Overview
Refractory heart failure refers to heart failure that persists despite optimal medical therapy, often necessitating advanced support modalities like extracorporeal membrane oxygenation (ECMO) for temporary circulatory or respiratory assistance 12.Diagnosis
Persistent symptoms despite guideline-directed medical therapy
Elevated natriuretic peptides (BNP/NT-proBNP)
Echocardiographic evidence of systolic or diastolic dysfunction
Clinical signs of fluid overload or hypoperfusion 1Management
First-line treatments: Optimized medical therapy including ACE inhibitors, beta-blockers, diuretics, and aldosterone antagonists 1
Adjunctive therapies: In refractory cases, initiation of ECMO as a bridge to recovery, decision-making, transplant, or further diagnosis 12
Specific interventions: Venoarterial ECMO for circulatory support in refractory circulatory failure 2Special Populations
Pediatrics: Increased use of ECMO in pediatric intensive care settings without robust randomized controlled trial evidence 1
Elderly: No specific details provided in abstracts regarding unique management considerations for elderly patients
Comorbidities: No specific guidance provided for managing refractory heart failure in the context of comorbidities 12Key Recommendations
Consider ECMO as a supportive measure for patients with refractory cardiac failure to provide temporary circulatory support, serving as a bridge to recovery or other definitive treatments (Evidence: Moderate) 12
Evaluate neurological outcomes carefully in long-term survivors post-ECMO, as favorable outcomes are common in those who survive (Evidence: Moderate) 2
Implement suprainstitutional networks for remote ECMO support to enhance patient outcomes in refractory circulatory failure, leveraging multidisciplinary expertise (Evidence: Expert opinion) 2References
1 Das S, Gupta S, Das D, Dutta N. Basics of extra corporeal membrane oxygenation: a pediatric intensivist's perspective. Perfusion 2022. link
2 Aubin H, Petrov G, Dalyanoglu H, Saeed D, Akhyari P, Paprotny G et al.. A Suprainstitutional Network for Remote Extracorporeal Life Support: A Retrospective Cohort Study. JACC. Heart failure 2016. link