The available evidence suggests that while chronic inotropic support likely exerts a long-term deleterious effect on survival, their use is accompanied by short-term enhancements in symptomatology and decreases in medical resource use, thereby curtailing the overall medical costs. The decision to use chronic parenteral inotropic support should not be made lightly and must be considered only after all evidence based therapeutic options has been investigated thoroughly and tried (Fig. 1). This should include not only hemodynamic monitoring-based drug therapy but [figure: see text] also appropriate consideration for options such as heart transplantation or patient enrollment into large-scale drug trials that seek to answer pertinent issues relating to various aspects of advanced heart failure therapeutics. The use of parenteral inotropic support as a chronic bridge to transplantation is accepted widely but remains controversial in other scenarios. For instance, when refractory congestion or hypoperfusion is exhibited in the absence of any definitive medical or mechanical option, it may be wise to contemplate inotropic support after appropriate informed consent has been obtained from the patient. Lastly, it is of great importance to continually seek ways to transit the patient from this approach to a definitive therapeutic end point, such as with transition to oral beta-blockade, which may be better tolerated in the patient with advanced heart failure using an inotropic umbrella.