Ambulatory Inotropes as a Bridge to Heart Transplantation – a Safe Alternative to Mechanical Support?

Background: Patients with advanced systolic heart failure are susceptible to acute deterioration refractory to standard medical therapies. This case series explored our local experience with ambulatory parenteral inotropic therapy as a means to support susceptible patients on the heart transplant waiting list. Method: We reviewed medical records of all patients treated with ambulatory inotropes through the national transplant centre. Fifteen patients were treated between 2001 and 2018. Mean age was 43.6 years (range, 11–63 y). Inotropes used were dobutamine (dose range 3–10 μg/kg/min; mean, 4.4 μg/kg/min) and milrinone (dose range 0.3–0.5 μg/kg/min; mean, 0.46 μg/kg/min). Levosimendan was used intermittently in 8/15 patients. All patients had inotropes administered via a peripherally inserted central catheter. Median duration of therapy was 139 days (range, 20–717 d). Results: 14/15 patients were transplanted successfully (one withdrew from the waitlist by personal choice). The dominant aetiology of heart failure was dilated cardiomyopathy (n = 7/15). There was an improvement in functional status in 9/13 patients (data incomplete in 2/15). During the 2,707 patient days on inotropes, there were no deaths, and no patients were withdrawn from inotropes for adverse effects. Two patients had arrhythmia requiring implantable cardioverter-defibrillator therapy, and there were five minor complications in three patients. Conclusion: When managed by a specialist team ambulatory inotropic therapy for advanced heart failure resistant to standard medical therapy appears to be a reasonably safe and effective alternative therapy to bridge actively listed patients to heart transplantation.