Table 6.
Framework of Major Medical Decisions in Advanced Heart Failure Faced by Patients and Their Clinicians
| Types of Options | Specific Examples of Interventions | Generally Considered Only for HF With Reduced LVEF | Examples of Uncommon Outcomes That Could Be Anticipated With “What If” Discussions in High-Risk Patients |
|---|---|---|---|
| Major interventions that may improve cardiac function | CABG Valve surgery | Worsened cardiac function/inability to come off bypass or IABP: Place MCS? | |
| Pericardial stripping | Ventilator dependence: Extubate? When? | ||
| Percutaneous valve intervention | Stroke: Feeding tube? Institutional care? | ||
| PCI | Coronary occlusion: Revert to CABG? | ||
| CRT | X | Unable to place coronary sinus lead: Convert to thoracotomy? | |
| Therapies that only reduce the risk of sudden cardiac death | ICD | X | Terminal or permanently disabling disease: Device deactivation? |
| Adjunctive therapies instituted during acute decompensation with potential chronic dependence | Temporary support devices (IABP, percutaneous VAD, ECMO) | X | Unable to wean: Convert to permanent MCS or withdraw? |
| IV inotropes | X | Unable to wean: Transition to home inotropes or discontinue? | |
| Renal replacement therapy (dialysis or ultrafiltration) | Failure of acute injury to resolve: Initiate indefinite hemodialysis or discontinue? | ||
| Advanced surgical therapies to exchange disease | Transplantation | X | Early graft failure or other serious postoperative complications: MCS or withdraw support? |
| Later graft failure: Retransplantation? | |||
| Permanent MCS/LVAD | X | Stroke, infection, or recurrent bleeding: Turn off device? | |
| Noncardiac procedures for comorbidities | Joint replacement Hernia repair | Worsening heart failure causing hemodynamic and/or respiratory collapse: Continue ventilatory support and/or initiate circulatory support? | |
| Resection of pulmonary nodule Asymptomatic aortic aneurysm repair Screening colonoscopy | Not generally to be done, because risks are thought to outweigh potential benefit |
HF indicates heart failure; LVEF, left ventricular ejection fraction; CABG, coronary artery bypass grafting surgery; IABP, intra-aortic balloon pump; MCS, mechanical circulatory support; PCI, percutaneous coronary intervention; CRT, cardiac resynchronization therapy; ICD, implantable cardioverter-defibrillator; VAD, ventricular assist device; ECMO, extracorporeal membranous oxygenation; and IV, intravenous.