July 22, 2025
When managing advanced heart failure, treatment spans a broad therapeutic spectrum. Treatment options include medicine, medical devices and surgery, and the possibilities for transplantation are expanding. The key is discovering heart failure early.
"We must recognize heart failure as soon as we can. Patients can decompensate quickly and if they are established with heart failure, the signs can be identified and treated," says Philip J. Spencer, M.D., a cardiovascular transplant surgeon at Mayo Clinic in Rochester, Minnesota. "It's important to address comorbidities such as diabetes, addiction and weight control so that as many treatment options are possible when decompensation arises."
Mayo Clinic Transplant Center specialists are experienced in serious or complex heart failure cases. "We use a proactive, multidisciplinary approach to advanced heart failure, emphasizing early guideline-directed medical therapy (GDMT) initiation, lifestyle modifications, utilization of mechanical support when appropriate, and leveraging artificial intelligence (AI) technologies to enhance diagnostic and prognostic capabilities," says Rohan M. Goswami, M.D., an advanced heart failure and transplant cardiologist in the Transplant Center at Mayo Clinic in Jacksonville, Florida.
Lifestyle and medication
"The major benefit to heart failure treatment at Mayo Clinic is the system of care. We can treat the most critically ill of patients with a variety of therapies and support," says Dr. Spencer.
Early on, nonpharmacological strategies, such as restricting sodium and fluid, can significantly impact patient outcomes. Patients can limit their fluid intake to 50 ounces a day and sodium intake to 2,000 mg a day.
"With advanced heart failure, GDMT remains foundational for treatment. Therapy may include beta blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor plus neprilysin inhibitors (ARNIs), MRAs and sodium-glucose cotransporter-2 (SGLT2) inhibitors," says Dr. Goswami.
"There are many treatment options depending on a patient's comorbid conditions and at what point they receive medical therapy," says Dr. Spencer. "As conditions worsen, inotropic medical therapy can improve a patient's symptoms but not life expectancy," says Dr. Spencer. The inotropic medications help the heart with pumping until other treatments begin to work.
"If patients are unable to tolerate GDMT — due to hypotension, worsening renal function or intolerance to medications — this should trigger an early referral to an advanced heart failure team. Withdrawing medications without escalating care can lead to rapid decompensation; timely referral enables consideration of mechanical support or transplant evaluation before irreversible decline occurs," says Dr. Goswami.
Durable therapy
For those with refractory symptoms, mechanical circulatory support such as durable left ventricular assist device (LVAD) or temporary devices such as the Impella 5.5 (an axillary-placed heart pump), and ultimately heart transplantation, remain the definitive options.
An LVAD is implanted into the left ventricle to pump blood. The risks include bleeding, infections and stroke, which can limit survival and affect a patient's eligibility for an organ transplant. Mayo Clinic transplant specialists are experts in using the Impella 5.5. The device assists in pumping blood from the heart to the rest of the body, as a bridge to transplant or heart recovery.
If a patient's heart function isn't supporting blood flow, extracorporeal membrane oxygenation (ECMO) may be used. With ECMO, blood is pumped outside of the body to a heart-lung machine, which removes carbon dioxide and sends oxygen-rich blood to the body. This allows the heart and lungs to rest and heal.
"Hemodynamic support with Impella 5.5 facilitates early unloading of the left ventricle, leading to improved renal perfusion, reduced pulmonary hypertension and right ventricular recovery — all of which are crucial in optimizing transplant candidacy or native heart recovery," says Dr. Goswami.
Advances in transplants
"Mayo Clinic is a large center that has relied on the newest FDA-approved devices such as Impella 5.5 and the latest Organ Care System (OCS) device to transport heart allografts from the 48 contiguous states," says Dr. Spencer.
"Impella 5.5's utility in select cases has expanded the transplant window, allowing multidisciplinary teams more time to evaluate and manage complex physiology. It is more than a bridge-to-transplant device. It's a therapeutic tool that enhances recovery potential, procedural readiness and long-term outcomes," says Dr. Goswami.
"We're using uniform cooling at 10 degrees Celsius to transport hearts long distance from donors who have undergone normothermic regional perfusion (NRP) to assess their heart, which may be superior to the current standard of normothermic machine perfusion (NMP) technology," says Dr. Spencer. Mayo Clinic embraced NMP technology early and is now among the few centers using NRP and uniform 10-degree Celsius cold storage transport. With advancements in surgical techniques and immunosuppression, Mayo Clinic experts are expanding successful outcomes for complex procedures.
"Most uniquely we've developed a pathway to manage highly sensitized recipients by performing combined heart and liver transplantation (CHLT) procedures. By transplanting the liver first, we can neutralize antibodies that would otherwise subject the patient to antibody-mediated heart rejection," says Dr. Spencer. In CHLT procedures, NMP offers more preservation time and less metabolic disturbance. With fewer concerns for cold ischemia, the donor pool can be expanded.
Impella 5.5 and AI
Mayo Clinic Transplant Center specialists are experienced in normalizing and recovering native heart function in patients using Impella 5.5. "Currently, we are involved in unique work within our AI Transplant-Critical care research team that focuses on heart failure and shock patients with Impella 5.5. Our Impella 5.5-based AI work is progressing, and we have uncovered newer factors that may help with predicting potential early native heart recovery using standard data from heart ultrasounds and pressure measurements," says Dr. Goswami. "This early prospective data shows us that not only are there new factors uncovered by AI that traditional research has not elucidated, but that there are certain patients who may benefit with earlier placement of Impella 5.5 in their advanced heart failure care."
Looking ahead
The integration of AI into clinical practice is transforming heart failure management. "We've developed a machine learning algorithm that is now being validated outside of Mayo Clinic in a similar population," says Dr. Goswami. "The role of AI in this field is ever evolving and our continued efforts are working towards shaping a new paradigm in heart failure care, where AI enhances early detection, risk stratification and individualized treatment pathways — ultimately improving outcomes for patients with complex cardiac conditions."
For more information
Refer a patient to Mayo Clinic.