Reference Guide

Heart Failure, Transplantation & Valvular Disease

End-stage HF, ISHLT guidelines, transplant management, and structural heart

Profile	Description	Time Frame for MCS
1 – Critical Cardiogenic Shock	Hemodynamic instability despite escalating inotropes/MCS	Hours
2 – Progressive Decline	Inotrope-dependent with ongoing deterioration	Days
3 – Stable but Inotrope-Dependent	Hemodynamically stable on inotropes, cannot wean	Weeks
4 – Resting Symptoms	Daily symptoms at rest without inotropes	Weeks to months
5 – Exertion Intolerant	Comfortable at rest, limited activity	Variable
6 – Exertion Limited	Comfortable with modest activity	Variable
7 – Advanced NYHA III	Clinically stable with meaningful activity	Not indicated

Stage A (At Risk): Large MI, prior HF, acute-on-chronic decompensation without hypoperfusion
Stage B (Beginning Shock): Relative hypotension, tachycardia, elevated lactate trending up
Stage C (Classic CS): CI <2.2, PCWP >15, requiring vasopressors/inotropes; lactate >2
Stage D (Deteriorating): Failing initial interventions, escalating support, multi-organ dysfunction developing
Stage E (Extremis): Refractory cardiac arrest, PEA/VF, ECPR considered
Key Principle: Early invasive hemodynamic assessment (PAC) and early MCS consideration before Stage D/E

Listing Criteria: Refractory advanced HF (INTERMACS 1–4) despite optimized GDMT, estimated 1-year mortality >20% without transplant
Absolute Contraindications: Active malignancy, irreversible pulmonary hypertension (PVR >5 WU unresponsive to vasodilators), active systemic infection, severe irreversible end-organ dysfunction
Preoperative Desensitization: For highly sensitized patients (cPRA >50%), plasmapheresis, IVIg, rituximab, and/or bortezomib protocols per ISHLT 2024
Donor Selection: Size matching, ischemic time <4h (ideally <6h with ex-vivo perfusion), donor age/comorbidities assessment

Denervated Heart: Resting HR 90–110 bpm; no vagal response. Responds to direct-acting agents (isoproterenol, epinephrine) NOT indirect (atropine ineffective)
RV Failure (30–50%): Most common cause of early mortality. Manage with iNO, milrinone, epinephrine ± temporary RVAD
Primary Graft Dysfunction (PGD): ISHLT grading. Severe PGD → VA-ECMO as bridge to recovery
Immunosuppression Induction: Basiliximab or ATG; triple maintenance with tacrolimus, mycophenolate, prednisone
Rejection Surveillance: Endomyocardial biopsy at protocol intervals; treat cellular rejection per ISHLT grading (≥2R requires pulse steroids)
Infection Prophylaxis: CMV (valganciclovir), PJP (TMP-SMX), fungal (nystatin/fluconazole), toxoplasmosis in high-risk

Valve	Key Post-Op Issues	CVICU Priorities
Aortic (SAVR)	Conduction block (LBBB/CHB 3–10%), bleeding, stroke, prosthetic endocarditis	Temporary pacing wires ready; monitor PR/QRS; anticoagulation per valve type
Aortic (TAVR)	New LBBB (15–25%), paravalvular leak, vascular access complications, AKI from contrast	Continuous telemetry ≥48h; assess for PPM need; monitor access site
Mitral (repair/replace)	SAM/LVOTO after repair, LV dysfunction, AF, annular dehiscence	TEE confirmation; avoid hypovolemia + vasodilators if SAM suspected
MitraClip	Residual MR, pericardial effusion, single-leaflet device attachment	Serial echo; watch for hemodynamic deterioration
Tricuspid	RV failure, AV block, hepatic congestion	Optimize RV function; temporary pacing; gentle diuresis

Mechanical Aortic: INR 2.0–3.0 (add aspirin 75–100 mg)
Mechanical Mitral: INR 2.5–3.5 (add aspirin 75–100 mg)
Bioprosthetic: Aspirin ± warfarin first 3–6 months, then aspirin alone
TAVR: Dual antiplatelet (aspirin + clopidogrel) × 3–6 months per institutional protocol
Bridge Anticoagulation: Heparin infusion when INR subtherapeutic in high-risk mechanical valves

Indications: Bridge to transplant (BTT), destination therapy (DT), bridge to candidacy/decision
Flow Dynamics: Continuous-flow (CF) devices (HeartMate 3, HVAD); pulsatility index (PI) reflects native LV contribution
Target Parameters: Flow 4–6 L/min, speed per device, PI 3–5 (HM3), power 4–7 W
Suction Events: Low flow + low PI → hypovolemia, RV failure, tamponade, arrhythmia → volume, reduce speed, echo
Pump Thrombosis: Rising power (HM3 >9 W), elevated LDH >2.5× ULN, dark urine → heparin, consider thrombolytics or device exchange
Anticoagulation: Warfarin (INR 2.0–3.0) + aspirin 81–325 mg; bridge with heparin post-op
RV Failure Post-LVAD: Occurs in 20–40%; preoperative predictors include elevated CVP, low PAPi, poor RV strain

S.K.

The World-Class Cardiac Intensivist

This content is for educational reference only. Always follow institutional protocols and exercise clinical judgment.

Advanced Heart Failure Management