Page 8 - Heart Failure Clinical Guidelines

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F. Advanced Therapies

1. Pacemaker Therapy
a. Permanent pacemaker implantation should be used in advanced second or third degree AV
block associated with ventricular dysfunction
b. LV apical pacing can be used in epicardial ventricular pacing systems when technically feasible

2. Cardiac Resynchronization Therapy
a. CRT indicated for patients with systemic LV, EF<35%, left bundle branch block pattern with
prolonged QRS with heart failure symptoms
b. CRT can be considered for systemic RV with EF<35%, right bundle branch block or complete
bundle branch block pattern with prolonged QRS with heart failure symptoms

3. AICD
a. Indicated with patients with heart failure and aborted sudden cardiac death if technically
feasible and without identifiable reversible cause
b. Considered in unexplained syncope or uncontrolled ventricular tachyarrhythmias with at least
moderate LV dysfunction and DCM
c. Indicated for patients with adolescent HCM or AVC with 1 or more major risk factors for
sudden cardiac death.

4. VAD
a. Placement of a VAD for the outpatient pediatric heart failure patient should be considered for
patients who are receiving continuous intravenous inotrope therapy and develop
a) worsening end organ function
b) failure to thrive
c) increasing pulmonary vascular resistance
d) continued heart failure symptoms
e) arrhythmias not responsive to medical treatment and thought to be from abnormal
hemodynamics
risk/benefit profile mechanical circulatory support varies greatly based upon patient
characteristics and current available ventricular assist devices, therefore each individual patient
should be reviewed by a multi-disciplinary group prior to VAD placement for pediatric heart
failure patients who are outpatient or stable inpatients

5. Transplant
Indications for heart transplantation evaluation include (but are not limited to):
a. continued heart failure symptoms despite adequate medical treatment
b. heart failure requiring continuous intravenous inotropes
c. intractable arrhythmias despite adequate medical/invasive therapy
d. congenital heart disease not amenable to further surgical palliation
e. transplant coronary disease with restrictive physiology

A more detailed list of indications for heart transplantation are in the heart transplantation
protocol