Advanced heart failure — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 54-year-old man has non-ischaemic dilated cardiomyopathy with an LVEF of 25%. He takes foundational medical therapy at the highest doses he tolerates and has a CRT-defibrillator; his heart failure team judges that additional medical and interventional options have been used.^[1] He has NYHA class III–IV symptoms, two hospitalizations in the last 12 months for congestion needing high-dose intravenous diuretics, and a 6-minute walk distance of 260 m that is judged to be of cardiac origin.^[1] His beta-blocker was halved last month because of symptomatic hypotension. He is motivated and has no absolute contraindication to heart transplantation or durable MCS.^[1]

1. Does he meet the ESC 2026 definition of advanced HF? Justify your answer against each criterion. (2)^[1]
2. Name two ESC 2026 Table 15 high-risk criteria that he meets. (2)^[1]
3. Give the ESC 2026 recommendation on referral that applies to him, with class and level. (2)^[1]
4. Which two investigations does ESC 2026 recommend as part of his evaluation for transplantation and durable MCS, with class and level? (2)^[1]
5. What does ESC 2026 say the down-titration of his beta-blocker should prompt, and what should not delay referral? (2)^[1]

Model answers — SAQ 1

1. Yes: ESC 2026 Table 14 requires all four criteria despite FMT, AMT and GDIT, and he meets each: NYHA class III or IV; severe cardiac dysfunction (LVEF ≤30%) (1 mark).^[1] ≥2 unplanned hospitalizations for congestion needing high-dose i.v. diuretics in the last 12 months, and a 6-min walk distance <300 m estimated to be of cardiac origin (1 mark).^[1]
2. Any two of: Rule of three, HFH ≥2 within the last year; I NEED HELP, NYHA class III/IV; I NEED HELP, HFH >1; I NEED HELP, prognostic medication intolerance or the need to downtitrate (1 mark each; at least one item from either list marks high risk).^[1]
3. Early consultation with an advanced HF centre (a centre performing LVAD implantation and/or heart transplantation) is recommended in patients with advanced HF or at risk of advanced HF, who are motivated and do not have absolute contraindications for heart transplantation or durable MCS, in order to evaluate candidacy (1 mark).^[1] ESC 2026, Class I, Level A (1 mark).^[1]
4. Cardiopulmonary exercise testing is recommended in patients with advanced HF, as part of the evaluation for heart transplantation and durable MCS (ESC 2026, Class I, Level C) (1 mark).^[1] Right heart catheterization is recommended in patients with advanced HF, as part of the evaluation for heart transplantation and durable MCS (ESC 2026, Class I, Level C) (1 mark).^[1]
5. Down-titration of neurohormonal therapy (dose reduction or cessation), such as his halved beta-blocker, should prompt contact with, or referral to, an advanced HF centre if there are no absolute contraindications for MCS or heart transplantation (1 mark).^[1] AMT implementation should not delay early referral to advanced HF therapies (ESC 2026) (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 61-year-old woman with advanced HFrEF and a severely reduced LVEF has NYHA class IV symptoms despite FMT and GDIT. She is in hospital on intravenous dobutamine. She is clinically stable, but three documented attempts to wean the infusion have each produced symptomatic hypotension and rising creatinine. Her beta-blocker and RAS inhibitor doses were not changed during the infusion.^[2][1] Right heart catheterization shows a pulmonary vascular resistance that does not fall with vasodilator testing, so the transplant team does not list her now.^[1]

1. Which INTERMACS profile is she, using AHA/ACC/HFSA 2022 Table 17? (1)^[2]
2. How does ESC 2026 supplementary Table S18 define inotrope dependency? (2)^[1]
3. How does ESC 2026 Table 17 treat her pulmonary vascular resistance, and what does its footnote advise? (2)^[1]
4. Give the ESC 2026 recommendation on durable MCS that applies to her, with class and level. (2)^[1]
5. Give the AHA/ACC/HFSA 2022 durable LVAD row for inotrope-dependent patients, with COR and LOE. (1)^[2]
6. Name two absolute contraindications to LVAD implantation in ESC 2026 Table 16 that must be excluded. (2)^[1]

Model answers — SAQ 2

1. Profile 3, stable but inotrope dependent: clinically stable on mild-moderate doses of intravenous inotropes after repeated documentation of failure to wean without symptomatic hypotension, worsening symptoms, or progressive organ dysfunction (usually renal) (1 mark).^[2]
2. Failure to wean intravenous inotropic support within 72 h (1 mark).^[1] Without development of symptomatic arterial hypotension, worsening renal or hepatic function (eGFR decrease >30%, or clinically important elevation in liver enzymes or INR) or worsening congestion with NYHA class IV symptoms; the diagnosis should not be made during simultaneous introduction or uptitration of beta-blockers or RAS inhibitors (1 mark).^[1]
3. Elevated pulmonary vascular resistance (if pharmacologically irreversible) is one of the other contraindications to heart transplantation (1 mark).^[1] Footnote c: LVAD as bridge to candidacy should be considered (1 mark).^[1]
4. Durable MCS (LVAD) is recommended in selected patients with advanced HFrEF, despite FMT and GDIT, as BTT, BTC, BTR, or as destination therapy to improve symptoms and reduce the risk of death (1 mark).^[1] ESC 2026, Class I, Level C; eligibility criteria are in Table 16, which lists INTERMACS 2–4 in HF with severely reduced LVEF among the indications (1 mark).^[1]
5. In select patients with advanced HFrEF with NYHA class IV symptoms who are deemed to be dependent on continuous intravenous inotropes or temporary MCS, durable LVAD implantation is effective to improve functional status, QOL, and survival (COR 1, LOE A) (1 mark).^[2]
6. Any two of: severe right ventricular dysfunction despite euvolaemic status; severe irreversible end-organ (kidney and/or liver) disease; severe irreversible neurological disease; severe pulmonary disease; contraindication to long-term oral anticoagulation; medical non-adherence and/or other psychosocial limitations; insufficient social supports to achieve compliant care in the outpatient setting; psychological instability that jeopardizes proper follow-up and intensive therapeutic regime after implantation (1 mark each).^[1]