Tailored therapy before transplantation for treatment of advanced heart failure: effective use of vasodilators and diuretics

Abstract

Because of the limited supply of donor hearts, many candidates for heart transplantation must remain on waiting lists for several months. Although most such patients are considered to be refractory to standard therapy with vasodilators, diuretics, and digoxin, many will respond to a more intensive approach specifically tailored to hemodynamic goals in advanced heart failure. In this article the principles, design, and benefits of tailored therapy are reviewed. In addition, six common ideas about the management of advanced heart failure, derived from other patient populations, are shown to be myths. These myths are (1) that a low ejection fraction precludes good hemodynamics, exercise capacity, and survival; (2) that high ventricular filling pressures are necessary to maintain cardiac output in patients with chronic dilated heart failure; (3) that vasodilators in chronic advanced heart failure act primarily to increase ejection fraction and total stroke volume; (4) that hemodynamics measured during drug titration do not predict long-term benefit; (5) that the interval risk of deterioration and death without transplantation increases with time from evaluation; and (6) that for patients with low ejection fractions, heart transplantation is always better than medical therapy.