Patients at risk of RV failure may benefit from primary pharmacological support to increase myocardial contractility and to decrease PVR using a combination of epinephrine, milrinone and inhaled pulmonary vasodilators [e.g. inhaled nitric oxide (iNO) or/and iloprost]. Observational studies have demonstrated a beneficial effect of iNO therapy [235, 236]. However, iNO did not significantly reduce the incidence of RV failure in a multicentre randomized study [237]. Expert panels concluded that it is reasonable to consider using iNO during LVAD implantation [238, 239].