Advanced HFrEF, inotrope dependence and LVAD as bridge to candidacy — case discussion

Presentation

Practice case (not a real patient). A 57-year-old woman has ischaemic HFrEF with an LVEF of 20%. She takes foundational medical therapy at maximally tolerated doses, additional medical therapy where indicated, and has a CRT-defibrillator.^[1] Over the last 12 months she has had three hospitalizations with congestion needing high-dose intravenous diuretics, two appropriate defibrillator shocks, and her loop diuretic dose has doubled. She has NYHA class IV symptoms. She is motivated and lives with her husband.^[1]

Step 1 — Is this advanced heart failure, and should she be referred?

Discussion:

• She meets three ESC 2026 Table 14 criteria outright: NYHA class III or IV symptoms, LVEF ≤30%, and ≥2 hospitalizations for congestion needing high-dose i.v. diuretics in 12 months; criterion 4 (inability to exercise, 6-min walk <300 m, or pVO₂ <12–14 mL/kg/min (12 for patients on beta-blocker) or <50% predicted, estimated to be of cardiac origin) still needs to be assessed, and all four must be present despite FMT, AMT and GDIT.^[1]
• She is at high risk under ESC 2026 Table 15 either way: Rule of three (HFH ≥2 within the last year) and I NEED HELP items N (NYHA class III/IV), D (defibrillator shocks), H (HFH >1) and E (escalating diuretics).^[1]
• ESC 2026 recommends early consultation with an advanced HF centre in patients with advanced HF or at risk of advanced HF, who are motivated and do not have absolute contraindications for heart transplantation or durable MCS, in order to evaluate candidacy (Class I, Level A).^[1]
• AHA/ACC/HFSA 2022 says a complete assessment of the patient is not required before referral.^[2]

Step 2 — At the advanced HF centre

• Cardiopulmonary exercise testing and right heart catheterization are each recommended in advanced HF as part of the evaluation for heart transplantation and durable MCS (ESC 2026, Class I, Level C).^[1]
• Her CPET shows a peak VO₂ of 10 mL/kg/min on a beta-blocker, which meets ESC 2026 criterion 4 (pVO₂ <12–14 mL/kg/min; the 12 mL/kg/min cut-off refers to patients on beta-blocker), provided her exercise limitation is estimated to be of cardiac origin; with her other three criteria present despite FMT, AMT and GDIT, she then meets all four Table 14 criteria.^[1]
• Right heart catheterization shows a cardiac index of 1.8 L/min/m² with rising creatinine and bilirubin despite euvolaemia.^[1]

Step 3 — She deteriorates on the ward

While awaiting the transplant or LVAD decision at the advanced HF centre, she develops worsening renal and hepatic function and cool peripheries, and starts intravenous dobutamine.^[1] Three attempts to wean it over the next 3 days each produce symptomatic hypotension; her beta-blocker and RAS inhibitor doses are not changed.^[1] Back on a moderate dose of dobutamine she is clinically stable, and her renal and hepatic function improve.^[2][1]

• ESC 2026: continuous inotropes should be considered in patients with advanced HFrEF, low cardiac output and evidence of hypoperfusion or end-organ dysfunction, as BTD, BTT or bridge to durable MCS, to increase cardiac output and improve symptoms (Class IIa, Level C).^[1]
• She now meets the ESC 2026 Table S18 definition of inotrope dependency: failure to wean within 72 h without symptomatic arterial hypotension, with no beta-blocker or RAS inhibitor change at the time.^[1]
• She is clinically stable on a moderate dose, each documented attempt to wean has produced symptomatic hypotension, and her organ function is improving rather than continuing to deteriorate. That fits INTERMACS profile 3 (stable but inotrope dependent) in AHA/ACC/HFSA 2022 Table 17, not profile 2, which describes continuing deterioration on inotropes.^[2]

Step 4 — Transplant or LVAD?

• With HF and a severely reduced LVEF, INTERMACS 2–4 is an ESC 2026 Table 16 indication for an LVAD.^[1]
• ESC 2026: durable MCS (LVAD) is recommended in selected patients with advanced HFrEF, despite FMT and GDIT, as BTT, BTC, BTR, or as destination therapy to improve symptoms and reduce the risk of death (Class I, Level C).^[1]
• AHA/ACC/HFSA 2022: in select patients with advanced HFrEF with NYHA class IV symptoms who are deemed to be dependent on continuous intravenous inotropes or temporary MCS, durable LVAD implantation is effective to improve functional status, QOL, and survival (COR 1, LOE A).^[2]
• With her renal and hepatic function improved on dobutamine, the team checks the ESC 2026 absolute contraindications, including severe irreversible end-organ (kidney and/or liver) disease, severe RV dysfunction despite euvolaemic status and contraindication to long-term oral anticoagulation; none is present.^[1]
• Her pulmonary vascular resistance is high and does not fall with vasodilator testing; ESC 2026 Table 17 lists pharmacologically irreversible elevated PVR among the contraindications to transplantation, and its footnote says LVAD as bridge to candidacy should be considered.^[1]
• ESC 2026 defines bridge to candidacy as the use of durable and temporary MCS (usually LVAD) to improve end-organ function and/or to make an ineligible patient eligible for heart transplantation.^[1]

Step 5 — Planning ahead

• ESC 2026 recommends proactive discussion of HF trajectory, goals of care and advance care planning in patients with advanced HF to facilitate communication on end of life and QoL (Class I, Level B1).^[1]
• AHA/ACC/HFSA 2022 says every form of MCS will eventually be turned off, and this should be addressed with patients before discussions about MCS.^[2]
• She carries a CRT-defibrillator and her health has deteriorated: ESC 2022 VA/SCD Recommendation Table 21 says informed discussion with patient and family about ICD deactivation options and shared decision-making is indicated prior to implantation and in case of significant health status deterioration (Class I, Level C).^[16]
• After implantation, ESC 2026 says bleeding events can be minimized by avoiding antiplatelet therapy in addition to anticoagulation; ARIES-HM3 (randomised, double-blind, placebo-controlled; 628 patients with advanced HF and a fully magnetically levitated LVAD on a VKA) found placebo noninferior to aspirin 100 mg/d for survival free of haemocompatibility events at 12 months (74% vs 68%), and aspirin avoidance was associated with reduced nonsurgical bleeding.^[1][8]