support, critical
organ hypoperfusion, often confirmed by worsening acidosis and/or lactate levels. “Crash
and burn.”
Profile 2: Progressive decline Definitive intervention needed within few
Patient with declining function despite intravenous inotropic support, may be manifest by days.
worsening renal function, nutritional depletion, inability to restore volume balance.
“Sliding on inotropes.” Also describes declining status in patients unable to tolerate
inotropic therapy.
Profile 3: Stable but inotrope-dependent Definitive intervention elective over a
Patient with stable blood pressure, organ function, nutrition, and symptoms on continuous period of weeks to few months.
intravenous inotropic support (or a temporary circulatory support device or both), but
demonstrating repeated failure to wean from support due to recurrent symptomatic
hypotension or renal dysfunction. “Dependent stability.”
Profile 4: Resting symptoms Definitive intervention elective over a
Patient can be stabilized close to normal volume status but experiences daily symptoms of period of weeks to few months.
congestion at rest or during ADL. Doses of diuretics generally fluctuate at very high levels.
More intensive management and surveillance strategies should be considered, which may
in some cases reveal poor compliance that would compromise outcomes with any therapy.
Some patients may shuttle between 4 and 5.
Profile 5: Exertion intolerant Variable urgency, depends upon maintenance
Comfortable at rest and with ADL but unable to engage in any other activity, living of nutrition, organ function, and activity.
predominantly within the house. Patients are comfortable at rest without congestive
symptoms, but may have underlying refractory elevated volume status, often with renal
dysfunction. If underlying nutritional status and organ function are marginal, patients may
be more at risk than INTERMACS 4, and require definitive intervention.
Profile 6: Exertion limited Variable, depends upon maintenance of
Patient without evidence of fluid overload is comfortable at rest, and with ADL and minor nutrition, organ function, and activity
activities outside the home but fatigues after the first few minutes of any meaningful level.
activity. Attribution to cardiac limitation requires careful measurement of peak oxygen
consumption, in some cases with haemodynamic monitoring to confirm severity of cardiac
impairment. “Walking wounded.”
Profile 7: Advanced NYHA class III Transplantation or circulatory support may
A placeholder for more precise specification in future, this level includes patients who are not currently be indicated.
without current or recent episodes of unstable fluid balance, living comfortably with
meaningful activity limited to mild physical exertion.
...........................................................................................................................................
Modifiers for profiles Possible profiles to modify
...........................................................................................................................................
TCS-Temporary Circulatory Support can modify only patients in hospital (other devices 1, 2, 3 in hospital.
would be INTERMACS devices). This includes IABP, ECMO, TandemHeart, Levitronix,
BVS 5000 or AB5000, Impella.
A-Arrhythmia can modify any profile. Recurrent ventricular tachyarrhythmias that have Any profile.
recently contributed substantially to clinical compromise. This includes frequent ICD
shocks or requirement for external defibrillator, usually more than twice weekly.
FF-Frequent Flyer can modify only outpatients, designating a patient requiring frequent 3 if at home, 4, 5, 6. A Frequent Flyer would
emergency visits or hospitalizations for diuretics, ultrafiltration, or temporary intravenous rarely be profile 7.
vasoactive therapy.
ADL, activities of daily living; ECMO, extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump; ICD, implantable cardioverter-defibrillator; NYHA, New York
Heart Association.
Reprinted with permission from Stevenson et al.8
© 2018 The Authors

cases co-morbidities may improve after application of advanced team in arriving at comprehensive risk assessments to inform
........................................................................................................................................................................
therapies.15 – 18 End-organ damage, in particular kidney or liver dys- decisions.9 However, there are several important considerations
function and pulmonary hypertension, may be a consequence of and limitations that are often overlooked when applying these tools
acute congestion and/or low-output state, but it may be difficult in clinical settings and in clinical trial design.
to distinguish primary and secondary dysfunction or to predict First, many prognostic tools were derived and validated in
reversibility. selected clinical trial populations or at single centres and may
not be generalizable to ‘real-world’ heart failure populations or
individual patients. Second, most of the available tools for esti-
Updated definition of advanced heart mating prognosis were not derived from advanced heart failure
failure cohorts. Third, risk markers and scores perform well for mortality
To address these areas, an update to the definition of advanced but less well for cardiovascular or heart failure specific death
heart failure is warranted. Our updated criteria for the identi- or hospitalization.9,26 – 28 Fourth, not all risk markers are also
fication of patients with advanced heart failure are outlined in risk factors. Thus, targeting a risk marker will not automatically
Table 3. Compared with the former HFA definition of advanced improve outcomes. One example includes pharmacologic inter-
heart failure, we have updated the following criteria: ventions targeting haemodynamics, which do not correct the
underlying aetiology of heart failure and do not improve outcome,
although an impaired haemodynamic profile is a very powerful
• Criterion 2 is now based completely on the most recent
indicator of poor prognosis. Finally, appropriate clinical use of any
ESC heart failure guidelines.9 The ESC criteria are sufficient
prognostic variable (biomarker) or multiparametric score requires
to define cardiac dysfunction, and they can be used for the
understanding of discrimination (between event and non-event),
definition of advanced heart failure when accompanied by
calibration (predicted vs. actual outcome), and reclassification
other criteria that characterize patient severity. Using the ESC
(how well addition of information correctly reclassifies events).24
criteria for cardiac dysfunction gives the same importance to
For example, NT-proBNP discriminates very well (i.e. higher val-
all patients with heart failure, independent of LVEF. With a few
ues accurately predict greater heart failure risk), but it calibrates
exceptions, such as patients with hypertrophic cardiomyopathy
poorly because there is no particular value of NT-proBNP that
or restrictive cardiomyopathy,19 the vast majority of patients
corresponds to a particular expected mortality rate or that can be
with an indication for heart transplantation or MCS have a
used to list a patient for cardiac transplantation. Finally, it must be
reduced LVEF. However, at least 50% of patients hospitalized
kept in mind that different prognostic scores may perform more
for acute heart failure have a preserved LVEF, and these patients
or less equally in patient cohorts, while providing very different
may also be considered advanced provided the other criteria
prognostic estimates when applied to individuals.29
outlined in the definition are present.
Nevertheless, objective risk markers and scores, especially as
• Criterion 3 now includes heart failure hospitalization.
part of a comprehensive assessment performed by the heart fail-
Unplanned visits for heart failure have been added and
ure team, are useful for prognostication, prioritization, and triage
given the same value as a heart failure hospitalization.20 – 23
for advanced heart failure interventions, including selection for car-
Malignant arrhythmias have been added as a major cause of
diac transplantation.25 It is useful to consider risk markers from
acute events. Criterion 3 acknowledges that acute events
multiple pathophysiological domains (Table 4).8,25,27,28,30 – 127 Clini-
leading to one or more unplanned visit(s) or hospitalization(s)
cal history such as recurrent heart failure hospitalizations, and the
within 12 months are the hallmark of advanced heart fail-
physician’s impression from the patient encounter are critical. An
ure, independent of treatment, with emphasis placed on the
expanding spectrum of parameters are available from echocardio-
instability of the clinical course and resource utilization.
graphy and other imaging modalities, and they may serve not only
for prognostication but also to guide patient management, grad-
ually taking the place of right heart catheterization, though with
some limitations.128,129 Invasive haemodynamic assessment does
Prognostic stratification not improve the accuracy of heart failure prognostication, but it is a
Accurate prognostication is especially important in advanced heart critical component of the work-up for potential heart transplanta-
failure to identify the ideal time for referral to an appropriate tion or long-term MCS recipients. It allows an accurate estimate of
centre (i.e. those centres capable of providing advanced heart important parameters, such as the pulmonary capillary wedge pres-
failure therapies), to properly convey expectations to patients sure, pulmonary vascular resistance, transpulmonary gradient, and
and families, and to plan treatment and follow-up strategies.24,25 adds to the assessment of right ventricular function.25,130,131 Inva-
However, detailed prognostication is complex and difficult. It is sive haemodynamic monitoring is not routinely recommended for
required for selection for advanced heart failure therapy, but it in-hospital management of patients with advanced heart failure,132
is not required for referral to an advanced heart failure centre. but it is useful for the evaluation and treatment of patients in crit-
Referral requires only the presence of advanced heart failure. ical conditions, e.g. cardiogenic shock, not responding to standard
Numerous single risk markers and composite risk scores have treatment. The cardiopulmonary exercise test (CPET) provides a
been derived, validated, and are available as interactive online set of integrated parameters that are impacted by cardiac, pul-
tools. These multiparametric scores can assist the heart failure monary, peripheral and psychological factors, and it is a critical
© 2018 The Authors

Table 3 Updated HFA-ESC criteria for defining advanced heart failure
All the following criteria must be present despite optimal guideline-directed treatment:
1. Severe and persistent symptoms of heart failure [NYHA class III (advanced) or IV].
2. Severe cardiac dysfunction defined by a reduced LVEF ≤30%, isolated RV failure (e.g. ARVC) or non-operable severe valve
abnormalities or congenital abnormalities or persistently high (or increasing) BNP or NT-proBNP values and data of severe
diastolic dysfunction or LV structural abnormalities according to the ESC definition of HFpEF and HFmrEF.9
3. Episodes of pulmonary or systemic congestion requiring high-dose intravenous diuretics (or diuretic combinations) or episodes
of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing >1 unplanned visit or hospitalization in
the last 12 months.
4. Severe impairment of exercise capacity with inability to exercise or low 6MWTD (<300 m) or pVO2 (<12–14 mL/kg/min),
estimated to be of cardiac origin.
In addition to the above, extra-cardiac organ dysfunction due to heart failure (e.g. cardiac cachexia, liver, or kidney dysfunction) or
type 2 pulmonary hypertension may be present, but are not required.
Criteria 1 and 4 can be met in patients who have cardiac dysfunction (as described in criterion #2), but who also have substantial
limitation due to other conditions (e.g. severe pulmonary disease, non-cardiac cirrhosis, or most commonly by renal disease with
mixed aetiology). These patients still have limited quality of life and survival due to advanced disease and warrant the same intensity
of evaluation as someone in whom the only disease is cardiac, but the therapeutic options for these patients are usually more
limited.
ARVC, arrhythmogenic right ventricular cardiomyopathy; BNP, B-type natriuretic peptide; ESC, European Society of Cardiology; HFA, Heart Failure Association; HFmrEF,
heart failure with mid-range ejection fraction; HFpEF, heart failure with preserved ejection fraction; LV, left ventricular; LVEF, left ventricular ejection fraction; NT-proBNP,
N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; pVO2 , peak exercise oxygen consumption; RV, right ventricular; 6MWTD, 6-minute walk test
distance.
component of the work-up in patients with advanced heart failure indication for left ventricular assist device (LVAD) in patients with
............................................................................................
who are able to perform the test. Co-morbidities are common and advanced heart failure.110,137,138 Therefore, this risk score should
important prognostic markers in heart failure. In selecting advanced be used cautiously in the setting of advanced heart failure.
heart failure interventions, physicians should consider both prog- Although there are no validated studies that indicate which
nosis without therapy (indication) and the potential for adverse variables and cut-offs can be used as criteria for referral to
outcomes with interventions (contraindications). Contraindica- advanced heart failure centres, the totality of data on heart failure
tions are often related to co-morbidities that cannot be modified by prognostication allows for some suggested clinical, laboratory, and
heart failure therapy and predispose patients to adverse outcomes echocardiography criteria that may serve as triggers for referral.
after heart transplantation or MCS. End-organ dysfunction such as These are listed in Table 6.
chronic kidney disease (CKD) may be intrinsic or secondary to Finally, non-patient-related factors, such as organization of care
heart failure. Liver dysfunction in the setting of advanced heart fail- and access to treatment and follow-up, are also strongly associated
ure has been less extensively investigated than renal insufficiency. with outcomes. Despite the availability of an extensive set of
The most common indices of acute and chronic liver damage due prognostic parameters, predicting outcomes both in the absence
to congestive and/or low-output state are increased transaminase and presence of advanced heart failure interventions remains
levels (AST, ALT) and increased serum bilirubin, respectively.16 difficult, and patients are often referred to advanced heart failure
End-organ damage impacts outcomes, and it is important for the centres too late. The concept of active screening for advanced
heart failure team to assess whether such damage is likely reversible intervention has been proposed to improve appropriate referral
after transplantation or MCS. Other co-morbidities, such as dis- and treatment in advanced heart failure139,140 (Figure 1).
ordered iron metabolism, must be systematically investigated9 as
treatment may improve quality of life and symptoms.9
No single variable can account for all prognostic dimensions. Exercise testing
Multivariable prognostic scores outperform individual markers Cardiopulmonary exercise testing is reproducible and provides
both in terms of discrimination and calibration. Numerous scores important information about cardiovascular reserve and progno-
have been derived and validated for both acute heart failure sis. Traditionally, CPET has been part of the evaluation of ambula-
and outpatients. Selected prognostic scores for advanced but tory patients with advanced heart failure if they were considered
non-hospitalized heart failure include the Heart Failure Survival for heart transplantation or long-term MCS. Guidelines for list-
Score (HFSS),133 the Seattle Heart Failure Model (SHFM),109 the ing elective patients for heart transplantation still state that a
Metabolic Exercise test data combined with Cardiac and Kid- peak exercise oxygen consumption (pVO2 ) ≤12 mL/kg/min is a
ney Indexes (MECKI) score,134 – 136 and the Meta-Analysis Global potential indication for heart transplantation (≤14 if beta-blocker
Group in Chronic Heart Failure (MAGGIC)105 (Table 5). The SHFM intolerant).25 Importantly, confirmation that peak values have been
has been shown to underestimate the risk of decompensation and achieved is mandatory, for instance by ensuring a respiratory
© 2018 The Authors

........................................................................................................................................................................
Table 4 Risk markers in patients with advanced heart Table 4 Continued.
failure
Other imaging
General clinical Pulmonary congestion by lung ultrasound85
Age30 Inflammation and fibrosis on CMR
Male sex31 Poor viability on stress echo and CMR84
↑ QRS duration32,33 Reduced miBG uptake86,87
Longer HF duration30 Cardiopulmonary exercise test
Higher NYHA class34 – 37 pVO2 59,88
Lower and labile SBP and lower DBP and MAP30,38 – 40 6-min walk test127
Lower pulse pressure41 VE /VCO2 slope25,64
↑ HR in sinus rhythm but not in atrial fibrillation30,42 – 44 Co-morbidity
Reduced HR variability45 – 47 Cardiovascular
Recent /recurrent HF hospitalizations30 Ischaemic heart disease/prior myocardial infarction30
Haemodynamic profiles48,49 Prior transient ischaemic attack/stroke
Cardiomegaly30
Peripheral arterial disease
S350
Atrial fibrillation30
Poor quality of life
Ventricular arrhythmia, sudden cardiac death, ICD shocks
Reduced peripheral muscle strength120
Non-cardiovascular
Rales30
Chronic kidney disease89,90
Oedema30
Diabetes30
JVD50
Chronic obstructive pulmonary disease
Hepatomegaly
Smoking30
Ascites
Laboratory and biomarkers121 Anaemia91
Copeptin51,122,123 Higher red cell distribution width92
Low sodium52 Higher white blood cell count93
Cardiomyocyte injury Iron deficiency
Troponin53 – 57 Liver dysfunction and low albumin94,95
Cardiomyocyte stress Sleep apnoea and Cheyne–Stokes breathing
Higher BNP and/or NT-proBNP56,58 – 62 Depression96 – 98
Increased NT-proBNP over time53,63 Frailty99
ANP64 Cachexia30,100,101
MR-proANP62,124 Cognitive dysfunction102
Inflammation Diuretic resistance
CRP65,66 Composite scores27,28
ESR67 Simplified variables103
Oxidative stress and fibrosis INTERMACS8,104
ST256 MAGGIC105,106
Galectin-3125 BIOSTAT-CHF107
GDF-15126 BCN Bio-HF108
MR-proADM68 SHFM109,110
Lower LDL HFSS111 – 117
Uric acid69 UCLA score118
Low T370 Treatment and organization-related factors
Albuminuria71 Poor guideline adherence119
Imaging
Echocardiography ANP, atrial natriuretic peptide; BCN Bio-HF, Barcelona Bio-Heart Failure;
Lower LVEF72 – 74 BIOSTAT-CHF, A Systems Biology Study to Tailored Treatment in Chronic Heart
Failure; BNP, B-type natriuretic peptide; CMR, cardiac magnetic resonance; CRP,
Large areas of hypo/akinesis
C-reactive protein; DBP, diastolic blood pressure; ESR, erythrocyte sedimenta-
LV dilatation74 tion rate; GDF-15, growth differentiation factor 15; HF, heart failure; HFSS, Heart
Diastolic dysfunction75,76 Failure Survival Score; HR, heart rate; ICD, implantable cardioverter-defibrillator;
Mitral regurgitation30 INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Sup-
Aortic stenosis port; JVD, jugular venous distention; LDL, low-density lipoprotein; LV, left ven-
tricular; LVEF, left ventricular ejection fraction; MAGGIC, Meta-Analysis Global
LV hypertrophy72,77
Group in Chronic Heart Failure; miBG, metaiodobenzylguanidine; MAP, mean
LV mass72 arterial pressure; MR-proADM, mid-regional pro-adrenomedullin; MR-proANP,
Left atrial enlargement72,78,79 mid-regional pro-atrial natriuretic peptide; NT-proBNP, N-terminal pro-B-type
Right ventricular function80,81 natriuretic peptide; NYHA, New York Heart Association; pVO2 , peak exercise
Pulmonary hypertension80,82 oxygen consumption; SHFM, Seattle Heart Failure Model; SBP, systolic blood
pressure; UCLA, University of California, Los Angeles; VE /VCO2 , minute
Resting dobutamine stress strain83,84 ventilation–carbon dioxide production relationship.
© 2018 The Authors

Table 5 Prognostic scores
Score Components Comments

...........................................................................................................................................
HFSS133 • Presence/absence coronary artery disease Score is based on a sum of these variables multiplied by
• Resting heart rate defined coefficients
• Left ventricular ejection fraction
• Mean arterial blood pressure Low risk: ≥8.1
• Presence/absence of intraventricular conduction Medium-risk: HFSS 7.20 to 8.09
delay High-risk: HFSS ≤7.1
• Serum sodium
• Peak oxygen uptake
HFSS = [(0.0216 * resting HR) + (–0.0255 * mean BP)
+ (–0.0464 * LVEF) + (–0.047 * serum sodium) +
(–0.0546 * peak VO2 ) + (0.608 * presence or
absence of IVCD) + (0.6931 * presence or absence
of ischaemic heart disease)]
SHFM109 • Demographics Incorporates impact of interventions (medical and

• Clinical characteristics device) and provides estimates of 1, 2, and 5-year
• Medications survival
• Laboratory data
• Devices
www.seattleheartfailuremodel.org
MECKI134 – 136 • Percent predicted peak VO2 Incorporates data from the CPET as well as kidney
• VE /VCO2 slope function
• Haemoglobin
• Serum sodium
• LVEF
• eGFR by MDRD
MAGGIC105 • Age Risk model converted into integer score

• Gender Generalizable to a broad spectrum of patients
• LVEF
• Systolic blood pressure
• Body mass index
• Serum creatinine
• NYHA class
• Smoking history
• Co-morbidities (e.g. diabetes, COPD)
• Length of heart failure diagnosis
• Medications
www.heartfailurerisk.org
BP, blood pressure; COPD, chronic obstructive pulmonary disease; CPET, cardiopulmonary exercise test; eGFR, estimated glomerular filtration rate; HFSS, Heart Failure
Survival Score; HR, heart rate; IVCD, intraventricular conduction defect; LVEF, left ventricular ejection fraction; MAGGIC, Meta-Analysis Global Group in Chronic Heart
Failure; MDRD, Modification of Diet in Renal Disease; MECKI, Metabolic Exercise test data combined with Cardiac and Kidney Indexes; NYHA, New York Heart Association;
SHFM, Seattle Heart Failure Model; VE /VCO2 , minute ventilation–carbon dioxide production relationship; VO2 , oxygen consumption.
exchange rate >1.05. In addition to pVO2 , other CPET findings remains highly valuable to identify patients with potential indica-
.............................
may help inform the evaluation of heart transplantation candi- tions for heart transplantation or long-term MCS and should be
dacy. In women or patients <50 years of age, achieving a pVO2 part of the work-up for elective patients with advanced heart fail-
≤50% of predicted may be appropriate to determine heart trans- ure in whom these treatments are considered, particularly in those
plant referral.25 Additionally, patients with a ventilation equivalent patients reporting a disproportion between symptoms and objec-
of carbon dioxide (VE /VCO2 ) slope >35, particularly those with a tive parameters.142
submaximal CPET, have a poor prognosis, and VE /VCO2 slope may The 6-min walk test (6MWT) is easy to perform and widely
be applied in the patient evaluation.25 Performing high quality CPET used in heart failure. It should be emphasized that CPET and
is not a simple task and reliable results require staff skilled in the 6MWT are very different measures. Peak oxygen uptake during
procedure as well as meticulous interpretation.141 However, CPET CPET expresses maximal cardiac output and the arteriovenous
© 2018 The Authors

Table 6 Suggested clinical, laboratory, and echocardiographic criteria to trigger referral*
Clinical Laboratory Imaging Risk score data

...........................................................................................................................................
• >1 HF hospitalization in • eGFR <45 mL/min • LVEF ≤30% • MAGGIC predicted
last year • SCr ≥160 mmol/L • Large area of akinesis/dyskinesis survival ≤80% at 1 year
• NYHA class III–IV • K >5.2 or <3.5 mmol/L or aneurysm • SHFM predicted survival
• Intolerant of optimal • Hyponatraemia • Moderate†-severe mitral ≤80% at 1 year
dose of any GDMT HF • Hb ≤120 g/L regurgitation
drug • NT-proBNP ≥1000 pg/mL • RV dysfunction
• Increasing diuretic • Abnormal liver function • PA pressure ≥50 mmHg
requirement test • Moderate-severe tricuspid
• SBP ≤90 mmHg • Low albumin regurgitation
• Inability to perform CPET • Difficult to grade aortic stenosis
• 6MWT • IVC dilated or without
• CRT non-responder respiratory variation
clinically
• Cachexia, unintentional
weight loss
• KCCQ
• MLHFQ
6MWT, 6-min walk test; CPET, cardiopulmonary exercise test; CRT, cardiac resynchronization therapy; eGFR, estimated glomerular filtration rate; GDMT, guideline-directed
medical therapy; Hb, haemoglobin; HF, heart failure; IVC, inferior vena cava; K, potassium; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVEF, left ventricular ejection
fraction; MAGGIC, Meta-Analysis Global Group in Chronic Heart Failure; MLHFQ, Minnesota Living with Heart Failure Questionnaire; Na, sodium; NT-proBNP, N-terminal
pro-B-type natriuretic peptide; NYHA, New York Heart Association; PA, pulmonary artery; RV, right ventricular; SBP, blood pressure; SCr, serum creatinine; SHFM, Seattle
Heart Failure Model.
* Note that this table reflects many clinically relevant but sometimes subjective and non-specific criteria. With these criteria, sensitivity has been prioritized over specificity,
i.e. many criteria may be present in patients who do not need referral, but by considering these criteria in a comprehensive assessment, there is a lower risk that high-risk
patients may be missed or referred too late. While cut-offs exist for transplantation listing or left ventricular assist device implantation, there are no data to support specific
cut-offs for referral to a HF centre.
† Moderate mitral regurgitation alone is not sufficient, but is one factor suggesting risk of progression and should be considered together with other variables.
oxygen difference during maximal exhaustion, while the 6MWT short-term therapies may be needed until MCS can be implanted
.............................................................................
is performed at submaximal exercise levels. Thus, the 6MWT or while the patient is waiting on the transplant list. Discussion
does not accurately reflect functional capacity as assessed by of the patient and overall plan for advanced heart failure therapies
pVO2 ,127 but it is correlated to pVO2 and predicts survival in with a specialized advanced heart failure centre (i.e. hub centre) can
heart failure in some,127 but not all studies.143 – 145 The 6MWT has be helpful to select the most appropriate short-term management
been used as a screening tool in advanced heart failure (<300 m) strategy.
and also as an endpoint in clinical trials. Use of the 6MWT is
encouraged to give objective evidence of functional impairment in
Intravenous vasoactive drugs
patients with advanced heart failure where CPET is not indicated
as described above. In addition, the 6MWT can be a useful It is well known that inotropes may improve haemodynamics
tool to assess frailty, which represents a significant risk marker and help reverse worsening end-organ function in advanced heart
and potential contraindication to non-pharmacologic strategies in failure (Table 7). However, inotropes studied in randomized clinical
advanced heart failure.99,146 trials have generally not been associated with improved outcomes,
and have, in some studies, worsened prognosis.147 – 149 Hence,
inotropes have no place in the routine treatment of advanced
heart failure. However, there is expert opinion that inotropic
Management strategies support may be necessary in refractory heart failure in selected
for patients with advanced heart patients as a bridge to temporary MCS, long-term MCS, or heart
transplantation. Inotropes may also be used as short-term therapy
failure in patients with low cardiac output and evidence of end-organ
dysfunction, for instance during decongestion. Long-term (i.e.
Short-term management of advanced
months) or chronic treatment after discharge with inotropes for
heart failure patients waiting for transplantation, is not routinely recommended.
Advanced heart failure therapies refer to long-term MCS or cardiac These patients should probably be considered for long-term MCS
transplantation. However, in situations where the patient’s clinical if feasible.150,151 However, patient preferences regarding inotropic
condition deteriorates, or end-organ function is compromised, therapy or MCS for patients awaiting transplantation should be
© 2018 The Authors

Age <75*
Co-morbidity causing YES

life expectancy <1 year**
NO
Advanced HF despite NYHA class II

optimal guideline
directed management
(including CRT/ICD if
indicated)
Any of these characteristics:
• Prior inotrope use
• LVEF <20%
• Intolerant of beta-blocker or RAS inhibitor/ARNI
• Hyponatraemia
• > 1 admission or unplanned visit to HF
clinic for HF in last 12 months
• SBP <90 mmHg
• Worsening renal function or SCr > 160 μmol/L
• Worsening liver function due to HF
• Haemoglobin <12 g/L
• Ventricular arrhythmias/ICD shocks
• Persistent congestions/need for escalating diuretic doses
YES NO
Manage in local HF service

Refer to or discuss with
advanced HF center
*>75 years if good functional status apart from HF (mono-organ disease) Re-evaluation in 3-6 months
**e.g. untreatable cancer, dementia, severe COPD
Figure 1 Triage of patients with advanced heart failure (HF) and appropriate timing of referral. ARNI, angiotensin receptor–neprilysin
inhibitor; COPD, chronic obstructive pulmonary disease; CRT, cardiac resynchronization therapy; ICD, implantable cardioverter-defibrillator;
LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; RAS, renin–angiotensin system; SBP, systolic blood pressure;
SCr, serum creatinine.
assessed. Continuous inotropes may be acceptable as a palliative Intermittent use of inodilators for long-term symptomatic
......................................
measure for patients without other advanced treatment options. improvement or palliation has gained popularity, especially use
Vasopressors (dopamine, norepinephrine, epinephrine) are of levosimendan, since the haemodynamic effect may last for >7
broadly associated with worse outcomes in observational days after a 12–24 h infusion because of the pharmacologically
studies,152 and low-dose dopamine does not improve conges- active metabolite with a long half-life.155 While meta-analyses of
tion or cardiovascular outcomes compared to placebo in acute several heterogeneous small trials of a repeated infusion strat-
decompensated heart failure.153,154 Hence, these agents should egy have suggested a positive effect on survival156 and a reduc-
be reserved for patients with low systolic blood pressure and tion in hospitalizations,157 such a survival effect has not been
evidence of organ hypoperfusion (cardiogenic shock) at the demonstrated in a single, adequately sized, prospective study. The
lowest dose that obtains the desired clinical goals, and only if LION-HEART pilot study randomized 69 patients with advanced
the low blood pressure is considered a reversible condition heart failure to placebo or levosimendan 0.2 μg/kg/min over 6 h
or definitive therapy (long-term MCS or transplantation) is every 2 weeks for 12 weeks.158 NT-proBNP over time, the
planned. primary endpoint, was significantly lower in the levosimendan
© 2018 The Authors

Table 7 Inotropes and vasoconstrictors
Mechanism of action Haemodynamic effect Comment

...........................................................................................................................................
Inodilators
Dobutamine Beta-1 activation, slight beta-2 CO ↑, SVR ↓ Half-life minutes
vasodilatation
Milrinone PDE2 inhibition CO ↑, SVR ↓ Half-life 2 h
Levosimendan Calcium sensitization CO ↑, SVR ↓ Half-life (metabolite) days
Inotropes/vasoconstrictors
Dopamine Beta-1, alpha-adrenergic, and CO ↑, SVR ↑ 2–10 μg/kg/min: beta-1
dopaminergic activation >10 μg/kg/min: alpha, beta-1
Adrenaline Beta-1, alpha-adrenergic, CO ↑, SVR ↑
moderate beta-2 activation
Vasoconstrictors
Norepinephrine Beta-1, alpha activation SVR ↑, CO ↔/↓
Vasopressin V1 and V2 activation SVR ↑, CO ↔/↓
CO, cardiac output; PDE2, phosphodiesterase-2; SVR, systemic vascular resistance.
group compared to the placebo group. Patients randomized to ............................................................................................................ (‘braking phenomenon’) including hypertrophy and hyperfunction
levosimendan were also less likely to be hospitalized for heart of other sites of the nephron and to increased renin secretion in
failure or experience a decline in health-related quality of life com- the macula densa. Increased uremic anions and proteinuria also
pared to placebo. Adverse events were similar between groups.158 impair achievement of therapeutic concentrations at the diuretic’s
More studies are needed to determine if this approach may be tubular site of action.161
useful for patients with contraindications to transplantation or Concomitant administration of thiazide diuretics or metolazone
long-term MCS. with loop diuretics is used to overcome the braking phenomenon.
Whether or not to implant an implantable cardioverter- However, no evidence from clinical trials exists to guide this prac-
defibrillator (ICD) in patients listed for heart transplantation is tice. Ultrafiltration (UF) might be an alternative to loop diuretic
still a matter of debate. This decision is usually made on an indi- administration. It removes isotonic fluid without direct activation of
vidualized basis, balancing the expected risks of sudden death and the renin–angiotensin–aldosterone system, if fluid removal rates
device-related complications, and considering the expected wait- do not exceed capillary refill. Greater access to UF stems from the
ing time for transplantation. In the absence of randomized trials, development of simplified devices not requiring specialized techni-
the best evidence regarding this controversial topic comes from a cians or acute care settings.162
Swiss observational study,159 in which a significant survival benefit The adjustment of UF rates to patients’ vital signs and renal
was observed for ICD carriers, both as primary or secondary function may provide more effective decongestion and fewer heart
prevention, with a median waiting list time for transplantation failure events than standard of care.161 The results of UF studies
of only 8 months. In recent years, wearable defibrillators have are summarized in the online supplementary Table S1.
emerged as a potential effective and less invasive alternative to Practice guidelines suggest that patients with an inadequate
conventional implantable devices for this purpose.160 response to oral diuretic treatment should receive intravenous
diuretics starting with an intravenous dose greater than that of
the oral treatment. The initial dose of the intravenous treatment
Management of congestion should be increased in case of an inadequate response.6,9 Persistent
Most of the heart failure hospitalizations are due to signs and congestion can then be treated by adding thiazide, or thiazide-like,
symptoms of fluid overload.161 Recurrent congestion worsens diuretic agents, aldosterone antagonists. Only if these measures
patients’ outcomes. Loop diuretics remain the cornerstone for the fail can UF be considered.6,9 However, favourable results of trials
treatment of congestion in the patients with heart failure. Diuretic of early UF underscore the need for additional investigation of
therapy is thoroughly described in the current guidelines for heart UF in clinical settings as an alternative to high-dose diuretic
failure treatment and their further discussion goes beyond the aims treatment.163,164
of this article. The clinical course of patients with advanced heart Once an initial UF rate is chosen, it should be either main-
failure is often characterized by kidney dysfunction (cardiorenal tained or reduced because capillary refill from the interstitium
syndrome) and by diuretic resistance. The first may have multiple decreases as fluid is removed.165 Rates of UF >250 mL/h are
mechanisms including abnormal haemodynamics, neurohormonal not recommended.164 Patients with right-sided heart failure or
activation, excessive tubular sodium reabsorption, inflammation, HFpEF are susceptible to intravascular volume depletion and may
oxidative stress, and nephrotoxic drugs.161 Loop diuretic resistance only tolerate low UF rates (50 to 100 mL/h).164 Extracorporeal
is generally due to a series of renal adaptations after diuretic use fluid removal is better tolerated when conducted with low UF
© 2018 The Authors

rates delivered over several hours. Patients’ current weight can be enhance sodium removal by peritoneal dialysis.172 Future studies
........................................................................................................................................................................
compared with that preceding the signs and symptoms of conges- should determine if peritoneal dialysis is associated with improved
tion and used as the target for fluid removal.164 Inline haematocrit survival.
sensors permit continuous estimation of blood volume changes
during UF and can be programmed to stop fluid removal if the
Short-term mechanical circulatory support
haematocrit exceeds a set threshold (e.g. 5% to 7%) and resume
therapy when the haematocrit value falls below the pre-specified Among patients with advanced heart failure, short-term MCS
level, indicating an adequate intravascular volume. Bioimpedance may be indicated in the setting of cardiogenic shock. Several
vector analysis, bioimpedance spectroscopy, electromagnetic tech- percutaneous and paracorporeal devices are available which can be
nology and pulmonary artery pressure sensors all have limitations used for a few days, up to several weeks, to allow cardiac recovery
for estimation of blood volume and more research in this area as well as recovery of other organs such as the kidneys, liver, and
is needed.161 brain. Although insertion of most short-term devices is relatively
The Peripheral Ultrafiltration for the Relief from Congestion simple and straightforward, the care of patients on short-term
in Heart Failure (PURE-HF) trial (NCT03161158) will evalu- MCS requires specific expertise which should also include a plan
ate whether peripheral UF combined with low-dose intravenous when cardiac recovery does not occur after a period of support.
diuretics result in fewer heart failure events and cardiovascular In this way, short-term MCS can be used as a bridge-to-decision
deaths at 90 days compared to guideline-directed therapy including (BTD) for long-term MCS or heart transplantation.173 As there
intravenous diuretics in patients with heart failure hospitalized for is no single ideal device, their use should be primarily guided by
congestion. clinical judgment and local experience.174
Peritoneal dialysis is a home-based therapeutic modality than
can be used in patients with refractory heart failure, cardiorenal Intra-aortic balloon pump
syndrome and fluid overload. The peritoneum is used as the filter An intra-aortic balloon pump (IABP) consists of a percutaneously
through which solute molecules can be exchanged between the implanted catheter with a balloon inflated with gas (usually helium,
dialysate (delivered to the peritoneal cavity through a catheter) and a low-density gas) that is positioned in the aorta between the
the blood.166 With peritoneal dialysis, removal of sodium and water left subclavian artery and the renal arteries. Intra-aortic balloon
by UF occurs because of the osmotic pressure gradient between pumps have been used clinically for more than five decades. The
the hypertonic dialysate and the hypotonic peritoneal capillary mechanism of action is based on the principle of diastolic aug-
blood. Peritoneal dialysis has a role in patients with concomitant mentation, i.e. the balloon is inflated during diastole and deflated
heart failure with and without advanced CKD (Stages IV/V) in during systole, thus facilitating coronary flow and improving oxygen
whom peritoneal dialysis is used as an UF strategy and those supply to the myocardium and reducing afterload, thus reducing
with heart failure and end-stage renal disease in whom peritoneal oxygen consumption. Its contribution to cardiac output is small,
dialysis is the renal replacement therapy of choice (CKD Stage V). merely 0.5 L/min by some approximations. A small (n=10) study
Studies of peritoneal dialysis in heart failure patients with CKD and reported a median increase of 20% in cardiac index and signifi-
refractory fluid overload have shown this modality is associated cant reductions in left ventricular stroke work and left ventric-
with weight loss, improved quality of life, and reduction in heart ular end-systolic pressure in patients undergoing IABP support
failure hospitalizations and increase in LVEF.167 – 170 However, these before LVAD implantation.175 Currently, IABP are primarily used
studies lack a control group, have a short follow-up, and insufficient for cardiogenic shock in the setting of acute ischaemic heart dis-
power to detect an effect on mortality. ease, and for protective support during high-risk percutaneous
During the first 60–90 min of intraperitoneal dwell of coronary intervention, but scientific evidence for these applica-
dextrose-containing peritoneal dialysis solutions, rapid trans- tions is lacking.176,177 Intra-aortic balloon pumps are sometimes
port of free water across the aquaporin channels occurs, whereas used to provide mechanical support to patients with cardiogenic
the solute-rich water moves more slowly through the small pores shock prior to LVAD implantation, but the evidence for this prac-
of the peritoneal membrane. This results in an early drop in the tice is also limited. A small single-centre study (n=56) reported
concentration of sodium in the dialysate. This approaches the that IABP provided clinical stabilization in 57% of the patients who
serum concentration as the diffusive movement of sodium con- received IABP prior to LVAD implantation, whereas the remaining
tinues and dwell time is sufficiently long.166 The longer dwells of 43% had further clinical deterioration.178 Higher right ventricular
continuous ambulatory peritoneal dialysis may be preferred when and left ventricular cardiac power indices and higher pulmonary
sodium removal is the primary target, as it is in fluid-overloaded artery pressure may predict patients more likely to respond to
patients with heart failure.170 Several strategies allow adequate IABP.178 In general, newer devices that generate greater support
sodium and water removal with automated peritoneal dialysis.169 and provide better unloading of the left ventricle are currently
One approach is to substitute conventional dextrose-based dial- preferred.
ysis solutions with icodextrin, a high molecular weight glucose
polymer which induces transcapillary UF.171 Another strategy is
to decrease the number of nocturnal cycles to increase the dwell Extracorporeal membrane oxygenation
time. For patients with significant residual renal function, dietary Extracorporeal membrane oxygenation (ECMO) is a cardiopul-
sodium restriction and concomitant use of loop diuretics may monary bypass machine modified for easier and longer use and
© 2018 The Authors

transport. Extracorporeal membrane oxygenation devices have a ECMO flow should be carefully balanced to prevent hypoxic blood
........................................................................................................................................................................
centrifugal blood pump that can provide up to 6 L/min of flow, as perfusing the brain and the well-oxygenated blood mainly perfusing
well as an oxygenator to provide full respiratory support. Thus, the rest of the body. Absence of native cardiac output may even
ECMO provides full systemic circulatory support and can be useful result in complete clotting of the left ventricle despite adequate
to restore end-organ perfusion. heparin treatment. ECMO can readily be used in cardiogenic
Extracorporeal membrane oxygenation can be used in shock caused by end-stage chronic heart failure as a short-term
either veno–arterial or veno–venous configurations. The bridge-to-transplantation (BTT), BTD, or bridge-to-candidacy
veno–arterial mode provides full cardiopulmonary support, (BTC).180,181 The SAVE score (www.save-score.com) can be used
while the veno–venous mode provides only respiratory support, as a tool to predict survival in patients with cardiogenic shock
i.e. oxygenation of venous blood, and it is used primarily in cases in which ECMO is considered.183 ECMO has been registered for
of severe respiratory insufficiency with preserved cardiac output. use up to 30 days.
Extracorporeal membrane oxygenation can be configured with A recent meta-analysis of cohort studies suggested better sur-
central or peripheral access. Central ECMO requires surgical vival rates and neurological outcomes in cardiac arrest patients
access and cannulation of the ascending aorta, and it is predomi- when treated with ECMO in comparison to controls in whom
nantly used for postcardiotomy short-term MCS in patients who ECMO was not used.184 Furthermore, ECMO provided better sur-
fail to wean off cardiopulmonary bypass. Conversely, peripheral vival in patients in cardiogenic shock when compared to IABP.
ECMO can be placed by interventional cardiologists or trained The same effect was not observed when ECMO was compared
intensivists using the Seldinger technique for insertion of cannulas to Impella or TandemHeart.185
in the femoral artery and vein.
Implantation and management of ECMO demands a dedicated
team with expertise in this specific area. Perfusion technicians TandemHeart® percutaneous ventricular assist device
(Cardiac Assist, Inc., Pittsburgh, PA, USA)
are essential for ECMO circuit priming and initiation; transoe-
sophageal echocardiography or fluoroscopic guidance is advisable TandemHeart is a device that connects the left atrium with the
for cannula positioning, and vascular or cardiac surgeons must iliofemoral artery.186,187 TandemHeart consists of a 21 Fr inflow
be available to manage possible vascular complications. Extra- cannula (inserted via the femoral vein to the right atrium and
corporeal membrane oxygenation support demands anticoagula- trans-septally into the left atrium), a centrifugal continuous extra-
tion with heparin; activated clotting time should be monitored corporeal blood pump, and an outflow arterial cannula (15-19 Fr,
frequently and maintained between 160–180 s. Complications of inserted in the iliofemoral artery). A membrane oxygenator can be
ECMO support are frequent and are mostly related to vascu- added to the TandemHeart circuit to provide respiratory support.
lar complications, bleeding, thrombosis, and infections. In the TandemHeart has Food and Drug Administration (FDA) approval
case of peripheral ECMO, distal limb ischaemia remains rela- for 6 h of support and also CE mark, which includes approval for
tively frequent despite the routine addition of a cannula for distal Protec Duo veno–venous cannula up to 30 days (www.tandemlife
limb perfusion. .com).
Although ECMO provides full support for the patient, it may The need for trans-septal puncture and positioning of the
have non-physiologic and sometimes detrimental haemodynamic inflow cannula into the left atrium demands proficiency in
consequences on the myocardium. Draining blood from the its use. This makes the implant procedure more complex
venous side results in a reduction of preload to the heart, and, and longer as compared to other short-term percutaneously
consequently, reduces filling pressures of both ventricles. On the implanted devices.
arterial side, ECMO delivers 4–6 L/min of flow to the aorta result- The main advantages of this device are the direct unloading of
ing in increased afterload to the left ventricle. Therefore, ECMO the left atrium which results in a decrease in left ventricular filling
in itself does not necessarily decompress the heart, and depending pressures, volumes and oxygen demand and that it does not require
on the severity of myocardial dysfunction and presence of aortic or passage into the left ventricle. However, positioning of the cannula
mitral regurgitation, peripheral femoro–femoral ECMO may even in the left atrium carries a risk of complications, such as perforation,
increase left ventricular end-diastolic pressures and volumes. The or most frequently, cannula migration to a suboptimal position or
resulting pulmonary venous congestion may lead to pulmonary back to the right atrium. Furthermore, pumping blood out of the
oedema and compromise respiratory function.179 In these cases, a left atrium depends on preload to the left ventricle. TandemHeart
few modifications in the ECMO circuit can be performed to opti- can be easily configured to a right ventricular support system
mize support, such as inserting a left atrial vent for unloading the (TandemHeart RVAD).188
pulmonary veins/left atrium (e.g. with central ECMO) or the left Other contraindications include significant peripheral vascular
ventricular apex (e.g. with peripheral ECMO), or adding a second disease, general contraindications for anticoagulation therapy, pres-
device to unload the left ventricle [e.g. IABP, Impella Ventricular ence of right or left atrial thrombi, ventricular septal defect, or
Support Systems (Abiomed Inc., Danvers, MA, USA), or other severe aortic insufficiency. Anticoagulation therapy is mandatory
short- to-medium-term surgically implanted MCS device].180,181 due to the high risk of thromboembolic events. Requirements for
Percutaneous left atrial septostomy has also been reported as activated clotting time are even higher than for ECMO, and should
a method to unload the left heart in ECMO-supported patients be around 300 s, which significantly increases the risk of bleeding
with refractory pulmonary oedema.182 Native cardiac output and complications.
© 2018 The Authors

Other important complications of TandemHeart support are support is intended for up to 30 days, but longer is possible. It
........................................................................................................................................................................
vascular site complications, infections, and thromboembolic inci- requires anticoagulation with intravenous heparin. This device can
dents. The major disadvantage is the immobility of the supported be used as a bridge-to-recovery or as a BTD for those patients who
patient; care providers must secure the inflow cannula since move- need a longer duration of support than is feasible by the previous
ment of the tip from the left to right atrium results in significant mentioned devices. Also, the possibility of right ventricular sup-
right-to-left shunting with catastrophic desaturation. port can be an advantage.195,196 A new approach, minimally invasive
TandemHeart improves haemodynamics by adding up to 4 L/min CentriMag support integrated with ECMO (Ec-VAD) not requiring
of cardiac output and lowering pulmonary capillary wedge pres- a sternotomy has been reported.197 The Ec-VAD circuit is config-
sure. However, a positive effect on survival has not been established ured with left ventricular apical cannulation via mini-thoracotomy
in studies performed to date.189,190 and femoral venous cannulation as inflows and right axillary artery
cannulation as an outflow.
Impella® ventricular support systems (Abiomed Inc.,
Danvers, MA, USA)
Long-term management of advanced
The Impella device is a small axial flow pump placed across the
heart failure
aortic valve, aspirating blood from the left ventricle and expelling
it to the ascending aorta. In this way, it unloads the left ventricle, Advanced heart failure therapies are indicated when
improving haemodynamics combined with decreasing pulmonary guideline-directed medical and device therapies have been
capillary wedge pressure, and increasing coronary artery flow. implemented and optimized as appropriate in the individual
Contraindications include severe aortic valve disease (both steno- patient but heart failure has progressed such that symptoms
sis and regurgitation), implanted mechanical aortic valve, or can no longer be adequately managed or end-organ function is
existence of left ventricular thrombus. Impella is manufactured in compromised. Although details on guideline-directed medical
three versions: 2.5 device (12 Fr, maximum flow 2.5 L/min), CP and device therapies for chronic heart failure are not described
device (14 Fr, maximum flow 2–4 L/min), and 5.0 device (21 Fr, herein, physicians should refer to existing guideline documents9
maximum flow 5 L/min). Impella 5.0 is not fully percutaneous to ensure optimization prior to considering advanced heart failure
and requires a surgical procedure to insert a 21 Fr catheter in therapies, and for guidance on the continued management of
the femoral artery. Preliminary experience with the transaxillary these patients.
approach has been reported.191
The distal tip of the catheter is designed as a pigtail catheter Conventional cardiac surgery
which contributes to stability in the left ventricular cavity and
For patients with an LVEF ≤35% and coronary artery disease
reduces suction events. Survival benefit with the 2.5 device in
amenable to surgical revascularization, coronary artery bypass
cardiogenic shock could not be demonstrated, and it is gener-
grafting in addition to medical therapy significantly reduced the
ally advised to use either the CP device or the 5.0 device in
primary outcome of all-cause death, and the secondary outcomes
such cases.192 Recent results suggest that when used as part
of cardiovascular death and all-cause death or cardiovascular hos-
of a standardized protocol in patients with cardiogenic shock
pitalization compared to medical therapy alone over 10 years of
and isolated left ventricular failure, early active haemodynamic
follow-up in the Surgical Treatment for Ischemic Heart Failure
support with Impella CP may be associated with improved
(STICH) trial.198,199 Coronary artery bypass graft surgery is rec-
outcomes and lower than previously reported or predicted
ommended for such patients with left main stenosis or left main
mortality rates.193
equivalent.200 For patients with unacceptably high surgical risk,
The Impella device is FDA approved for partial support of up
coronary intervention is an option and may be facilitated under
to 6 days, and it has a CE mark for up to 5 days. As with all
protection using an Impella device.201
peripheral percutaneous devices, peripheral artery disease is a
In severe symptomatic aortic valve stenosis with mean gradient
contraindication to its use, as well as the inability to anticoagulate
>40 mmHg, aortic valve replacement (AVR) is recommended irre-
patients for any reason. Major complications of Impella use are
spective of the degree of left ventricular dysfunction. In patients
associated with vascular injury, bleeding, thrombosis, haemolysis,
with prohibitive surgical risk due to co-morbidities but with
and device migration. Recently, Impella has been shown also as an
projected survival >1 year after aortic valve intervention, tran-
option for acute right ventricular support or for left ventricular
scatheter aortic valve implantation should be considered. In ‘true’
unloading during ECMO.181,194
low-flow, low-gradient severe aortic stenosis202 (valve area <1 cm2 ,
mean gradient <40 mmHg, stroke volume index <35 mL/m2 ),
CentriMag acute circulatory support system (St. Jude, with a depressed LVEF, left ventricular function usually improves
Minneapolis, MN, USA) after AVR if left ventricular dysfunction is due to excessive after-
The CentriMag is a magnetically levitated paracorporeal centrifu- load; however, outcome is less certain if left ventricular dysfunc-
gal pump which can be used for left ventricular, right ventricular, tion is due to scarring. In severe aortic regurgitation, AVR is rec-
and biventricular support. It requires surgical implantation by way ommended in all symptomatic patients as well as asymptomatic
of sternotomy but results in full circulatory support and com- patients with LVEF ≤50%.202 According to the most recent valvular
plete cardiac unloading. Maximal flow is 10 L/min and duration of guidelines, ‘in patients with severe secondary mitral regurgitation
© 2018 The Authors

and LVEF <30% who remain symptomatic despite optimal medical a high mortality risk without heart transplant that also have a
........................................................................................................................................................................
management (including CRT if indicated) and who have no option good expected survival post-transplant.205 Third, co-morbidities
for revascularization, the Heart Team may consider a percutaneous should be evaluated to detect conditions that may negatively
edge-to-edge procedure or valve surgery after careful evaluation affect surgical and/or post-transplant outcomes or require special
for a ventricular assist device or heart transplant according to indi- management.25,204 Diagnostic and other tests [e.g. complete medi-
vidual patient characteristics.’202 Additionally, ‘in patients with LVEF cal history, physical examination, CPET,25,88 right heart catheteriza-
<30% and severe functional mitral regurgitation due to coronary tion, evaluation of peripheral vascular disease, assessment of frailty
artery disease, but with evidence of myocardial viability, mitral valve and nutritional status,206 determination of organ function (lung,
surgery should be considered with revascularization.’202 However, liver and kidney), screening for neoplasms or active infections],25
there is a legitimate concern that the more advanced the heart prognostic scores (e.g. HFSS,133 SHFM,109 IMPACT207 ), and other
failure stage, the less likely that a mitral repair operation or clip pro- studies as indicated based on co-morbidities (Table 9)208 – 213 are
cedure can benefit the patient. The ongoing COAPT (Cardiovascu- used to assess these three components of the pre-cardiac trans-
lar Outcomes Assessment of the MitraClip Percutaneous Therapy plant evaluation. Other health maintenance assessments should
for Heart Failure Patients with Functional Mitral Regurgitation, be performed (e.g. vaccination status) and addressed as clinically
NCT01626079) will evaluate the safety of the MitraClip system indicated. Blood group compatibility is mandatory for adult heart
in 610 patients with heart failure and its effects on death and heart transplant patients. HLA antibody assessment is recommended;
failure hospitalization. however, there is no consensus regarding the level and type of
antibodies that contraindicate a specific donor.214 Finally, a com-
plete psychosocial evaluation should be included in the evaluation
Heart transplantation
of all heart transplant candidates during the initial screening pro-
Heart transplantation is the treatment of choice for carefully cess to identify social and behavioural factors that may cause dif-
selected patients with advanced or end-stage heart failure. ficulties during the waiting period, convalescence, and long-term
Although controlled trials have never been conducted, there is follow-up, particularly regarding substance abuse, adherence to
consensus within the cardiology community that heart transplan- therapy and follow-up visits.213 Assessing that the patient has ade-
tation significantly improves survival, exercise capacity, quality of quate social support (i.e. family or friends able to give support and
life and return to work compared with conventional treatment, who are willing to make long-term commitments for the patient’s
provided that proper selection criteria are applied (Table 8).9,25 welfare) is also a critical component.215 An important aspect of
The main limitation of heart transplantation is the limited supply of the pre-transplant cardiac evaluation is the identification of those
donor hearts, which can vary substantially by country. Availability patients who do not yet need a heart transplant and should either
may impact indications and contraindications for heart transplant not be listed or removed if already listed with close monitoring and
applied locally. follow-up.
Since the first case of human heart transplant in 1967,203 Some aetiologies of advanced heart failure (e.g. hypertrophic
post-transplant survival has improved because of developments cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right
in recipient and donor selection, immunosuppression, and man- ventricular dysplasia, complex congenital heart disease, and infil-
agement of infectious complications. Thus, heart transplantation trative cardiomyopathies) require specific approaches to diagnosis,
is now considered the gold standard therapy for refractory heart prognosis, and determination of transplant eligibility, as described
failure. Data from the latest International Society for Heart and elsewhere.25 Patients with restrictive cardiomyopathy and severe
Lung Transplantation (ISHLT) Registry shows 1-year survival of heart failure symptoms may be candidates for cardiac transplanta-
around 90% and median survival of 12.2 years.19 Transplantation tion. Collaboration with other specialties is necessary to manage
not only improves survival but also functional status and quality of other organ systems impacted by these diseases. For example,
life. At 1 to 3 years post-cardiac transplant, the proportion of sur- in addition to heart transplantation, a hepatic transplant may
vivors capable of normal activity (defined as physician-rated Karnof- be required for familial amyloidosis related to mutations in the
sky score 80–100%) is 90%.204 The main challenges after heart transthyretin gene, or an autologous stem cell transplantation
transplantation are the consequences of both limited effective- may be indicated for light chain amyloidosis.25 Special considera-
ness and complications of immunosuppressive therapy (e.g. infections are needed for patients with congenital heart disease and
tions, antibody-mediated rejection, cardiac allograft vasculopathy, in recipients that harbour chronic infections (e.g. Chagas dis-
late graft dysfunction, malignancy, renal dysfunction, hypertension, ease, tuberculosis, human immunodeficiency virus, hepatitis C,
diabetes mellitus).204 and hepatitis B).25
The patient evaluation before listing for transplant involves four
main considerations. First, the presence of refractory heart failure
should be confirmed to ensure that there are no other treat- Unstable patients
able aetiologies or alternative explanations for advanced symp- Pre-operative clinical stability is a strong predictor of early
toms. This step is important to guarantee the patient’s candidacy post-transplant outcomes; however, clinical instability can also be a
for cardiac transplant and to reserve scarce donor organs for priority criterion in some countries for organ allocation. Mechan-
patients with the greatest need. Second, prognosis should be esti- ical circulatory support systems can bridge selected patients to
mated. The greatest survival benefit is achieved in patients with transplantation who are extremely ill and have a high-expected
© 2018 The Authors

Table 8 Indications and contraindications to heart transplantation
Patients to consider 1. End-stage HF with severe symptoms, a poor prognosis, and no remaining alternative treatment options
2. Motivated, well informed, and emotionally stable
3. Capable of complying with the intensive treatment required postoperatively
Contraindications 1. Active infection
2. Severe peripheral arterial or cerebrovascular disease
3. Pharmacologic irreversible pulmonary hypertension (LVAD should be considered with subsequent re-evaluation to
establish candidacy)
4. Cancer (a collaboration with oncology specialists should occur to stratify each patient as to their risk of tumour
recurrence)
5. Irreversible renal dysfunction (e.g. creatinine clearance <30 mL/min)
6. Systemic disease with multiorgan involvement
7. Other serious co-morbidity with poor prognosis
8. Pre-transplant BMI >35 kg/m2 (weight loss is recommended to achieve a BMI <35 kg/m2 )
9. Current alcohol or drug abuse
10. Any patient for whom social supports are deemed insufficient to achieve compliant care in the outpatient setting
BMI, body mass index; HF, heart failure; LVAD, left ventricular assist device.
Adapted from Ponikowski et al.9 and Mehra et al.25
mortality while awaiting a suitable donor heart. Short-term MCS Originally considered only as a lifesaving therapy for patients
.........................................................................................................
can also serve as a bridge in patients initially ineligible for transplan- who were ineligible for heart transplantation, the proportion of
tation, such as those in cardiogenic shock with end-organ damage. long-term MCS devices implanted for destination therapy (DT) to
In these cases, short-term MCS may stabilize haemodynamics heart transplants is increasing.220 This growth is due to a growing
and end-organ perfusion and permit an evaluation of candidacy shortage of donor hearts, increasing numbers of advanced heart
(e.g. determine extent of brain damage or other end-organ injury failure patients, and continuous improvements in MCS technologies
post-resuscitation).9,173 Although urgent cardiac transplant listing and survival rates.
is possible in many countries, the appropriateness of this strategy
is now being debated. Among patients listed for emergent cardiac
Patient selection for long-term durable mechanical
transplant in the Spanish National Heart Transplant Registry circulatory support
database, recipients meeting the INTERMACS profile 1 criteria
The INTERMACS profiles can help identify potential candidates
(cardiogenic shock) and profile 2 criteria (progressive clinical
for MCS221 (Table 2). INTERMACS profile 1 indicates critical car-
decline despite treatment with inotropes) had the highest risk of
diogenic shock with very limited time for decision and interven-
primary graft failure, dialysis requirement, and in-hospital mortality
tion. Similarly, INTERMACS profile 2 indicates progressive decline
following heart transplantation.216 Therefore, in these critically
despite inotropic support. In these patients, many centres pre-
ill patients, short-term MCS as a BTD might constitute a more
fer to use either paracorporeal or percutaneous short-term assist
reasonable initial strategy than an urgent transplant.
devices as a BTD. Long-term MCS devices are also an option
for these patients. INTERMACS 3 patients are those who are
stable on inotropes and are optimal candidates for implantable
Long-term mechanical circulatory support
MCS, as their outcomes are significantly better than patients cat-
Long-term support with durable MCS devices like LVAD in egorized as INTERMACS 1 or 2, and the potential for benefit
patients with advanced heart failure has survival benefits and overwhelms the risks of complications. Data from selected ret-
improves quality of life compared with conventional treatments rospective studies showed that survival rates were even better
in inotrope-dependent patients or in patients with contraindica- in non-inotrope dependent NYHA class IV patients or advanced
tions for heart transplantation.9 The Randomized Evaluation of NYHA class III patients (INTERMACS profiles 4–7).151,222,223 A
Mechanical Assistance for the Treatment of Congestive Heart prospective, non-randomized, observational, propensity-adjusted
Failure (REMATCH) trial first showed improved 1-year survival study comparing LVAD with optimal medical management showed
in inotrope-dependent, transplant-ineligible patients with advanced that a greater proportion of patients treated with LVAD survived
heart failure treated with an LVAD, but 2-year survival was not for 12 months and had improvement in 6-min walk distance, along
statistically different.217 Since then, technology of LVAD and con- with a higher rate of adverse events and hospitalizations, compared
servative management have improved.217,218 Managing patients with to those receiving optimal medical management.151
long-term MCS requires a multidisciplinary Heart Team approach, Although INTERMACS profiles alone are insufficient to evalu-
and by gaining experience, centres may actually improve patient ate an individual patient for MCS, based on available data selected
survival.219 INTERMACS 1–2 patients and all INTERMACS 3 patients should
© 2018 The Authors

Table 9 Considerations in assessment of co-morbidities
Co-morbidity Parameters to evaluate

...........................................................................................................................................
Age208 Frailty
Co-morbidity burden
Local organ availability and quality
Obesity Body mass index
Diabetes mellitus End-organ damage (e.g. neuropathy, nephropathy)
Glycated haemoglobin
Renal impairment Estimated GFR
Renal ultrasonography
Proteinuria estimation
Presence of renal arterial disease
Candidacy for combined heart/kidney transplant209
Cancer Active malignancy
Collaboration with oncologist for prior cancer previously treated
Previous tumour type, response to therapy
Metastatic work-up
Cerebral or peripheral vascular disease Diagnostic work-up as indicated to assess clinical severity
Potential to limit rehabilitation
Substance abuse Tobacco (including environmental or second-hand exposure)
Alcohol
Recreational drugs
HIV210,211 Active or prior opportunistic infections
Adherence to combination anti-retroviral therapy
HIV RNA
CD4 count
Chagas disease212 Serology testing for T. cruzi in patients at risk
Hepatitis B and C Antibody/antigen testing
HCV RNA PCR
Liver function tests
Viraemia
Serology
Liver biopsy
Psychosocial Complete evaluation
Potential for adherence to therapy213
CD4, cluster of differentiation 4; GFR, glomerular filtration rate; HCV, hepatitis C virus; HIV, human immunodeficiency virus; PCR, polymerase chain reaction;
RNA ribonucleic acid.
be considered for MCS. Furthermore, carefully selected INTER- of heart function (bridge to recovery). In this context, however,
...................................................
MACS 4–7 patients who are willing to accept a risk of adverse in countries with low or declining transplant rates, implanting
events in exchange for potentially longer survival and better func- an LVAD as a BTT usually becomes DT, unless pump-related
tional status can be considered for MCS.104,151,224 In addition to complications occur such as chronic driveline infection, bleeding, or
INTERMACS profiles 1–2, risk factors for early mortality after thrombosis.
MCS system implantation include renal dysfunction, elevated biliru- High pulmonary vascular resistance or transpulmonary gradi-
bin, advanced age, female gender, presence of right heart failure and
ent, or a recently treated cancer are contraindications for heart
need for concomitant cardiac surgery.225 – 227
transplantation but not for MCS. On the other hand, severe right
Patient selection for MCS overlaps with indications for heart
ventricular dysfunction228 is a contraindication for LVAD, because
transplantation.25 However, as heart transplantation is still the gold
there are still no good long-term solutions for right ventricu-
standard, the use of LVAD therapy should be projected in light
of the possibility to offer transplant opportunity to the patient, lar or biventricular mechanical support. Severe renal insufficiency
and it would be advisable that indications/contraindications to is a contraindication for heart transplantation, but renal or liver
transplant are ruled out by the transplant centre before a device function may improve after MCS,229 as may pulmonary vascular
is implanted. Based on this concept, LVADs may be implanted resistance.230 Thus, with the exception of advanced age or other
according to three major treatment strategies: BTT, BTC and irreversible contraindications for transplant, MCS should primarily
DT. In rare circumstances, LVAD therapy may lead to a recovery be considered as BTC rather than DT. However, some patients
© 2018 The Authors

with MCS will develop contraindications for transplantation over years, the landscape of potential options in MCS has changed
........................................................................................................................................................................
time.231 dramatically. Currently, the three MCS devices most often used
In general, early referral of patients with advanced heart failure are the HeartMate II, HeartWare HVAD, and HeartMate 3
to transplant and MCS centres can assure the best timing and out- (Table 10).151,223,234,235,239 – 258 These devices have shown good
comes for both transplantation or long-term MCS. Early referral durability, reasonable but still relatively high rates of device-related
applies to a wide spectrum of patients ranging from housebound morbidity, improved functional capacity in implanted patients, and
NYHA class IV patients with poor exercise capacity despite optimal in the case of HeartMate 3, mid-term survival rates approaching
medical treatment plus CRT if needed, to NYHA class IV patients that of post-transplant survival (overall 2-year survival of 83%). The
who are refractory to conventional treatments. Shared decision incidence of adverse events with recent technological improve-
making is an important component of determining the appropri- ments (e.g. as with the fully magnetically-levitated HeartMate 3
ateness of long-term MCS.232 potentially almost eliminating pump thrombosis) has reduced the
rates of reoperation to replacement or removal a malfunctioning
Adverse events and morbidities related to mechanical device, and disabling strokes, although the incidence of other
circulatory support adverse events is similar between newer and older devices.258 Par-
ticular concern exists with stroke rates, especially with the HVAD
MCS-specific infections may be on the hardware itself or the body
device (29% at 2 years), and the HeartMate 3 has demonstrated
surfaces that contain them and include infections of the pump,
a halving of stroke rates at 2 years compared to the HeartMate
cannula, anastomoses, pocket, or the percutaneous driveline or
II device.258 Minimally invasive VAD implantation methods will
tunnel.233 Driveline exit site infection is a common complication,
hopefully further benefit the overall outcome of patients, but
occurring in 20–25% of patients (data from main randomized
structured investigation of these techniques is needed. Although
clinical trials),234,235 but the majority remain superficial and can
minimally invasive techniques avoid the need for open sternotomy,
be managed by antibiotics.236 Exit site swabs and blood cultures
they also have a greater potential for malposition, the same
are obligatory when driveline infection is suspected. Resistant and
cumulative incisional length, and still require an open sternotomy
complicated driveline infections (i.e. ascending driveline or pump
if the right ventricle fails.259 New technological breakthroughs
pocket infection) can be an indication for listing the patient for
are expected in the future (e.g. fully implantable pumps with
urgent heart transplantation if there are no contraindications.224
transcutaneous energy transmission).258 Importantly, appropriate
The ISHLT standardized definitions for MCS infections to dif-
long-term solutions for cases of severe right heart or biventricular
ferentiate ventricular assist device (VAD)-specific infections,
failure remain an unmet need, as neither biventricular support
VAD-related infections, and non-VAD infections.233 Driveline
with VADs or the total artificial heart can ensure a satisfactory
infection can be further classified into superficial and deep accord-
quality of life and acceptable adverse event profile.
ing to surgical/histology, microbiology, and clinical criteria as well
as general wound appearance.
Other complications include heart failure symptoms on MCS, Palliative care of patients with advanced
which may be attributed to device failure, mechanical issues, or heart failure
cannula malposition. Right ventricular dysfunction, new onset of
Optimal care of patients with advanced heart failure includes pal-
right heart failure, aortic insufficiency, ascites, and cachexia are also
liative care at their end-of-life period and whenever appropriate
important considerations.224
during the patient journey. Conventional therapy (cardiologic ther-
Treatment with anticoagulation and antiplatelet agents are
apeutic approach) may not sufficiently reduce patient suffering and
mandatory to minimize the risk for pump thrombosis. Both
maximize quality of life.
embolic ischaemic events and bleeding events secondary to these
Successful palliative care must involve shared care through a mul-
therapies remain major complications of MCS and contribute to
tidisciplinary approach. Patients and their caregivers should be able
readmission and death.237 Continuous flow devices have raised
to easily communicate with primary care, specialist palliative care
important considerations for haemocompatibility.237 Routine mon-
services and the specialized advanced heart failure service, accord-
itoring of plasma-free haemoglobin and lactate dehydrogenase as
ing to the resources of each centre.9,131,260,261 Aging, co-morbid
haemolysis markers are useful for early detection of pump throm-
conditions, end-organ damage, cognitive impairment, frailty and
bosis. In HeartWare HVAD carriers, routine log-file review has
limited social support complicate heart failure management, and
demonstrated its usefulness for the early detection of pump throm-
palliative care should address each of these components. End-of-life
bosis. In case of clinical suspicion, the diagnosis of pump thrombosis
decision making is even more challenging for patients with advanced
may be confirmed by means of an echocardiographic ramp test.238
heart failure when heart transplantation or long-term MCS have
failed.262 The PAL-HF (Palliative Care in Heart Failure) trial, a
Device selection single-centre study of 150 patients, showed that interdisciplinary
Currently, there are several vendors and a considerable number palliative care intervention in advanced heart failure patients
of devices that are used for medium-term and long-term MCS. resulted in greater benefits in quality of life, anxiety, depression
Continuous flow implantable MCS devices of the second and and spiritual wellbeing compared with usual care alone.263 The
third generation have shown significant superiority over pulsatile SWAP-HF (Social Worker-Aided Palliative Care Intervention in
first-generation implantable MCS devices. Thus, in the last 15 High-risk Patients with Heart Failure) trial showed that patients
© 2018 The Authors

Table 10 Overview of long-term mechanical circulatory support devices
Device Device characteristics Evidence from major clinical trials Major risks Ongoing/future studies
.........................................................................................................................................................................................
HeartMate II (Thoratec, Axial flow pump BTT strategy (prospective, single-arm, n=133): 75% Device failure
© 2018 The Authors

St. Jude, Implanted in pre-peritoneal survival 6 months, 68% survival 12 months239 Pump thrombosis244 – 246
Abbott)151,223,239 – 247 pocket, connected via HeartMate II LVAD242 (randomized continuous flow vs. Ischaemic stroke
inflow cannula to left pulsatile): improved 2-year survival free of stroke or Driveline infection247
ventricular apex, and via device failure for continuous flow vs. pulsatile Bleeding (haemorrhagic
outflow cannula to ROADMAP151,243 (observational, n=97 LVAD, n=103 stroke)
ascending aorta OMM): LVAD associated with better survival and RV failure
functional capacity at 2 years
HeartWare (HeartWare, Continuous flow Single-arm (transplant candidates, NYHA class IV, n=50): Ischaemic stroke
Advanced heart failure: HFA position statement
Medtronic)235,248 – 253,257 centrifugal pump 84% 1-year survival248 Haemorrhagic stroke

Implanted and positioned Post-CE mark approval registry (n=254): 85% 1-year RV failure
completely within survival, 73% 3-year survival249 Infection
pericardial space, ADVANCE (HeartWare vs. commercially available LVADs): Device failure252,253
connected via driveline to non-inferior to commercially available devices257 ; Pump thrombosis
controller continued access protocol 84% 1-year survival250 Driveline infection
ENDURANCE (randomized, open-label, n=446 advanced
HF ineligible for transplant, HeartWare vs. HeartMate II):

non-inferiority of HeartWare vs. other devices for
survival at 2 years free from disabling stroke or device
removal; higher rate of stroke, RV failure, sepsis235
HeartMate 3 (St. Jude, Continuous flow, centrifugal Single arm (n=50, BTT and DT): 98% 30-day survival, 92% No pump thrombosis in MOMENTUM 3: randomized,
Abbott)234,254 – 256,258 pump, bearing-less 6-month survival; 1-year survival similar to other MOMENTUM 3 compared HeartMate 3 vs. HeartMate II,
magnetically levitated devices254,255 to 10.1% in axial flow both BTT and DT (long-term
rotor, artificial pulse MOMENTUM 3 (randomized, HeartMate 3 vs. HeartMate group outcomes)256
II, both BTT and DT, n=294): centrifugal flow pump RV failure
non-inferior to axial-flow pump at 6 months; superiority Stroke
also established (HR 0.55, 95% CI 0.32–0.95, P=0.04)234 Infection
MOMENTUM 3 2-year outcomes (n=366): Driveline infection
• Survival free of disabling stroke or survival free of
reoperation to replace/remove device: HR 0.46, 95% CI
0.31–0.69, P<0.001 (superiority)258
• Rate of stroke: 10.1% vs. 19.2% (HR 0.47, 95% CI
0.27–0.84, P=0.02)
ADVANCE, Evaluation of the HeartWare Left Ventricular Assist Device for the Treatment of Advanced Heart Failure; BTT, bridge to transplant; CI, confidence interval; DT, destination therapy; ENDURANCE, Evaluation of the
HeartWare Ventricular Assist System for Destination Therapy of Advanced Heart Failure; HF, heart failure; HR, hazard ratio; LVAD, left ventricular assist device; MOMENTUM, Multicenter Study of MagLev Technology in Patients Undergoing
Mechanical Circulatory Support Therapy with HeartMate 3; NYHA, New York Heart Association; OMM, optimal medical management; ROADMAP, Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device
and Medical Management in Ambulatory Heart Failure Patients; RV, right ventricular.
1523
at high risk for mortality from heart failure frequently overesti-
........................................................................................................................................................................
Table 11 ‘I Need Help’—Markers of advanced heart
mate their life expectancy and a structured social worker-led pal-
failure
liative care intervention enhances prognostic understanding and
patient–physician communication regarding goals of care.264
I Inotropes Previous or ongoing
Communication with advanced heart failure patients is complex. requirement for
In heart failure, the trajectory of each patient is different. Stocker dobutamine, milrinone,
et al.265 showed that the majority of patients with heart failure dopamine, or levosimendan
reject the idea of heart failure as a terminal disease and prefer to N NYHA class/ Persisting NYHA class III or IV
focus on day-to-day management and maintenance, despite obvi- natriuretic and/or persistently high BNP
ous deterioration in disease stage and needs over time. Common peptide or NT-proBNP
expectations pre- and post- heart transplant or MCS and potential E End-organ Worsening renal or liver
complications should be discussed with patients and their care- dysfunction dysfunction in the setting of
givers, ideally, during the assessment and evaluation period for heart failure
advanced heart failure therapies. Whenever possible, goals and E Ejection fraction Very low ejection fraction
preferences for end-of life issues should be discussed, especially in <20%
patients treated with MCS for DT. Living will and advance directive D Defibrillator Recurrent appropriate
shocks defibrillator shocks
preferences are useful, and patients should be encouraged to pre-
H Hospitalizations More than 1 hospitalization
pare the necessary documents. A comprehensive end-of life plan of
with heart failure in the last
care for each patient should be available. This plan of care should
12 months
be defined before MCS implantation or heart transplantation and
E Edema/escalating Persisting fluid overload and/or
revisited during the course of care.262 diuretics increasing diuretic
Patients with MCS as DT are particularly complex. A study at the requirement
Mayo Clinic on end-of-life care in long-term MCS patients showed L Low blood Consistently low BP with
that 78% of the patients who died were hospitalized, and of these, pressure systolic <90 to 100 mmHg
88% died in the intensive care unit. The main causes of death P Prognostic Inability to up-titrate (or need
were multiorgan failure, haemorrhagic stroke, and heart failure.266 medication to decrease/cease) ACEI,
Goals of palliative care include management of physical symptoms beta-blockers, ARNIs, or
(e.g. heart failure symptoms, pain, anxiety, depression, anorexia, MRAs
constipation, and insomnia). Psychosocial and spiritual concerns ACEI, angiotensin-converting enzyme inhibitor; ARNI, angiotensin
should also be addressed. receptor–neprilysin inhibitor; BNP, B-type natriuretic peptide; BP, blood
An important aspect is deciding when to discontinue advanced pressure; MRA, mineralocorticoid receptor antagonist; NT-proBNP, N-terminal
pro-B-type natriuretic peptide; NYHA, New York Heart Association.
therapies (e.g. MCS, ICD, or immunosuppressive treatment). This
Reprinted with permission from Baumwol.267
decision should be the patient’s whenever possible, or the patient’s
caregiver, family, or hospital ethics committee if the patient is
unable to independently convey their decisions. Support can be contraindications) for those therapies, as well as the need for
discontinued in the hospital, in hospice, or at home depending other advanced therapies for symptom management that may be
on patient and family preferences, feasibility, and local resources. unavailable at non-specialized centres (e.g. UF, peritoneal dialysis).
Nurses and health care personnel involved should be adequately A useful mnemonic has been proposed to aid in the identification
trained to correctly deactivate devices and associated alarms and of patients with advanced heart failure and timely referral for
to provide comfort care to the patient and psychological support consideration of advanced therapies (Table 11).267,268
to the family and care team. Ideally, secondary care centres without advanced heart fail-
ure therapies (spoke centre) should liaise with a tertiary hub
centre to develop a strong working relationship. Heart fail-
Organizational issues for patient ure patients are then managed within this ‘hub and spoke’
referral to advanced heart failure continuum of care (Figure 2). Spoke centres are responsible
for ensuring adherence to guideline-directed therapy and that
centres: hub and spoke network patients are referred to the tertiary hub centre at the appropriate
The broad spectrum of heart failure ranges from patients in time (Figure 1).
the early stages of the disease largely managed by primary care Each country should define the standards and organizational
physicians and secondary care cardiologists, to those who progress structures for advanced heart failure tertiary hub centres regarding
to more advanced stages and require specialized tertiary care. pathways for referring patients, which should be made available to
All heart failure patients should undergo regular follow-up to every patient, in relation to his/her individual characteristics and
detect progression of symptoms and disease. The criteria for needs.260,269 – 271 The tertiary hub centre should ensure that spoke
referral to an advanced heart failure tertiary hub centre, i.e. centres know how to communicate in an agile way (telephones,
those with capabilities for heart transplantation and MCS, must email address) including urgently, if necessary. Once a patient is
be based on need (i.e. indication) and eligibility (i.e. absence of referred for evaluation, the hub and spoke centre teams should
© 2018 The Authors

Spoke: Community HF units Specialized HF unit Tertiary Hub: Advanced HF unit

• Primary care provider • Intermediate HF care • Community and specialized services, plus:
• General cardiologist • Multidisciplinary team • Access to highly specialized care providers
• Day-to-day management of HF patient • HF knowledge and expertise • Advanced diagnostics and interventions (e.g.
• Education • Patient education programmes mechanical circulatory support, transplant)
• Patient triage and timely access to care • Training of referring physicians/primary care • Provide mentorship to community hub
• Access to cardiac diagnostics
• Pharmacologic assessment, optimization and
titration of evidence-based therapies
• Evaluation/implantation of device therapies
(e.g. ICD, CRT)
• Interventional cardiology
• Cardiac surgery
• Short-term mechanical circulatory support
• Risk factor assessment
• Specialist consultation
• Access to clinical trials
Spoke:
Primary care,
general
cardiology Spoke:
Spoke: Primary care,
Primary care, general
general cardiology
cardiology
Specialized
HF unit:
Spoke:
Spoke: Local hospital Primary care,
Primary care,
general
general
cardiology
cardiology
Spoke:
Specialized Specialized Spoke:
Primary care,
Primary care,
general HF unit: HF unit: general
cardiology Local hospital Tertiary Hub: Local hospital cardiology
Advanced HF unit
Spoke:
general cardiology
cardiology
Specialized
HF unit:
Local hospital
Spoke:
general cardiology
cardiology Spoke:
Primary care,
general
cardiology
Figure 2 Conceptual structure of a hub and spoke model of care for patients with advanced heart failure (HF). This figure presents a concept
for the structure of a hub and spoke model of care for patients with advanced HF. The roles for primary care, general cardiology (yellow),
specialized HF (orange), and tertiary centres (red) are described. Solid lines reflect main lines of communication and referral. Dashed lines
indicate secondary pathways for referral/communication (i.e. typically patients will first be referred to a specialized HF unit, but in some
circumstances direct referral to the tertiary hub bypassing the specialized HF centre may be appropriate.) This model depicts an overview
of the concept, which can be tailored to the local needs of the health care system. CRT, cardiac resynchronization therapy; ICD, implantable
cardioverter-defibrillator.
© 2018 The Authors

jointly agree whether the consultation can be done on an out- general condition. For a patient with long-term MCS, the drive-
........................................................................................................................................................................
patient basis or requires an inpatient transfer between the two line exit site should be meticulously inspected for potential infec-
hospitals. tion. The driveline, exit site, and other MCS system components
A protocol for the immediate management and safe transfer should be examined to ensure their integrity. Blood pressure
of unstable patients in cardiogenic shock must be developed and should be measured (preferably assisted with a Doppler ultra-
available at each tertiary hub centre, both for de novo patients and sonic device in patients with low pulsatility) and lowered if indi-
those with chronic, deteriorating heart failure. This protocol must cated. Blood pressure control is important since the risk of stroke
be individualized, taking into account geographical considerations is closely related to blood pressure for some devices like the
and resource availability at each spoke,272 – 276 including in some HVAD. Mean arterial pressure should be maintained <90 mmHg,
cases a team dispatched from the tertiary hub centre to retrieve and ideally <85 mmHg. Regular echocardiographic assessment
the patient.277,278 should be performed, determining the need for device optimiza-
While the patient is on the waiting list for heart transplantation, e.g. increasing or decreasing the device speed, depending
tion, decisions regarding cardiovascular care must be guided by the on the position of the interventricular septum, opening of the
advanced heart failure team at the tertiary hub. However, the spoke aortic valve, or size of the left ventricle. Alarm history should
centre physician has a key role in monitoring the patient’s condition be obtained at regular intervals. If possible, functional testing
and implementing therapeutic decisions. Two-way communication should be performed (e.g. 6-min walking distance). Special atten-
between spoke and hub centres is key for the successful manage- tion should be directed at maintaining adequate anticoagulation sta-
ment of the patient.260 Tertiary hub centres must provide education tus, and if available self-monitoring should be encouraged. Patients
on advanced heart failure therapies and share their experience with should be regularly educated on proper care of the driveline
spoke centres. exit site.
Post-transplant patients should undergo a pre-defined regi-
men of graft biopsies, titration of immunosuppressive and other
Principles of shared care after therapies, rejection monitoring, assessment for infections, trans-
heart transplantation or plant coronary artery disease and/or cardiac allograft vasculopathy,
immunosuppression side effects, and other potential complications
mechanical circulatory support including neoplasia, and co-morbidities that require comprehensive
As the numbers of patients receiving heart transplants are plateau- treatment. Shared care with referral cardiologists and primary care
ing or declining, there is an increasing need for more long-term physicians is needed.
MCS implantations. These advanced therapies should preferably be Treatment and follow-up of patients who are post-cardiac trans-
established within centres that offer both transplantation and MCS, plant or MCS recipients requires an interdisciplinary approach to
although consensus has not been reached regarding this issue. meet the complex needs of these patients. In addition to the trans-
Each hub and spoke centre should develop their own pathways plant cardiologist and MCS device specialist, a dedicated trans-
for shared care. plant/MCS device nurse is important to educate the patient and
Follow-up of patients after heart transplantation or implantation caregivers, as well as coordinate health care team members. A
of MCS devices consists of both immediate post-operative period cardiac surgeon should also be included in case of surgical com-
and long-term follow-up. In the immediate post-transplant or plications. For patients with MCS, driveline infection is primar-
post-MCS implantation, care should be shared among intensivists, ily a surgical problem. Ideally, a nutritionist, physiotherapist, psy-
surgeons and cardiologists. In the early phase, haemodynamic mon- chologist, psychiatrist, and general practitioner should also be a
itoring is of great importance for both therapies, allowing for more part of the team taking care of patients treated with advanced
accurate titration of inotropic or vasodilator therapy. Haemody- heart failure therapies. Depending on co-morbidities and com-
namic monitoring, along with echocardiographic imaging, allows plications, other specialists should participate in shared care as
for early detection of some of the potential adverse events that appropriate. Highly experienced tertiary centres are required
might occur in the immediate post-operative period (e.g. hypo- to provide this multidisciplinary approach to shared care and
volaemia, tamponade, acute right heart failure). Echocardiography address the needs of heart failure patients managed with advanced
is an integral part of cardiac allograft evaluation as well as device therapies.
optimization, which includes setting the pump speed of the device
and adjusting medical therapy to achieve optimal unloading of the
left ventricle, while balancing the preload provided to the right
Conclusion
ventricle. Advanced heart failure remains a major clinical challenge. Changes
Long-term follow-up of patients with advanced heart failure ther- in the clinical characteristics and clinical practice of heart failure
apies is ideally done through the outpatient clinic. At each appoint- treatment have made it necessary to develop the present update
ment for patients with long-term MCS, patient history and physical of the original criteria for the definition of advanced heart failure.
examination and laboratory assessment (e.g. haemolysis, anaemia, New biomarkers and imaging tools may allow better prognostic
liver, renal, and infection markers) should be performed, with spe- stratification and the assessment of mechanisms of disease pro-
cial attention to blood pressure, signs of congestion, shortness of gression. However, robust data are lacking from prospective, con-
breath, potential infection, bleeding, thrombosis, and the patient’s trolled trials demonstrating the clinical usefulness of these new
© 2018 The Authors

methods. Once guideline-directed management therapy is insuffi- as an investigator from Abbott, CARMAT, Corvia, and Novartis;
........................................................................................................................................................................
cient, the patient may benefit from advanced heart failure therapies. speaker/advisor for Abbott, CARMAT, ORION Pharma, Bayer,
Inotropic agents have frequently been used as intermittent intra- Corvia, and Novartis. S.T.: advisor to Medtronic, HeartWare,
venous infusions, but no definitive outcome data from prospective, CorWave, and 3R. E.B.C.: personal fees (travel grants, lecture fees,
randomized trials are available and some studies have shown an advisory board) from Novartis, Rovi, Abbott Vascular, Servier,
association with increased mortality. Thus, these agents provide MSD; academic grant from Abbott Vascular (PCHF Course of
only symptomatic treatment or stabilization in unstable conditions. the ESC); research grant from Fundacion Mutua Madrilena. T.H.:
Impressive progress has been made with MCS devices. At least four personal fees (lecture) from Novaris, Boehringer Ingelheim.
devices are available for the immediate treatment of cardiogenic S.N.: research investigator for Amgen; personal fees (advisory
shock. Heart transplantation is considered the treatment of choice board, speaker bureau) from Medtronic, Novartis, Actelion,
for eligible patients with excellent survival and quality of life, but Bayer, GlaxoSmithKline; non-financial support from Abbott. J.B.:
it is limited by organ availability, graft dysfunction, and side effects honoraria for lectures and/or consulting from Novartis, Pfizer,
of immunosuppression. Long-term MCS can be used as a BTT or Vifor, Bayer, Servier, Orion, CVRx, Abiomed, Abbott/St. Jude
as DT. Recent improvement in the characteristics of MCS devices Medical/Thoratec, Medtronic/Heartware; research support from
will broaden their indications and make them a valid alternative to Zoll, CVRx, Bayer, Vifor, Abiomed, Medtronic. F.R.: research
medical treatment in patients with advanced heart failure. Lastly, grants from St. Jude Medical, Novartis; personal fees (lectures,
palliative care is indicated when patients are ineligible for advanced advisory board meetings, steering committee member) from
heart failure therapies or after advanced therapies have been per- St. Jude Medical, Servier, Zoll, AstraZeneca, Sanofi, Novartis,
formed and patient progresses to end-of-life. Finally, it is important Amgen, BMS, Pfizer, Fresenius, Vifor, Roche, Bayer, Abbott.
to note that no therapy in advanced heart failure is based on reli- F. R. received as direct personal payment speaker fees, honoraria,
able prospective studies, and there is an urgent need to develop consultancy, advisory board fees, investigator, committee member,
evidence-based treatment algorithms to prolong life, increase life etc. from Amgen, Boehringer-Ingelheim, Novartis, Pfizer, BMS,
quality, and reduce the burden of hospitalization in this vulnerable Servier, Sanofi Aventis, Zoll Medical, Abbott/St. Jude Medical,
patient population. Fresenius Nutrition, Vifor International, Cardiorentis, Heartware
and as payment to institution speaker fees, honoraria, consultancy,
advisory board fees, investigator, committee member, tc. from
Supplementary Information Bayer, Novartis, Abbott/St. Jude Medical. The other authors have
Additional supporting information may be found online in the no conflicts of interest to disclose.
Supporting Information section at the end of the article.
Table S1. Ultrafiltration clinical trials: overview of study designs
and key findings.
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European Journal of Heart Failure (2018) 20, 1505–1535 HFA POSITION STATEMENT

Advanced heart failure: a position statement

© 2018 The Authors

Introduction purpose of this document, we consider ‘advanced’, ‘refractory’,

© 2018 The Authors

Table 1 Prior definitions and indicators of advanced heart failure

© 2018 The Authors

Profile Time frame for intervention

© 2018 The Authors

© 2018 The Authors

Table 3 Updated HFA-ESC criteria for defining advanced heart failure

© 2018 The Authors

© 2018 The Authors

Table 5 Prognostic scores

Score Components Comments

SHFM109 • Demographics Incorporates impact of interventions (medical and

MAGGIC105 • Age Risk model converted into integer score

© 2018 The Authors

Table 6 Suggested clinical, laboratory, and echocardiographic criteria to trigger referral*

Clinical Laboratory Imaging Risk score data

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Co-morbidity causing YES

Advanced HF despite NYHA class II

Manage in local HF service

© 2018 The Authors

Table 7 Inotropes and vasoconstrictors

Mechanism of action Haemodynamic effect Comment

CO, cardiac output; PDE2, phosphodiesterase-2; SVR, systemic vascular resistance.

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© 2018 The Authors

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© 2018 The Authors

© 2018 The Authors

Table 8 Indications and contraindications to heart transplantation

© 2018 The Authors

Table 9 Considerations in assessment of co-morbidities

Co-morbidity Parameters to evaluate

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© 2018 The Authors

© 2018 The Authors

Medtronic)235,248 – 253,257 centrifugal pump 84% 1-year survival248 Haemorrhagic stroke

European Journal of Heart Failure © 2018 European Society of Cardiology

at high risk for mortality from heart failure frequently overesti-

© 2018 The Authors

Spoke: Community HF units Specialized HF unit Tertiary Hub: Advanced HF unit

© 2018 The Authors

© 2018 The Authors

© 2018 The Authors

© 2018 The Authors

© 2018 The Authors

© 2018 The Authors

© 2018 The Authors

© 2018 The Authors

© 2018 The Authors

© 2018 The Authors

© 2018 The Authors

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