Chronic Inotropic Therapy in the Current Era: Old Wines With New Pairings.

I n the current issue of Circulation: Heart Failure, Hashim and fellow researchers from the University of Alabama at Birmingham have published their outcomes for advanced heart failure (HF) patients supported with chronic inotrope infusions for a variety of indications, including bridging to transplanta-tion, anticipation of left ventricular assist device (LVAD) placement or for palliation. 1 This single-center retrospective series of 197 patients describes better patient survival than most previous reports, with a median survival of 18 months compared with 3 to 6 months. 2–4 Median survival was 9 months for those patients in whom continuous inotropic therapy was intended solely as palliation, with a 1-year actuarial survival of 48% and a 2-year actuarial survival of 38%. Filling pressures and cardiac index improved, and subjective symptom class decreased from Class IV at baseline to median Class III after discharge. Intravenous inotropic therapy has been described as the " until therapy. " 2 Patients with Stage D HF may be discharged on this therapy with the intention of use until cardiac transplantation or determination of transplant eligibility and can also be used until decision or implementation of mechanical circulatory support. Outcomes of inotropic therapy for these patients are highly influenced by regional transplant waiting times and more recently by the threshold for implantation of ventricu-lar assist devices. The focus of this editorial will instead be the outcomes and options for those patients discharged on inotropic therapy intended as the last specific intervention to improve symptoms of HF until the end. What accounts for the apparent improvement in survival in this report? These clinicians experienced in triage of Class D patients studied an appropriate HF population similar to experiences previously summarized with median survival of ≈6 months on chronic inotropic therapy. 2,4 There were multiple previous hospitalizations, and the mean ejection fraction was 18%; cardiac index, 1.7 L/min per m 2 ; pulmonary capillary wedge pressure, 26 mm Hg; and cardiac index, 1.9 L/ min per m 2. In the most detailed report from the previous era, Hershberger in 2003 4 described a 1-year survival of only 6% in patients with similarly severe compromise and no option for transplantation, with cardiac index of 1.9 L/min per m 2 and pulmonary capillary wedge pressure of 28 mm Hg, although he documented more rigorous criteria for failed weaning. Could the improved survival in this report result from the high rate of continuation of neurohormonal …