What is the next step in managing a patient with severe left ventricular systolic dysfunction, already on optimized Guideline-Directed Medical Therapy (GDMT), with a left ventricular ejection fraction of 20-25% and trace mitral and tricuspid regurgitation?

Management of Severe Left Ventricular Systolic Dysfunction with LVEF 20-25% Despite Optimized GDMT

For patients with severe left ventricular systolic dysfunction (LVEF 20-25%) already on optimized GDMT, the next step should be evaluation for advanced heart failure therapies including mechanical circulatory support or cardiac transplantation.

Assessment of Current Status

Before proceeding with advanced therapies, confirm:

• Truly optimized GDMT (all four pillars):

  • Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) at target doses 1
  • ARNI (sacubitril/valsartan) or ACEi/ARB at maximum tolerated doses 2
  • MRA (spironolactone or eplerenone) 1
  • SGLT2 inhibitor (dapagliflozin or empagliflozin) 1

• Evaluate for potential reversible causes:

  • Ischemia requiring revascularization
  • Valvular disease requiring intervention (though trace MR/TR noted is not significant)

Next Steps Algorithm

1. Referral to Advanced Heart Failure Center

   • Severely reduced LVEF (20-25%) despite GDMT indicates advanced heart failure 2
   • Global longitudinal strain of -7.1% confirms severe systolic dysfunction
   • Atrial dilation suggests chronic disease progression

2. Device Therapy Considerations

   • If not already in place, evaluate for ICD (Class I recommendation for LVEF ≤35%) 1
   • Assess for CRT eligibility based on QRS duration and morphology 1

3. Advanced Heart Failure Therapies

   • Evaluate for mechanical circulatory support (LVAD) 2
   • Assess candidacy for heart transplantation 2
   • Consider continuous intravenous inotropic support as bridge therapy (Class IIa) 2

4. Mitral Valve Intervention Assessment

   • Despite only trace MR currently, evaluate for potential benefit from transcatheter edge-to-edge repair (TEER) if MR progresses 2
   • TEER may be considered for patients with severe symptoms despite GDMT with LVEF 20-50% (Class IIa) 2

Monitoring and Follow-up

• Serial monitoring of natriuretic peptide levels to guide therapy 2
• Regular echocardiographic assessment for LV remodeling and valvular function 2
• Close monitoring of renal function, electrolytes, and blood pressure 2

Special Considerations

• If blood pressure is low, consider selective β₁ receptor blockers which have less BP-lowering effect than non-selective beta-blockers 2
• If beta-blockers are not well tolerated hemodynamically, ivabradine may be a viable alternative 2
• Avoid downtitration of GDMT if possible, as this is associated with poor prognosis 3, 4
• For patients with low BP, start with lowest doses and up-titrate slowly with small increments 2

Palliative Care Considerations

• If not a candidate for advanced therapies, consider long-term continuous intravenous inotropic support for symptom control (Class IIb) 2
• Ensure goals of care discussions are conducted 2

Pitfalls to Avoid

1. Prematurely reducing or discontinuing GDMT due to low BP without attempting careful titration strategies 2, 4
2. Failing to refer to advanced heart failure specialists despite severe LV dysfunction 2
3. Overlooking the prognostic significance of even trace valvular regurgitation in severe LV dysfunction 5
4. Underutilizing device therapy in eligible patients 1
5. Neglecting to optimize GDMT before considering advanced therapies 6

The management of patients with severe LV dysfunction despite optimized GDMT requires a systematic approach focused on advanced therapies while maintaining optimal medical management. Early referral to an advanced heart failure center is crucial for timely evaluation for mechanical support or transplantation to improve survival and quality of life.