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©2013 UpToDate ® Print Email ACC/AHA guideline summary: Management of refractory end-stage heart failure (HF, stage D) Class I - There is evidence and/or general agreement that the following approaches are effective for management of patients with end-stage HF • Referral to an HF program with expertise in this problem. • Careful control of fluid status. • Referral for cardiac transplantation if potentially eligible. • Options for end-of-life care should be discussed with patient and family. • Patients with an implantable cardioverter-defibrillator should be informed about the option of inactivating the device. Class IIa - The weight of evidence or opinion is in favor of the usefulness of the following approach in patients with end-stage HF • A left ventricular assist device as permanent or "destination" therapy in highly selected patients with an estimated one-year mortality exceeding 50 percent. Class IIb - The weight of evidence or opinion is less well established for the usefulness of the following approaches in patients with end-stage HF • Placement of a pulmonary artery catheter as a guide to therapy if persistent severe symptoms. • Mitral valve surgery (repair or replacement) for severe secondary mitral regurgitation. • Continuous intravenous infusion of an inotropic agent for palliation of symptoms. Class III - There is evidence and/or general agreement that the following approaches are not useful or may be harmful in patients with end-stage HF • Partial left ventriculectomy in nonischemic cardiomyopathy. • Routine intermittent infusions of vasoactive and positive inotropic agents. Data from Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391.