People with advanced heart failure have severe symptoms that interfere with their daily lives. While doctors cannot cure advanced heart failure, treatments and procedures ranging from open-heart surgery to palliative care can help lessen the condition’s impact.

Heart failure happens when the heart muscle cannot pump blood as well as it should. This results in blood backing up and fluid building up in the lungs, causing someone to be short of breath. In this state, cardiac output is low, meaning that the heart cannot deliver enough blood to the rest of the body.

In advanced heart failure, the condition progresses to the point that traditional therapies are no longer working. More than 6 million adults in the United States have heart failure, and around 10% of those have advanced heart failure.

In this article, we examine the potential treatments available for advanced heart failure. We discuss the guidelines, medicinal and surgical strategies, and palliative care.

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Doctors cannot cure advanced heart failure, so they may present people with various decisions on how to move forward with their care. A person may need to:

  • consider whether they would like to try aggressive treatment
  • choose whether to prioritize quality of life or length of life
  • decide how they feel about resuscitation

A person should work with a doctor to decide the best treatment for them, considering their life goals and end-of-life preferences.

In 2022, the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America (HFSA) updated their joint guidelines for managing heart failure, including advanced heart failure.

The guidelines state that if a person with advanced heart failure wants to try to prolong their life, a doctor should refer them to a specialist team that assesses suitability for advanced heart failure therapy.

Doctors may recommend medication, such as inotropic therapy, when other drugs no longer manage heart failure symptoms. Inotropic therapy involves receiving an infusion of medications that helps the heart muscle contract and stimulates the heart to pump harder.

However, the ACC/AHA/HFSA guidelines warn that giving a person intravenous inotropic medicines in the long term can be harmful. Doctors typically prescribe these drugs to make someone comfortable at the end of their life or while a person is waiting to transition to another treatment.

Doctors treat advanced heart failure with the following specialized medical interventions.

Open-heart surgery

Open-heart surgery involves stopping the heart during the surgery and restarting it afterward. A heart-lung machine takes over circulating and oxygenating blood while a surgeon performs heart surgery. The AHA says it is unclear whether this type of procedure works for advanced heart failure.

There are several types of open heart surgery. Not all types are suitable in cases of advanced heart failure.

Depending on the underlying reason for heart failure, one of the following surgeries may be an option:

  • Coronary artery bypass graft: In cases of heart failure from coronary artery disease, a surgeon may use a vein or artery from elsewhere in the body to route blood flow around a blockage.
  • Valve surgery: If there is damage to the aortic or mitral valve, a surgeon may repair or replace it.
  • Pericardiectomy: A surgeon may relieve pressure on the heart by removing some of the heart lining, or pericardium, that has become stiff as a result of inflammation.

Percutaneous interventions

A surgeon may access the heart by threading specialized tools through a blood vessel. A person not suited to heart surgery may benefit from a percutaneous procedure.

During a valve intervention, a cardiologist can use a balloon to widen a narrowed valve, a clip to close a leaky valve, or a catheter to implant an artificial valve.

A cardiologist can perform a percutaneous coronary intervention or coronary angioplasty to open clogged coronary arteries using balloons and stents.

Cardiac resynchronization therapy

A person with advanced heart failure may have a delay in the contraction of the left and right ventricles. The ventricles need to contract in coordination to pump blood effectively.

In cardiac resynchronization therapy, a surgeon fits a person with a special pacemaker to coordinate the electrical signals between the ventricles. This helps the chambers pump in a coordinated manner.

Baroreflex activation therapy

Doctors can implant a Food and Drug Administration-approved device to electrically stimulate the baroreceptors of the blood vessels that supply blood to the brain, neck, and face, known as the carotid artery.

A 2020 study suggests that this therapy is safe and significantly improves a person’s quality of life, exercise capacity, and NT-proBNP levels. High levels of NT-proBNP in the blood are an indicator of heart failure.

Mechanical circulatory support

Doctors can fit a person with effective mechanical circulatory support on a temporary or long-term basis. This can help improve a person’s symptoms and heart function and reduce their risk of death.

The ACC/AHA/HFSA guidelines state that some people with advanced heart failure who are receiving inotropic therapy or temporary mechanical circulatory support can benefit from the implantation of a left ventricular assist device. This can improve quality of life and survival.

The following mechanical support devices can help a person with advanced heart failure for days or weeks while they await a more permanent solution:

  • Intra-aortic balloon pump: This lessens the heart’s workload by inflating a balloon inside the aorta when the heart relaxes and deflating it before the heart contracts.
  • Percutaneous ventricular assist device: This device takes over the workload of the left ventricle, using a tube in the left side of the heart to pull oxygenated blood from the heart and send it around the body.
  • Extracorporeal membrane oxygenation: This involves passing blood through a machine to increase its oxygen content before returning the oxygenated blood to the body.

However, the AHA highlights drawbacks of these devices, such as an increased risk of stroke, bleeding in the gastrointestinal tract, and infection.

Heart transplant

Some people with advanced heart failure may benefit from heart transplant surgery. Heart transplant surgery can improve their chances of survival and quality of life.

People with advanced heart failure commonly have hyponatremia, or low levels of sodium in the blood, and fluid buildup that is not responsive to medications that help relieve fluid retention, known as diuretics.

Heart failure nutrition advice usually focuses on limiting salt and fluid intake. However, research suggests that restricting fluids has limited benefit for increasing sodium levels.

Advanced heart failure can reduce the kidneys’ ability to remove sodium and water from the body. In cases of kidney failure, dialysis may be necessary to remove excess fluid and other waste products from the blood.

People with advanced heart failure should discuss their dietary requirements with a doctor or a registered dietitian to ensure that they receive evidence-based advice.

A specialist heart failure team can provide palliative care, which aims to help relieve symptoms and improve a person’s quality of life, anxiety and depression symptoms, and spiritual well-being regardless of the stage of illness.

Palliative care is not the same as hospice care and does not mean a person needs to stop receiving treatment for heart failure. The exact strategy for palliative care depends on each individual’s needs and preferences.

Doctors cannot cure advanced heart failure, but treatments can help a person live longer. In some cases, a person with a newer-generation left ventricular assist device has an 80% chance of surviving at least 2 years. This is nearly equivalent to early survival after a heart transplant.

The median survival rate for an adult heart transplant recipient is now more than 12 years, while the median survival rate in people with advanced heart failure who do not receive advanced treatments is less than 2 years.

When a person has advanced heart failure, their symptoms are severe enough to interfere with daily life.

While doctors cannot cure advanced heart failure, a range of treatments can help lessen the impact of symptoms and extend a person’s life.

To determine the most suitable treatment strategy, a person should evaluate their needs with the help of healthcare professionals and loved ones.