INitiation and Titration of Guideline Directed Medical TheRApy in HearT Failure Cardiogenic Shock With ImpElla 5.5 for Cardiac Recovery

1. Age ≥ 18 and \< 80 years
2. Subject or subject's legally authorized representative (LAR) has signed the Informed Consent Form
3. LVEF ≤ 40%

4. Subject is presenting with decompensated heart failure and meets at least two (2) of the following cardiogenic shock criteria:

   1. Hypotension (sustained episode of systolic blood pressure ≤ 90 mmHg for at least 30 minutes or need for inotropic/vasoactive agents to maintain such blood pressure)
   2. Hypoperfusion (physical sign(s) of organ hypoperfusion or serum lactate >2 mmol/L)
   3. Cardiac index (CI) \< 2.2 L/min/m2 determined to be secondary to cardiac dysfunction, in the absence of hypovolemia
   4. Required support with an intra-aortic balloon pump (IABP) or Impella CP™

5. Subject has inadequate heart failure GDMT based on the most recent outpatient prescription prior to index admission, defined as:

   1. On 2 or less of the 4-Pillar HF Drug Classes (BB, MRA, SGLT2i, and RASi)
   2. If on BB and RASi, at least one of the two medications is \< 50% of the maximal target dose

Exclusion Criteria:

1. Underlying unmodifiable conditions that limit initiation of GDMT prior to enrollment, including but not limited to:

   1. Drug allergies or hypersensitivities* to HF GDMT medications, unless alternative can be identified

      *Drug allergy/hypersensitivity is an immune-mediated reaction to a medication. Adverse reactions must be a result of immune or inflammatory cell stimulations by the mеԁiсаtion.

   2. Known bilateral renal artery stenosis
   3. Type 1 diabetes
   4. 2o or 3o AV block, unless pacemaker is in place
   5. Angioedema, hereditary or idiopathic
   6. Pregnancy, known or confirmed by a pregnancy test if of childbearing potential
2. ST-segment elevation or acute coronary syndrome (ACS) prior to enrollment
3. Septic shock, shock from non-cardiac origins, or mixed shock
4. SCAI Stage E cardiogenic shock per study definition (Appendix C) prior to enrollment
5. In cardiac arrest prior to enrollment

6. Prolonged use (or use with complication) of Intra-aortic balloon pump (IABP) or Impella CP™ prior to enrollment, meeting at least one of the following:

   1. IABP use >24 hours if placed at the enrolling site or >48 hours if transferred on IABP
   2. Impella CP™ use >24 hours if placed at the enrolling site or >48 hours if transferred on Impella CP™
   3. Experienced complication(s) from IABP including clinically significant vascular injury, limb ischemia, end organ damage, or bleeding requiring transfusion(s) per Investigator's discretion
   4. Experienced complication(s) from Impella CP™ including clinically significant hemolysis, vascular injury, limb ischemia, end organ damage, or bleeding requiring transfusion(s) per Investigator's discretion
7. On mechanical circulatory support other than IABP or Impella CP™ (i.e. ECMO, etc) or on mechanical ventilation for non-procedural reasons prior to enrollment
8. Revascularization or cardiac surgery within 30-days prior to enrollment
9. Infiltrative/restrictive cardiomyopathy (sarcoidosis and amyloidosis), hypertrophic cardiomyopathy, constrictive pericarditis, pericardiac tamponade, or myocarditis requiring high-dose immunosuppression
10. Complex adult congenital heart disease
11. Primary severe valvular disease
12. Predominant RV dysfunction per Investigator's discretion
13. History of heart transplant or listed for heart transplant or planned for heart transplantation prior to enrollment
14. Planned to be implanted with a permanent VAD within 180-days of the index hospitalization date
15. Continuous outpatient inotropic support prior to the index hospitalization date
16. Planned to pursue palliative care or hospice, or life expectancy of less than 1 year due to non-cardiac illness at the time of index hospitalization date
17. Currently on dialysis, or has pre-existing end-stage chronic kidney disease (stage 4 and above), or has nephropathy of hereditary, infectious, or autoimmune origin
18. Pre-existing functional liver disease including liver cirrhosis, alcoholic hepatitis, metabolic dysfunction associated steatohepatitis (MASH), or genetic liver disease
19. Pre-existing pulmonary disease with oxygen dependency
20. History of stroke or intracranial hemorrhage ≤ 90 days prior to the index hospitalization date, or a history of cerebrovascular disease with significant (> 80%) uncorrected carotid stenosis, or any permanent neurological deficit with modified Rankin Scale (mRS) >2

21. Any contraindication that precludes placing an Impella 5.5™, including but not limited to:

    1. Aortic valve stenosis/calcification with orifice area ≤ 0.6cm2 or aortic insufficiency of any grade greater than mild on pre-procedure echocardiography
    2. Presence of mechanical aortic valve or heart constrictive device
    3. Mural thrombus in the left ventricle
    4. Severe arterial disease precluding placement of Impella
    5. Presence of atrial or ventricular septal defect
    6. Left ventricular rupture
    7. Cardiac tamponade
    8. Combined cardiorespiratory failure
22. Infection of the planned procedural access site or systemic active infection including sepsis and bacteremia
23. Intolerance to anticoagulant or antiplatelet therapies, or will refuse blood transfusions
24. Subject has other medical, social or psychological problems that, in the opinion of the Investigator, compromises the subject's ability to give written informed consent and/or to comply with study procedures
25. Participation in the active treatment or follow-up phase of another clinical study of an investigational drug or device
26. Subject belongs to a vulnerable population, such as prisoners, pregnant women, handicapped, mentally disabled persons, or economically or educationally disadvantaged persons per 21CFR56.111(a)(3) and 111(b)