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Understanding you have options

Having advanced heart failure doesn’t mean you have no treatment options. New therapies and technologies offer more choices than ever.

This is why shared decision-making helps. Your health care professional can help your understand and choose the best treatment options for your goals and priorities.

Consider implantable cardioverter defibrillators (ICDs). For a patient who wants to live as long as possible, an ICD can lower the risk of sudden cardiac death by shocking the heart back to its normal heartbeat. However, an ICD may not be suitable for patients who have expressed the desire to die in their sleep.

Your life goals and end-of-life preferences help decide what’s best for you.

Understanding your treatment options

Advanced heart failure can’t be cured, but it can be treated. Treatments can reduce your symptoms and improve heart function. But treatments come with risks and benefits. Talk about your options with your health care professional.

People may not always understand the possible side effects or trade-offs of a treatment. For example, a mechanical heart pump, called a left ventricular assist device (LVAD) can help the heart pump better and reduce symptoms such as shortness of breath. It can improve quality of life and extend lifespan. It also increases the risk of infection, , blood clots and gastrointestinal bleeding. Also, the pump’s electrical cord must be worn outside the body on a belt or harness.

At some hospitals, palliative care specialists help patients make medical decisions, such as whether to get an LVAD.

Research suggests that cognitive and other issues should be discussed and monitored as part of the treatment plan. Talk with your health care professional about the benefits and risks of each treatment you need now and in the future. 

Treatment options for advanced heart failure

Major interventions

• Open-heart surgery might be an option for some patients with stable advanced heart failure. The surgery requires stopping the heart and using a machine to pump blood until the heart is restarted. It can help patients with treatable causes of heart failure, such as coronary artery disease or valve defects. The success of the surgery depends on the patient’s condition and specific heart problem.
• High-risk surgeries for advanced heart failure include:
  • Coronary artery bypass graft: If heart failure is caused by coronary artery disease, bypass surgery might be an option. A surgeon uses arteries or veins taken from other parts of the body to reroute blood flow around blocked heart arteries.
  • Valve surgery: Heart valves control the one-way flow of blood through the heart. In advanced heart failure, the mitral valve might leak if the muscles around it become too weak to close tightly. Sometimes, heart failure is caused by stiffness, or stenosis, of the aortic valve. This prevents it from opening completely and reduces blood flow to the body. Surgeons can repair or replace a damaged valve.
  • Pericardiectomy: The pericardium is a thin sac around the heart. Long-term inflammation can make it stiff and thick, causing constrictive pericarditis. This squeezes the heart and stops it from beating normally. During a pericardiectomy, most of the stiff sac is removed to relieve pressure on the heart.
  • Heart transplant: A heart transplant replaces a failing heart with a healthy donor heart. Heart failure symptoms can improve or disappear after the transplant. But, it also comes with its own issues.
    
    Heart transplant patients must take daily medication to prevent rejection of the new heart. These medications can cause side effects such as diabetes, kidney disease and high blood pressure. Patients are also at higher risk for infection and cancer.
    
    About 85% of people who have a transplant are still alive one year after surgery. Each year after that, survival rates decrease by only about 3% to 4% due to complications. Heart transplant remains a good treatment option for patients with advanced heart failure.  
    
    
• Percutaneous interventions are nonsurgical procedures done on a beating heart. Instead of open-heart surgery, special tools are used through a small opening in the groin. These procedures can be used for advanced heart failure patients who can’t have surgery. Options include: 
  • Percutaneous valve intervention: Different procedures are used for different valve defects. 
    •  A narrowed valve can be widened with a balloon. 
    • For a leaky valve, a clip can reduce the leak. 
    • A  faulty valve can be replaced with an artificial one through a catheter. 
  • Percutaneous coronary intervention (PCI), or coronary angioplasty, uses an inflatable balloon to open a blocked heart artery. The balloon pushes against the blood vessel wall to restore blood flow. Sometimes, a small mesh tube called a stent is put in the artery to keep it open.
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• Permanent implantable devices
  • Pacemaker: Advanced heart failure can cause delayed contractions of the right and left ventricles. (The ventricles are the heart’s main pumping chambers that normally contract at the same time.) In cardiac resynchronization therapy, or CRT, a pacemaker helps the ventricles pump together by coordinating their electrical signals.
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  • An implantable cardioverter defibrillator (ICD) can reduce the risk of sudden cardiac death. It shocks the heart to stop a fatal irregular heartbeat, called arrhythmia, and restore a normal rhythm. ICD decisions should consider the patient’s overall prognosis and quality of life, not just personal preference. An ICD does not improve heart function or relieve symptoms of advanced heart failure. It is a safeguard against possibly fatal events, such as cardiac arrest or a heart attack. Most newer ICDs can also work as a pacemaker.
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Temporary therapies

Short-term treatments can sometimes help a patient recover from a condition that can get better, such as acute kidney failure. Temporary treatments can also be a step toward a permanent solution, such as a heart transplant.

However, if the patient’s health gets worse, these solutions might be needed for a long time. Health care professionals and patients should talk about the possibility of long-term use before deciding on one of these treatments:

• Temporary mechanical support devices can help the heart pump blood after a heart attack, severe inflammation of the heart muscle (myocarditis) or another heart emergency. These devices support the heart temporarily, until it recovers. Examples include: 
  • An intra-aortic balloon pump is a small balloon placed inside the aorta, the major artery connected to the heart. The balloon is connected to a machine outside the body that inflates the balloon when the heart relaxes and deflates it before the heart pumps. This helps reduce the heart’s workload and increases blood flow. The pump is usually needed for only a few days.
  • A percutaneous ventricular assist device (LVAD) takes over the workload of the left ventricle, which pumps blood to the body. Normally, blood moves from the left atrium to the left ventricle and then out to the body. With an LVAD, a tube placed in the left atrium pulls oxygen-rich blood out of the heart and circulates it throughout the body. The device might be inserted through a small opening in the skin. The pump and its controller remain outside the body. The device is typically used for up to two weeks.
  • Extracorporeal membrane oxygenation (ECMO) is a machine that increases the oxygen in the blood and then returns it to the body. ECMO is typically needed for only days or weeks.
• Positive inotropic drugs are given through an IV to make the heart beat more strongly.
• Renal replacement therapy: Advanced heart failure can strain the kidneys, making it hard for them to remove sodium and water. If the kidneys fail, renal replacement therapy, such as dialysis, can remove waste and extra fluid from the blood.
• An implantable left ventricular assist device (LVAD) can temporarily help patients waiting for a donor heart. If a heart transplant isn’t possible, an LVAD can help the heart pump blood for the long term.
  
  The pump is placed in the upper abdomen and works like a mechanical heart. It moves blood from the left ventricle to the aorta. A tube connects the pump to a battery and control system worn outside the body. 

Other health problems

People with advanced heart failure can develop other health problems. Surgery for these problems can be risky. It’s important to consider if the benefits outweigh the risks. Talk to your health care professional about your health issues and potential surgeries.