ABSTRACT
In this chapter, we discuss evidence-based advanced therapeutic options for patients presenting with acute decompensated heart failure, based upon their clinical profile. Patients who have a “warm and wet” phenotype with symptoms of congestion but preserved perfusion, should undergo fluid removal with intravenous diuresis, or ultrafiltration if they fail maximal diuretic therapy. Vasodilators may be considered to improve left ventricular filling pressures and perfusion while aiding with decongestion. In patients who have a “cold and wet” phenotype with both symptoms of congestion and hypoperfusion, intravenous inotropes such as dobutamine, milrinone, and dopamine may be utilized with appropriate hemodynamic monitoring. If refractory to medical management, patients should be evaluated for short-term mechanical circulatory support with e.g., intra-aortic balloon pump, Impella, or extracorporeal membrane oxygenation, and/or long-term mechanical circulatory support or heart transplant if no recovery is anticipated. Palliative care should be involved early in the management of these patients. Management of right heart failure involves addressing the underlying cause, preload optimization with either fluids or diuretics as necessary, afterload reduction with pulmonary vasodilators, and inotropes to enhance right ventricular contractility. Similar to left ventricular failure, mechanical circulatory support should be considered in cases with right ventricular failure refractory to medical management.
