title: Long-term intravenous inotropes in low-output terminal heart failure?
abstract: Intravenous inotropic therapy may be necessary to achieve short-term survival in end-stage heart failure patients with cardiogenic shock or extreme low output and severe organ hypoperfusion. However, mid- or long-term intravenous inotropic therapy is associated with an increased mortality in advanced stage D heart failure patients using β-adrenoceptor agonists (dobutamine) or PDE-3-inhibitors (milrinone). Intermittent levosimendan may evolve as a reasonable therapeutic option. Randomized trials or other meaningful scientific evidence addressing the optimal treatment of exclusively the most threatened subgroup of hospitalized patients with persistent severe organ hypoperfusion are missing, but urgently needed. Despite a lack of other beneficial pharmacological options, the use of long-term intravenous inotropic therapy as a treatment for refractory heart failure or as an obligatory criterion for high urgency (HU) listing of heart transplant candidates with a median waiting time of 66 days in Germany is not based on scientific evidence. In addition, it might create a disincentive to achieve the HU status as well as keeping it, thereby potentially exposing the patient to an unnecessary additional risk. Upcoming new allocation algorithms may possibly help to improve the inadequate present situation. There is need for both, a better definition and a better treatment of high risk terminal heart failure requiring high urgent transplant listing.
authors.affiliation: I. Medizinische Klinik, Klinikum Augsburg, Herzzentrum Augsburg-Schwaben, Stenglinstr. 2, 86156, Augsburg, Germany. wolfgang.scheidt@klinikum-augsburg.de.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: von Scheidt
authors.affiliation: Medizinische Klinik 8, Kardiologie, Paracelsus Medizinische Privatuniversität, Universitätsklinikum Nürnberg, Nürnberg, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Pauschinger
authors.affiliation: Medizinische Klinik und Poliklinik I, Deutsches Zentrum für Herzinsuffizienz - Comprehensive Heart Failure Center, Universitätsklinikum Würzburg, Würzburg, Germany.
authors.forename: Georg
authors.initials: G
authors.lastname: Ertl
mesh_terms: D061605:Administration, Intravenous; D002302:Cardiac Output / Q000187:drug effects*; D002303:Cardiac Output, Low / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D002316:Cardiotonic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D016009:Chi-Square Distribution; D004280:Dobutamine / Q000008:administration & dosage; D004334:Drug Administration Schedule; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D016027:Heart Transplantation; D006801:Humans; D006835:Hydrazones / Q000008:administration & dosage; D020105:Milrinone / Q000008:administration & dosage; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D011724:Pyridazines / Q000008:administration & dosage; D012307:Risk Factors; D000077464:Simendan; D013997:Time Factors; D016896:Treatment Outcome; D014850:Waiting Lists
chemical_list: D002316:Cardiotonic Agents; D006835:Hydrazones; D011724:Pyridazines; D000077464:Simendan; D004280:Dobutamine; D020105:Milrinone
keywords: Dobutamine; High urgency heart transplant listing; Inotropic therapy; Levosimendan; Low-output heart failure; Milrinone