This patient with symptomatic heart failure and a reduced left ventricular ejection fraction with evidence of significant conduction system disease should undergo placement of a biventricular pacemaker (cardiac resynchronization therapy [CRT]). He has progressive heart failure symptoms while on appropriate medical therapy and has New York Heart Association (NYHA) functional class III symptoms. With his ejection fraction less than 35% and left bundle branch block (LBBB), he is a candidate for a biventricular pacemaker, which has been demonstrated to reduce mortality and symptoms in patients with NYHA functional class III and IV heart failure by improving cardiac hemodynamics. The 2013 American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society(ACCF/AHA/HRS) guideline recommends CRT in patients with an ejection fraction of 35% or below, NYHA functional class III to IV symptoms on guideline-directed medical therapy, and LBBB with QRS duration greater than or equal to 150 ms. This patient already has an implantable cardioverter-defibrillator, which is indicated for patients with NYHA functional class II to III heart failure and an ejection fraction less than 35%. Now that he has developed a LBBB and an increase in symptoms, it is reasonable to proceed with placement of a biventricular pacemaker as well.

Inotropic therapy, such as dobutamine, is reserved for patients with end-stage heart failure, either as a bridge to transplantation or for palliative care. Patients in this category often have recurrent hospitalizations for heart failure, have evidence of end-organ compromise such as worsening kidney and liver function, and have very poor exercise tolerance. Although this patient has progressive symptoms, he has not reached this stage yet, and has no indication for inotropic therapy.

The patient has no evidence of volume overload on examination and a borderline low blood pressure; therefore, increasing his diuretic dose would not be expected to improve his symptoms and may worsen them by lowering his cardiac filling pressures and cardiac output.

The patient is fairly symptomatic but has not yet had optimal therapy, as he has an indication for CRT and has not yet received it. Left ventricular assist devices (LVADs) are reserved for patients with end-stage refractory heart failure as a bridge to heart transplantation or as destination therapy in selected patients who are not candidates for transplantation. However, prior to being considered for either an LVAD or heart transplantation, a patient must be on optimal medical therapy.