A. Case Management, Diet, and Exercise Training
Thirty to 50 percent of congestive heart failure patients who are hospitalized will be readmitted within 3-6 months. Strategies to prevent clinical deterioration, such as case management, home monitoring of weight and clinical status, and patient adjustment of diuretics, can prevent rehospitalizations and should be part of the treatment regimen of advanced heart failure.

Patients should routinely practice moderate salt restriction (2-2.5 g sodium or 5-6 g salt per day). More severe sodium restriction is usually difficult to achieve and unnecessary because of the availability of potent diuretic agents.

Exercise training improves activity tolerance in significant part by reversing the peripheral abnormalities associated with heart failure and deconditioning.

In severe heart failure, restriction of activity may facilitate temporary recompensation. However, in stable patients, a prudent increase in activity or a regular exercise regimen can be encouraged. Indeed, a gradual exercise program is associated with diminished symptoms and substantial increases in exercise capacity.

B. Coronary Revascularization
Since underlying coronary artery disease is the cause of heart failure in the majority of patients, coronary revascularization may both improve symptoms and prevent progression. However, trials have not been performed in patients with symptomatic heart failure. Nonetheless, patients with angina who are candidates for surgery should be evaluated for revascularization, usually by coronary angiography. Noninvasive testing for ischemic but viable myocardium may be a more appropriate first step in patients with known coronary disease but no current clinical evidence of ischemia. The benefit of evaluating patients with heart failure of new onset without angina or prior myocardial infarction is limited. In general, bypass surgery is preferable to PTCA in the setting of heart failure because it provides more complete revascularization.

C. Biventricular Pacing (Resynchronization)
Many patients with heart failure due to systolic dysfunction have abnormal intraventricular conduction that results in dyssynchronous and hence inefficient contractions. Several studies have evaluated the efficacy of “multisite” pacing, using leads that stimulate the right ventricle from the apex and the left ventricle from the lateral wall via the coronary sinus. Patients with wide QRS complexes (generally = 140 ms), reduced ejection fractions, and severe symptoms have been evaluated. Results from studies with up to 6 months of follow-up have reported an increase in ejection fraction and improvement in symptoms and exercise tolerance. Definitive data on mortality or morbidity are not yet available. Nonetheless, this appears to be a promising therapeutic approach in patients who remain symptomatic despite aggressive medical therapy. Devices that combine biventricular pacing and ICD capabilities are also available.

D. Cardiac Transplantation
Because of the poor prognosis of patients with advanced heart failure, cardiac transplantation has become widely used. Since the advent of cyclosporine immunosuppressive therapy and more careful screening of donor hearts, the survival of patients after cardiac transplantation has increased considerably. Many centers now have 1-year survival rates exceeding 80-90%, and 5-year survival rates above 70%. Infections, hypertension and renal dysfunction caused by cyclosporine, rapidly progressive coronary atherosclerosis, and immunosuppressant-related cancers have been the major complications. The high cost and limited number of donor organs require careful patient selection early in the course.

E. Other Surgical Treatment Options
Several surgical procedures for severe heart failure have received considerable publicity. Cardiomyoplasty is a procedure in which the latissimus dorsi muscle is wrapped around the heart and stimulated to contract synchronously with it. In ventricular reduction surgery, a large part of the anterolateral wall is resected to make the heart function more efficiently. Both approaches are too risky in end-stage patients and have not been shown to improve prognosis or symptoms in controlled studies, and for these reasons they have largely been dropped. Externally powered and implantable ventricular assist devices can be used in patients who require ventricular support either to allow the heart to recover or as a bridge to transplantation. The latest generation devices are small enough to allow patients unrestricted mobility and even discharge from the hospital. However, complications are frequent, including bleeding, thromboembolism, and infection, and the cost is very high, exceeding $200,000 in the initial 1-3 months.

Although 1-year survival was improved in a recent randomized trial, all patients died by 26 months.

F. Palliative Care
Despite the technologic advances of recent years, including cardiac resynchronization, implantable defibrillators, left ventricular assist devices, and totally implantable artificial hearts, it should be remembered that many patients with chronic heart failure are elderly and have multiple comorbidities. Many of them will not experience meaningful improvements in survival with aggressive therapy, and the goal of management should be symptomatic improvement and palliation .

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