Recommendations for Inotropic Support, MCS, and Cardiac Transplantation Recommendations COR LOE References Inotropic support Cardiogenic shock pending definitive therapy or resolution I C N/A BTT or MCS in stage D refractory to GDMT IIa B 275,276 Short-term support for threatened end-organ dysfunction in hospitalized patients with stage D and severe HFrEF IIb B 277 279 Long-term support with continuous infusion palliative therapy in select stage D HF IIb B 280 282 Routine intravenous use, either continuous or intermittent, is potentially harmful in stage D HF III: Harm B 172,283 288 Short-term intravenous use in hospitalized patients without evidence of shock or threatened end-organ performance is potentially harmful III: Harm B 277 279 MCS MCS is beneficial in carefully selected* patients with stage D HF in whom definitive management (e.g., cardiac transplantation) is anticipated or planned IIa B 289 296 Nondurable MCS is reasonable as a bridge to recovery or a bridge to decision for carefully selected* patients with HF and acute profound disease IIa B 297 300 Durable MCS is reasonable to prolong survival for carefully selected* patients with stage D HFrEF IIa B 301 304 Cardiac transplantation Evaluation for cardiac transplantation is indicated for carefully selected patients with stage D HF despite GDMT, device, and surgical management I C 305 *Although optimal patient selection for MCS remains an active area of investigation, general indications for referral for MCS therapy include patients with LVEF <25% and NYHA class III IV functional status despite GDMT, including, when indicated, CRT, with either high predicted 1- to 2- year mortality (e.g., as suggested by markedly reduced peak oxygen consumption and clinical prognostic scores) or dependence on continuous parenteral inotropic support. 