, as suggested by markedly reduced peak oxygen consumption and clinical prognostic scores) or dependence on continuous parenteral inotropic support. Patient selection requires a multidisciplinary team of experienced advanced HF and transplantation cardiologists, cardiothoracic surgeons, nurses, and ideally, social workers and palliative care clinicians. BTT indicates bridge to transplant; COR, Class of Recommendation; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LOE, Level of Evidence; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; N/A, not applicable; and NYHA, New York Heart Association. JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:1495 539 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary 6.4.3. Mechanical Circulatory Support CLASS IIa 1. MCS is bene cial in carefully selectedz patients with stage D HFrEF in whom de nitive management (e.g., cardiac transplantation) or cardiac recovery is anticipated or planned (289 296). (Level of Evidence: B) 2. Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices, is reasonable as a bridge to recovery or a bridge to decision for carefully selectedz patients with HFrEF with acute, profound hemody- namic compromise (297 300). (Level of Evidence: B) 3. Durable MCS is reasonable to prolong survival for carefully selectedz patients with stage D HFrEF (301 304). (Level of Evidence: B) 6.4.4. Cardiac Transplantation CLASS I 1. Evaluation for cardiac transplantation is indicated for carefully selected patients with stage D HF despite GDMT, device, and surgical management (305). (Level of Evidence: C) See Figure 3 for the stages in the development of HF. 7. The Hospitalized Patient: Recommendations See Table 22 for a summary of recommendations from this section and Figure 4 for the classi cation of patients presenting with acutely decompensated HF. Figure 3. 