Refractory heart failure.

Managing patients with heart failure is rooted in appropriate recognition of the syndrome and subsequent tailoring of therapies to individual patients based on the stage of the disease. An individual with asymptomatic left ventricular dysfunction (the earliest stage of heart failure) is treated quite differently than a patient with more advanced heart failure manifested by problematic fluid retention, peripheral organ hypoperfusion with dysfunction, and several comorbidities. The latter patient requires aggressive pharmacologic intervention coupled with other creative strategies that are individually tailored to each individual"s unique clinical circumstance. The therapies available include long-term administration of parenteral inotropic therapy, dialysis, insertion of a ventricular assist device, cardiac transplantation, dynamic skeletal myoplasty, volume reduction surgery, or more standard (but higher risk) operative procedures. New drugs are constantly undergoing evaluation and may lead to additional therapeutic improvements in patients with advanced heart failure. The key is recognizing the appropriate place for more radical therapies.