Advanced chronic heart failure (HF) is a condition in which HF has progressed to a stage where conventional evidence-based therapies are no longer effective,¹ and advanced therapies such as mechanical circulatory support, heart transplantation and/or palliative care are required. 

Within this subgroup of patients are those who are ineligible for advanced therapies and remain symptomatic. The National Heart Programme Heart Failure Model of Care² published in 2021 outlines the structures that should be adopted in the care of patients with HF, including those living with advanced disease. These patients can be burdened with HF symptoms as their disease advances. The Model of Care emphasises the importance of the role of the clinical nurse specialist and advanced nurse practitioner in the care of people with HF in the hospital, community and integrated care teams.

As outlined in this model, it is important to consider end-of-life care and control HF symptoms. These patients can benefit from home inotropes to relieve symptoms, improve quality of life and improve mortality. Prognosis for patients on home inotropes is approximately six to nine months.³

This article looks at the case of a patient deemed unsuitable for advanced therapies who is currently managed with intravenous home inotropes.

Case report

The patient in this case is a 59-year-old man who is regularly followed up in the advanced heart support clinic. He was originally diagnosed with a dilated cardiomyopathy in 2013 and, despite optimum HF medications and subsequent implantable cardioverter defibrillator (ICD) upgrade to cardiac resynchronisation therapy (CRT) in 2022, his disease continued to progress. The patient required frequent admissions for management of his advanced HF symptoms.

Due to multiple comorbidities, cardiac cachexia and renal impairment, the patient was deemed unsuitable for heart transplantation or mechanical circulatory support at a multidisciplinary level. During hospitalisation, his symptoms improved and stabilised with intravenous milrinone administered via peripherally inserted central catheter line (PICC). Milrinone, an intravenous inodilator agent, is a phosphodiestase inhibitor that has been shown to increase cardiac output, reduce preload and afterload, and improve overall symptoms in advanced HF.⁴ Significant improvement was noted in the patient’s right heart catheterisation pressures and symptoms following intravenous milrinone (see Table).

In joint evaluation, the multidisciplinary team, comprising the advanced HF and palliative care teams, the patient and his family, concluded that palliative care with a focus on symptom management and improved quality of life was the best approach. As his symptoms and right heart catheterisation pressures improved, the option of discharging home with continuous milrinone infusion was discussed. The patient and his family were made aware of the potential risks and benefits and agreed to the use of milrinone to manage symptoms and improve quality of life.

An application was submitted to the HSE and funding was approved. The patient and his family received extensive education and training regarding the management of the infusion, troubleshooting the pump and changing the line and syringes. Nursing, pharmacy, physiotherapy, a dietitian, a social worker and the palliative care team all participated in the successful discharge home of this patient.

The patient was discharged on a stable regime of intravenous milrinone at 0.25mcg/kg/min and diuretics. Initially he was reviewed weekly in the heart support clinic where his symptoms were assessed, PICC line flushed and dressed and labs reviewed. Subsequently, this was changed to monthly reviews in the heart support clinic as he remained stable. The PICC line was dressed weekly by the community intervention team.

Discussion

Worldwide, while the prevalence of advanced HF has increased, therapies and treatment options have improved.⁵ This has brought about an increase in patients requiring home inotropes in order to relieve symptoms, improve quality of life and prevent mortality, both as a bridge to advanced therapies or as an integrated strategy for palliative care.

Intravenous milrinone has also reduced hospitalisations, as well as decreased the overall costs of advanced HF.⁴ It appears that intravenous inotropes are an effective alternative for carefully selected patients who are severely symptomatic and advanced HF patients who are unsuitable for advanced therapies.

This case study describes the home use of intravenous inotropes to improve symptoms and quality of life of a patient living with advanced heart failure who is unsuitable for advanced therapies, i.e. mechanical circulatory support or cardiac transplantation.

The use of intravenous milrinone has allowed this patient to remain at home with his wife and two children. Although the patient still has limitations, he continues to work when he can, enjoys meeting friends and spending quality time with his family.

In his own words: “I feel very fortunate to have a huge amount of support in this regard. I won’t claim to be partying like it’s 1999 but I am enjoying good quality of life and time at home with my family that would not be possible without the freedom that this small milrinone infusion pump has given me.”

References

1. Metra M, Dinatolo E, Dasseni N. The New Heart Failure Association Definition of Advanced Heart Failure. Card Fail Rev 2019 Feb; 5(1):5-8. doi: 10.15420/cfr.2018.43.1
2. Health Service Executive. Heart Failure Model of Care 2021. Available at hse.ie/eng/about/who/cspd/icp/chronic-disease/moc/national-heart-failure-model-of-care-2021.pdf 
3. Ginwalla M. Home inotropes and other palliative care. Heart Failure Clinics, 2016. doi:10.1016/j.hfc.2016.03.005
4. Ayres JK, Maani CV. Milrinone. In: StatPearls Treasure Island (FL): StatPearls Publishing; 2023 Jan. https://www.ncbi.nlm.nih.gov/books/NBK532943/
5. Dunlay SM, Roger VL, Killian JM, Weston SA, Schulte PJ, Subramaniam AV, Blecker SB, Redfield MM. Advanced Heart Failure Epidemiology and Outcomes: A Population-Based Study. JACC Heart Fail 2021 Oct; 9(10):722-32. doi: 10.1016/j.jchf.2021.05.009