Advancing Heart Failure Care: Timely Referral and Life‑prolonging Strategies with HeartMate 3 Left Ventricular Assist Device

Heart failure (HF) remains a leading cause of morbidity and mortality globally, and advanced HF represents a severe stage of the disease affecting more than 64 million people across the world with rising prevalence.^1,2 Advanced HF is a leading cause of death and is associated with significantly diminished quality of life (QoL), which includes recurrent hospitalizations, debilitating symptoms, such as fatigue and shortness of breath, and reduced functional capacity.^1,2 By 2030, it is predicted to cost the US around $70 billion each year.⁸

Standard management relies on optimization of guideline-directed medical therapy (GDMT), such as angiotensin receptor/neprilysin inhibitors (ARNI)/angiotensin-converting enzyme (ACE) inhibitors, β-blockers, sodium-glucose co-transporter-2 (SGLT2) inhibitors, mineralocorticoid receptor antagonists (MRAs) and diuretics to reduce symptoms and slow the progression of HF.^1,2,3 IV inotropes are used for short-term support in acute decompensated Stage D HF to improve cardiac output and alleviate hypotension or hypoperfusion.^1,2,3 However, inotropes only provide temporary symptom relief and are not recommended for routine use in advanced HF unless the patient is in shock or severely hypotensive.^1,2,3 In cases where inotropes are being used or considered, the clinician should refer the patient to an advanced HF program for evaluation.⁷

Fortunately, innovations such as the HeartMate 3 Left Ventricular Assist Device (HM3 LVAD) have transformed the care of advanced HF patients, offering effective and reliable mechanical circulatory support with improved hemocompatibility and the potential for myocardial recovery or reversal of HF in certain cases.^7,8

Beyond Short-term Fixes: What are the Limitations of Inotropes in Advancing HF?

Most of us are very experienced in the role that inotropes play in the short-term management of acute decompensated HF by enhancing cardiac contractility and alleviating acute symptoms, such as hypotension, hypoperfusion and severe congestion. However, it is important that we remember that their benefits are limited to temporary relief and they do not alter the disease trajectory in advancing HF.^1,2,3

Not only do inotropes offer little survival gain, but their long-term use can also be associated with increased risks of arrhythmias and mortality.^1,2,3 Their prolonged use can also lead to dependency, where patients require continuous infusion to maintain stability, but which comes at the potential cost of tachyphylaxis and end-organ damage.⁷ In fact, whenever we are using inotropes, I would advise my colleagues that this should trigger a referral for advanced assessment as their ongoing use fails to address the underlying progressive nature of HF. In these cases, we should ask ourselves, are we extending survival or merely delaying inevitable decline of health? This question underlines to me the importance of shifting the treatment strategy from relying upon inotropes for symptom management to more life-prolonging therapies like LVADs or transplant.^3,7,8

Streamlining Referrals: How Can the “Rule of 3” Guide Decisions for Advanced Therapy?

The “Rule of 3” is a simple, mnemonic-based tool that I recommend clinicians use to help them identify patients who may benefit from referral to advanced HF therapy (Figure 1). It includes three key triggers:

1. Two or more hospitalizations for heart failure per year.
2. Escalating diuretic requirements over time to maintain clinical stability; and
3. Progressive intolerance or downtitration of GDMT such as β-blockers, ACE inhibitors, or ARBs.^3,4

These criteria align with broader assessment frameworks like the I-NEED-HELP mnemonic. I would advise all clinicians to apply the “Rule of 3” in a timely manner, so that they can make informed decisions on which patients to refer for LVAD or transplant evaluation, and thereby prevent further decline of health.^3,4

“I recommend using the “Rule of 3” as a daily checklist in your clinic to avoid missing opportunities for intervention.”

When GDMT Falls Short: How Should Clinicians Spot Inadequacy and Make Referrals for Advanced Therapies?

GDMT is the cornerstone of HF management, but it has limits in advanced stages. Signs of inadequacy include persistent New York Heart Association (NYHA) Class IIIB/IV symptoms, rising natriuretic peptides (e.g. BNP >300 pg/ml or NT-proBNP levels), end-organ dysfunction (e.g. creatinine >1.8 mg/dl), hypotension limiting uptitration of GDMT, or recurrent hospitalizations despite optimisation.^1–6 These indicators should signal to us that current medications are no longer sufficient to manage the disease progression.

At this stage, when the clinician notes GDMT is failing, I advise them to promptly refer their patient to a HF specialist for evaluation of advanced therapies such as LVAD implantation or heart transplantation (Figure 2). I would like to take this opportunity to remind my colleagues that early intervention can offer a bridge to recovery, stabilize patients, or prolong survival.^{1–3,8,10,11} Most patients with advanced HF are referred too late which increases risk and may limit their options for LVAD or transplantation.

“Act before the next crisis. Timely referrals can redefine patient trajectories.”

Delivering Superior Results: What Outcomes and Survival Rates are Associated with Implantation of HeartMate 3 LVAD?

I have studied the clinical data and can tell you that the HM3 offers excellent overall outcomes, with real-world survival rates of 85.7% at 1 year and 59.7% at 5 years, serving as a first-line circulatory support for advanced HF (Figure 3). It improves quality of life while reducing adverse events, including freedom from gastrointestinal bleeding (72.6% at 5 years), device malfunction (82.9%), and stroke (86.7%).^3,7

For younger patients (<50 years), the benefits of HM3 LVAD are even more pronounced, with 91.6% survival at 1 year and 72.6% at 5 years.⁷ HM3 prolongs life by enabling myocardial recovery through hemodynamic unloading and adds quality years prior to potential transplantation.^8,9

Heart Failure Guidelines: 1A Recommendation for LVAD Therapy Over Long-term Inotropes

The 2022 AHA/ACC/HFSA heart failure guidelines issued a Class 1A recommendation for LVAD therapy in advanced HF, based on robust survival and outcome data, emphasizing that the risks of long-term inotropes (no survival benefit) far outweigh those of LVAD or transplant when available (Table 2).¹

This newest endorsement prioritizes LVAD for inotrope-dependent patients, focusing on survival and functional improvements. I encourage clinicians to align their practice with this latest evidence, shifting from inotropes to HM3 for optimal care in appropriate patients.^1,2,3

Strategic Implantation: What is HeartMare 3 LVAD’s Role in Prolonging Life for Patients under 50?

Data from recent analyses demonstrate that HM3 yields high survival rates (e.g. 84.7% at 2 years in younger cohorts), adding quality years as a bridge to transplant or enabling potential myocardial recovery, with explant rates of approximately 10–20% in select cases.^7,8

Younger patients exhibit greater resilience to psychosocial risk factors like non-adherence, which are traditionally associated with poorer post-transplant outcomes, making HM3 a strategic first step.^7,8,10,11

I would like to share an inspirational case from my own practice. Last year, I had a 40-year-old male patient with idiopathic dilated cardiomyopathy, initially managed with GDMT (ARNI, β-blocker, SGLT2i and MRA). Despite optimization, he faced recurrent hospitalizations (three in a year), NYHA Class IIIB/IV symptoms, elevated NT-proBNP (>1,000 pg/ml), creatinine 1.9 mg/dl, ejection fraction (EF) 25% and GDMT intolerance (downtitrated β-blocker due to hypotension), meeting the Rule of 3 and I-NEED-HELP criteria. Recognizing GDMT failure and inotrope dependency risks, I referred him to the advanced HF team. At INTERMACS Profile 4, the patient received HM3 LVAD as a bridge to recovery or transplant. Post-implantation, his EF rose to 35%, symptoms improved to NYHA Class II, and he resumed part-time work and light exercise within 6 months. Now 18 months post-HM3, I am delighted to report that he is complication-free and is being considered for explantation.

“Could LVAD offer a fuller future for your younger patients, too?”

Conclusion

In summary, I advise my cardiology colleagues to discontinue inotropes in failing patients using tools like the “Rule of 3”, refer promptly when GDMT wanes, and embrace HM3 for superior outcomes, particularly in patients under 50, for life prolongation and potential recovery.^1–4,7 I encourage all cardiologists to integrate these strategies into their clinical practice, collaborate with HF teams, and continue to monitor outcomes.^10,11 By prioritizing LVAD therapy in this way, we can extend not just the survival of our patients but also help them thrive because, as I have shown, every referral advances patient-centered care.³