End stage chronic heart failure

Congestive heart failure (CHF) has kept its progressive nature despite significant advances in therapy. With more advanced disease, medical therapy is broadened. Even so, some patients remain severely symptomatic. However, before additional action is taken, it should be regarded if therapy really fails. Often, therapy is not increased sufficiently because of assumed rather than actual intolerability. Thus, increase in serum creatinine up to 30-50%, hyperkaliemia up to 5.5 mmol/l, and asymptomatic hypotension and bradycardia are usually acceptable. Cautious and slow start and uptitration are the more important the more severe heart failure is, but these patients also profit most from this therapy. If patients remain severely symptomatic despite adequate medical therapy, cardiac resynchronisation therapy (CRT) should be considered. It significantly improves both symptoms and prognosis. Although implantable defibrillators (ICD) are less effective in end-stage CHF, CRT and ICD may be combined as CRT may improve function status, making patients eligible also for ICD therapy. In selected patients, heart transplantation is still an option if no other therapeutic options are effective and there are no contraindications. In these patients, prognostic assessment of CHF is particularly important. Assist devices are used as bridge to transplant or more seldom to recovery only in many countries, but destination therapy may become more important in future therapy with improved devices. Many other therapies are under investigation at present. Thus, therapeutic options for end-stage CHF may further broaden in the near future.