Cardiac Output Autonomic Stimulation Therapy for Acute Heart Failure (COAST-AHF)

Inclusion Criteria: 1. Left Ventricular Ejection fraction \< 40%, measured in the last year 2. At least two of the following: * Pulmonary Capillary Wedge Pressure \> 18 mmHg * Pulmonary congestion on Chest X-ray * Jugular vein distension * Pulmonary rales * Edema * Dyspnea at rest * Two (2) emergency room visits or hospital admissions in the past three (3) months, or three (3) emergency room visits or admissions in the past six (6) months requiring intravenous diuretics, ultrafiltration or in-hospital inotropic therapy. 3. With or without evidence of low perfusion Exclusion Criteria: 1. Systolic Blood Pressure \< 90 mmHg or \> 160 mmHg 2. Catecholamine or inotropic therapy within the previous 48 hours 3. Levosimendan within the previous 72 hours 4. Chronic outpatient catecholamine or inotropic therapy 5. Presence of implanted pacemaker, implantable cardioverter defibrillator or cardiac resynchronization therapy device 6. Presence of or prior vagal nerve stimulator 7. Coronary artery bypass graft surgery, percutaneous coronary intervention, acute myocardial infarction, or valve replacement within prior 1 month 8. Second or third degree heart block 9. History of atrial or ventricular arrhythmias 10. History of mitral or aortic valve stenosis or regurgitation 11. Hypertrophic obstructive or infiltrative cardiomyopathy 12. Prior vagotomy 13. Prior heart transplant 14. Narrow angle glaucoma 15. Renal failure - either on dialysis or serum creatinine \> 2.0 mg/dl 16. Hepatic failure - bilirubin, serum glutamic oxaloacetic transaminase, or serum glutamic pyruvic transaminase \> four times upper limit of normal 17. Life expectancy \< 12 months per physician judgment 18. Women who are pregnant 19. Allergy to fentanyl, midazolam, propofol, eggs, egg products, soybeans, or soy products 20. Subjects unwilling or unable to provide consent