Name: Advanced HF: referral triggers, inotropes, transplant and LVAD
Creator: MedVellum
Published: 2026-10-09
Keywords: Advanced HF: referral triggers, inotropes, transplant and LVAD, Topics, heart-failure, EECC, ABIM Cardiovascular Disease Certification

Key answer

ESC 2026 defines advanced HF by four criteria that must all be present despite FMT, AMT and GDIT: severe and persistent symptoms (NYHA class III or IV); severe cardiac dysfunction; episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic combinations) or malignant arrhythmias causing ≥2 unplanned visits or hospitalizations in the last 12 months, or ≥1 episode of low output requiring inotropes or vasoactive drugs; and severe impairment of exercise capacity estimated to be of cardiac origin.^[1]
ESC 2026: early consultation with an advanced HF centre 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 (Class I, Level A).^[1]
ESC 2026 uses the Rule of three or I NEED HELP criteria (at least one of either list) to flag high risk of advanced HF; the AHA/ACC/HFSA 2022 I-Need-Help list differs in its NYHA (class IIIB to IV), EF (≤35%) and blood pressure (low systolic BP ≤90) items.^[1]^[2]
ESC 2026: 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 (Class I, Level C); heart transplantation is recommended in selected patients with advanced HF refractory to FMT and GDIT, and without contraindications, to improve QoL and survival (Class I, Level C).^[1]
ESC 2026: access to an integrated HF palliative care multidisciplinary team is recommended for patients in an advanced HF stage to improve QoL and reduce symptom burden (Class I, Level B2).^[1]

This page is about the patient whose heart failure keeps progressing despite optimal therapy.^[1] The skill being tested is recognising that patient early and sending them to an advanced HF centre while advanced therapies are still possible.^[1]^[2]

Foundational and additional drug therapy for HFrEF: Heart failure with reduced ejection fraction.
ICD and CRT before advanced therapies are considered: ICD and CRT indications in heart failure.
Temporary MCS and the SCAI shock stages: Cardiogenic shock: staging, MCS selection and outcomes.
Frailty, cachexia, iron deficiency and kidney disease: HF comorbidities: iron deficiency, CKD, gout and cachexia.

What advanced heart failure is

ESC 2026 describes advanced HF as a phase of the disease.^[1] Many patients with HF progress into advanced HF (stage D), with persistent severe symptoms and objective measures of cardiogenic impairment despite optimal therapy.^[1] In the Framingham population, 5.1%–7.7% of patients with HF had advanced HF.^[1] Prognosis in medically treated patients with advanced HF remains poor, with 1-year mortality >40%.^[1]

ESC 2026 Table 14: Criteria for definition of advanced heart failure (all criteria; all must be present despite FMT, AMT and GDIT)

Criterion	ESC 2026 wording
1	Severe and persistent symptoms of HF (NYHA class III or IV).
2	Severe cardiac dysfunction defined by at least one of: LVEF ≤30%; isolated RV failure (e.g. ARVC); non-operable severe valve abnormalities; non-operable severe congenital abnormalities; persistently high (or increasing) BNP or NT-proBNP values and severe LV diastolic dysfunction or structural abnormalities (i.e. HFpEF [footnote a: see ESC 2026 Table 10, simplified echocardiographic criteria for supporting objective evidence of HFpEF], hypertrophic or restrictive cardiomyopathies).
3	Episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic combinations) or malignant arrhythmias causing ≥2 unplanned visits or hospitalizations in the last 12 months, or ≥1 episode of low output requiring inotropes or vasoactive drugs.
4	Severe impairment of exercise capacity with inability to exercise, or low 6-min walk test distance (<300 m), or pVO₂ <12–14 mL/kg/min (footnote: the cut-off 12 mL/kg/min refers to patients on beta-blocker), or <50% predicted value, estimated to be of cardiac origin.

^[1]

FMT is foundational medical therapy, AMT additional medical therapy and GDIT guideline-directed interventional therapy.^[1] ESC 2026 adds that a severely reduced LVEF is common but not required, because advanced HF may develop in HFpEF or other structural abnormalities.^[1]

AHA/ACC/HFSA 2022 uses stage D for the same territory.^[2] AHA/ACC/HFSA 2022 Table 3 defines stage D (advanced HF) as marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize GDMT.^[2] AHA/ACC/HFSA 2022 notes that "end-stage", "advanced" and "refractory" HF have all been used to describe this population.^[2] AHA/ACC/HFSA 2022 describes the 2018 ESC definition, which it reproduces, as focusing on refractory symptoms rather than cardiac function, with advanced HF possible in isolated RV dysfunction, uncorrectable valvular or congenital disease, and preserved and mildly reduced EF.^[2]

^[1]

When to refer

ESC 2026 is blunt about timing.^[1] Early risk stratification and timely referral to an advanced HF centre are crucial to improve outcomes.^[1] The ESC 2026 key message: patients with advanced HF refractory to FMT and GDIT who do not have absolute contraindications must have timely referral for consideration of heart transplantation or MCS.^[1] AHA/ACC/HFSA 2022 gives the reason: after patients develop end-organ dysfunction or cardiogenic shock, they may no longer qualify for advanced therapies.^[2] AHA/ACC/HFSA 2022 take-home message 8 says patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF.^[2]

The ESC 2026 high-risk screens

ESC 2026 calls systematic assessment with the Rule of three or I NEED HELP criteria essential for timely referral to an advanced HF centre.^[1] One criterion from either list is enough.^[1]

ESC 2026 Table 15: Criteria for high risk of advanced heart failure (all criteria)

Group	Criterion
Rule of three (at least 1)	HFH (≥2 or ≥1 requiring inotropes within the last year)
Rule of three (at least 1)	Diuretic resistance
Rule of three (at least 1)	Intolerance to neurohormonal drugs with onset of cardiorenal syndrome
I NEED HELP (at least 1)	I: Inotropes
I NEED HELP (at least 1)	N: NYHA class III/IV or persistently high natriuretic peptides
I NEED HELP (at least 1)	E: End-organ dysfunction (liver, kidney)
I NEED HELP (at least 1)	E: EF <20% or poor RV function
I NEED HELP (at least 1)	D: Defibrillator shocks
I NEED HELP (at least 1)	H: HFH >1
I NEED HELP (at least 1)	E: Escalating diuretics
I NEED HELP (at least 1)	L: Low blood pressure, high heart rate
I NEED HELP (at least 1)	P: Prognostic medication intolerance or the need to downtitrate

^[1]

The AHA/ACC/HFSA 2022 version of I-Need-Help

AHA/ACC/HFSA 2022 prints its own I-Need-Help acronym as an aid to decision-making for referral to advanced HF.^[2] Three letters carry different thresholds from ESC 2026, so name the source when you recite it.^[2]^[1]

ESC 2026 Table 15

I NEED HELP

N: NYHA class III/IV or persistently high natriuretic peptides
E: EF <20% or poor RV function
E: Escalating diuretics
L: Low blood pressure, high heart rate
P: Prognostic medication intolerance or the need to downtitrate

AHA/ACC/HFSA 2022

I-Need-Help

N: NYHA class IIIB to IV or persistently elevated natriuretic peptides
E: EF ≤35%
E: Edema despite escalating diuretics
L: Low systolic BP ≤90, high heart rate
P: Prognostic medication; progressive intolerance or down-titration of GDMT

^[1] ^[2]

The other letters match in substance: I is inotropes (intravenous inotropes in the AHA/ACC/HFSA list), the first E is end-organ dysfunction, D is defibrillator shocks, and H is more than one HF hospitalization.^[1]^[2]

AHA/ACC/HFSA 2022 clinical indicators

AHA/ACC/HFSA 2022 (section 4.1): in patients with symptomatic HF, clinical factors indicating the presence of advanced HF should be sought via the history and physical examination (COR 1, LOE B-NR).^[2] The AHA/ACC/HFSA 2022 supportive text says recognising advanced HF allows earlier referral to an advanced HF center, when appropriate.^[2] AHA/ACC/HFSA 2022 lists the clinical indicators of advanced HF that should trigger possible referral to an advanced HF specialist.^[2]

AHA/ACC/HFSA 2022 Table 18: Clinical Indicators of Advanced HF (all indicators)

Indicator
Repeated hospitalizations or emergency department visits for HF in the past 12 mo.
Need for intravenous inotropic therapy.
Persistent NYHA functional class III to IV symptoms despite therapy.
Severely reduced exercise capacity (peak VO₂ <14 mL/kg/min or <50% predicted, 6-min walk test distance <300 m, or inability to walk 1 block on level ground because of dyspnea or fatigue).
Intolerance to RAASi because of hypotension or worsening renal function.
Intolerance to beta blockers as a result of worsening HF or hypotension.
Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose >160 mg/d or use of supplemental metolazone therapy.
Refractory clinical congestion.
Progressive deterioration in renal or hepatic function.
Worsening right HF or secondary pulmonary hypertension.
Frequent SBP ≤90 mm Hg.
Cardiac cachexia.
Persistent hyponatremia (serum sodium <134 mEq/L).
Refractory or recurrent ventricular arrhythmias; frequent ICD shocks.
Increased predicted 1-year mortality (eg, >20%) according to HF survival models (eg, MAGGIC, SHFM).

^[2]

The referral rows

Referral rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 11)	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.	Class I, Level A
AHA/ACC/HFSA 2022 (section 8.1)	In patients with advanced HF, when consistent with the patient’s goals of care, timely referral for HF specialty care is recommended to review HF management and assess suitability for advanced HF therapies (eg, LVAD, cardiac transplantation, palliative care, and palliative inotropes).	COR 1, LOE C-LD
NHFA/CSANZ 2018 (section 9.5)	Referral to a specialist centre for consideration of VAD implantation should be considered in patients with intractable, severe heart failure despite guideline-directed medical and pacemaker therapy, and who do not suffer from major comorbidities, to decrease mortality.	Strong recommendation FOR; moderate quality of evidence
NHFA/CSANZ 2018 (section 9.6)	Referral for heart transplant assessment should be considered in patients with heart failure associated with intractable NYHA Class III–IV symptoms who have exhausted all alternative therapies and who do not have overt contraindications, to decrease mortality.	Strong recommendation FOR; low quality of evidence

^[1] ^[2] ^[3]

The ESC 2026 row carries two footnotes worth knowing.^[1] Eligibility criteria are in its Tables 16 and 17, and the Task Force considers the row to have level of evidence A due to clear clinical effectiveness.^[1] ESC 2026 lists this row among its new recommendations (Table 5, under advanced heart failure).^[1]

Do not wait for a full work-up: AHA/ACC/HFSA 2022 says a complete assessment is not required before referral, because comprehensive multidisciplinary assessment is routinely performed when evaluating patients for advanced therapies.^[2]
Down-titration is a trigger: ESC 2026 says any of these down-titrations of neurohormonal therapy should prompt contact with, or referral to, an advanced HF centre if there are no absolute contraindications for MCS or heart transplantation, and AMT implementation should not delay early referral.^[1]
Transplant timing: NHFA/CSANZ 2018 says timing of referral can be difficult to judge, but recommends early referral because these patients are at high risk of complications that may exclude them from transplant consideration, such as fixed pulmonary hypertension or multiorgan failure.^[3]
Who gets missed: ESC 2026 says women and sociocultural minority groups are less likely to receive MCS and heart transplantation for reasons not explained by medical factors or social determinants of health, and deserve extra attention for timely referral and patient communication.^[1]
Networks: ESC 2026 calls a Hub and Spoke network between centres with different levels of care complexity key to good patient management.^[1]
NHFA/CSANZ 2018 practice advice: clinicians are advised to contact the specialist centres about any patient with heart failure who is responding poorly to conventional medical or device therapy.^[3]

Before you label a patient advanced, check the basics.^[2] AHA/ACC/HFSA 2022 notes that severely symptomatic patients with a new diagnosis of HF can often improve substantially if initially stabilized, and that patients should be evaluated for nonadherence to medications.^[2] AHA/ACC/HFSA 2022 also asks for a careful review of medical management to verify that all therapies likely to improve clinical status have been considered.^[2]

^[1]

Assessment at the advanced HF centre

ESC 2026 names cardiopulmonary exercise testing and right heart catheterization as key tools for risk stratification and eligibility assessment.^[1] Both have their own rows in Recommendation Table 11.^[1]

ESC 2026 Recommendation Table 11: Recommendations for diagnosis and evaluation of advanced heart failure (all rows)

ESC 2026 Recommendation Table 11 row	Class, Level
Early consultation with an advanced HF centre 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.	I, A
Cardiopulmonary exercise testing is recommended in patients with advanced HF, as part of the evaluation for heart transplantation and durable MCS.	I, C
Right heart catheterization is recommended in patients with advanced HF, as part of the evaluation for heart transplantation and durable MCS.	I, C

^[1]

The same tests appear in the ESC 2026 candidacy tables: the indication by the centre includes assessment of HF severity by RHC and/or CPET, both for LVAD and for transplantation.^[1] AHA/ACC/HFSA 2022 (section 4.7): in selected ambulatory patients with HF, CPET is recommended to determine appropriateness of advanced treatments (eg, LVAD, heart transplant) (COR 1, LOE C-LD).^[2] AHA/ACC/HFSA 2022 adds that CPET can refine candidate prognosis and selection for transplantation.^[2]

INTERMACS profiles

ESC 2026 says INTERMACS profiles describe clinical parameters and characteristics consistent with a need for advanced therapies, and that the SCAI classification may be useful in identifying patients for temporary MCS as a possible bridge to advanced therapies.^[1] The ESC 2026 Figure 17 legend says the INTERMACS classification supports risk stratification and guides the timing of durable MCS or heart transplantation in advanced HF.^[1] AHA/ACC/HFSA 2022 prints the seven profiles in its Table 17.^[2]

AHA/ACC/HFSA 2022 Table 17: INTERMACS Profiles (all profiles; features abridged for profiles 4, 6 and 7)

Profile	Description	Features (AHA/ACC/HFSA 2022 wording)
1	Critical cardiogenic shock	Life-threatening hypotension and rapidly escalating inotropic/pressor support, with critical organ hypoperfusion often confirmed by worsening acidosis and lactate levels.
2	Progressive decline	"Dependent" on inotropic support but nonetheless shows signs of continuing deterioration in nutrition, renal function, fluid retention, or other major status indicator; can also apply to a patient with refractory volume overload, perhaps with evidence of impaired perfusion, in whom inotropic infusions cannot be maintained because of tachyarrhythmias, clinical ischemia, or other intolerance.
3	Stable but inotrope dependent	Clinically stable on mild-moderate doses of intravenous inotropes (or has a temporary circulatory support device) after repeated documentation of failure to wean without symptomatic hypotension, worsening symptoms, or progressive organ dysfunction (usually renal).
4	Resting symptoms on oral therapy at home	At home on oral therapy but frequently has symptoms of congestion at rest or with activities of daily living (dressing or bathing).
5	Exertion intolerant	Comfortable at rest but unable to engage in any activity, living predominantly within the house or housebound.
6	Exertion limited	Comfortable at rest without evidence of fluid overload but able to do some mild activity.
7	Advanced NYHA class III	Clinically stable with a reasonable level of comfortable activity, despite a history of previous decompensation that is not recent.

^[2]

The table footnote lists modifier options.^[2] Among them, profiles 3 to 6 can be modified for recurrent decompensations leading to frequent (generally at least 2 in past 3 months or 3 in past 6 months) emergency department visits or hospitalizations for intravenous diuretics, ultrafiltration, or brief inotropic therapy.^[2]

^[2]

Frailty and nutrition

ESC 2026 says frailty, malnutrition, cardiac cachexia and sarcopenia are highly prevalent in advanced HF and are associated with a greater risk of death.^[1] When frailty is found, ESC 2026 asks whether it is primarily due to the cardiac condition or to other factors.^[1] Definitions and management of cachexia and sarcopenia are covered in HF comorbidities: iron deficiency, CKD, gout and cachexia.

Medical therapy when GDMT is failing

ESC 2026 starts with the aim: every effort should be made to reach target doses of FMT in all patients with HF, though patients with advanced HF are under-represented in RCTs.^[1] Most reach a stage where dose reduction or cessation of neurohormonal therapy is necessary due to progressive intolerance.^[1] Although evidence is lacking, ESC 2026 says it is reasonable to make individualized changes in FMT, and AMT if needed, on a patient-tailored basis.^[1]

Hypotension with a high arrhythmic burden: the ACE-I dose can be reduced so that beta-blockers can be prioritized (ESC 2026 example).^[1]
Hypoperfusion with persistently low stroke volume despite therapy: reduction or cessation of beta-blockers may be the first step to maintaining cardiac output, and amiodarone may be better tolerated than beta-blockers when arrhythmias occur (ESC 2026 example).^[1]

ESC 2026 Recommendation Table 12: Recommendations for medical management of advanced heart failure (all rows)

ESC 2026 Recommendation Table 12 row	Class, Level
Down-titration or discontinuation of beta-blockers or ivabradine should be considered in selected patients with advanced HFrEF and evidence of organ hypoperfusion, despite initial treatment, to increase cardiac output and improve symptoms.	IIa, C
Continuous inotropes should be considered in patients with advanced HFrEF, low cardiac output, and evidence of hypoperfusion or end-organ dysfunction, as BTD (bridge to decision), BTT (bridge to transplantation) or as bridge to durable MCS, to increase cardiac output and improve symptoms.	IIa, C
Kidney replacement therapy should be considered in patients with refractory volume overload and end-stage kidney failure to improve symptoms.	IIa, C
Ultrafiltration may be considered in patients with refractory volume overload unresponsive to escalation of diuretic therapy to reduce the risk of rehospitalization.	IIb, C

^[1]

Diuretic resistance is part of the picture.^[1] ESC 2026 says kidney dysfunction and loop diuretic resistance often characterize advanced HF, and doubling the loop diuretic dose or adding non-loop diuretics is indicated.^[1] In patients who fail to respond to diuretic-based strategies, kidney replacement therapies should be considered; ultrafiltration and peritoneal dialysis are the most common approaches.^[1]

On fluid, AHA/ACC/HFSA 2022 is cautious: for patients with advanced HF and hyponatremia, the benefit of fluid restriction to reduce congestive symptoms is uncertain (COR 2b, LOE C-LD).^[2] The full drug ladder for HFrEF is in Heart failure with reduced ejection fraction.

Inotropes

ESC 2026 explains what inotropes can and cannot do here.^[1] In patients with signs of hypoperfusion, they may improve haemodynamic parameters, augmenting cardiac output and aiding peripheral perfusion, and may reduce congestion when the response to diuretics is insufficient.^[1] ESC 2026 says inotropic therapy is often used to assess reversibility of end-organ dysfunction in the screening phase for durable MCS or transplantation, or to maintain cardiac output until those therapies become available.^[1] ESC 2026 adds that inotropes can be used as palliative therapy for the relief of symptoms in patients without other treatment options.^[1]

Because inotropic therapy may exacerbate or induce myocardial ischaemia and/or tachyarrhythmias, ESC 2026 says it should only be used in the lowest required dose and for as short a period as possible.^[1] AHA/ACC/HFSA 2022 adds that positive inotropic agents have not shown improved survival in patients with HF in either the hospital or the outpatient setting.^[2]

Inotrope rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 12)	Continuous inotropes should be considered in patients with advanced HFrEF, low cardiac output, and evidence of hypoperfusion or end-organ dysfunction, as BTD, BTT or as bridge to durable MCS, to increase cardiac output and improve symptoms.	Class IIa, Level C
AHA/ACC/HFSA 2022 (section 8.3, row 1)	In patients with advanced (stage D) HF refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation, continuous intravenous inotropic support is reasonable as "bridge therapy."	COR 2a, LOE B-NR
AHA/ACC/HFSA 2022 (section 8.3, row 2)	In select patients with stage D HF, despite optimal GDMT and device therapy who are ineligible for either MCS or cardiac transplantation, continuous intravenous inotropic support may be considered as palliative therapy for symptom control and improvement in functional status.	COR 2b, LOE B-NR
AHA/ACC/HFSA 2022 (section 8.3, row 3)	In patients with HF, long-term use of either continuous or intermittent intravenous inotropic agents, for reasons other than palliative care or as a bridge to advanced therapies, is potentially harmful.	COR 3: Harm, LOE B-R

^[1] ^[2]

Why bridge: AHA/ACC/HFSA 2022 says more prolonged use of inotropes as bridge therapy for those awaiting transplantation or MCS may have benefit in reducing pulmonary hypertension and maintaining end-organ perfusion beyond initial stabilization.^[2]
Palliative inotropes carry risk: arrhythmias and catheter-related infections, although an ICD does decrease the mortality associated with arrhythmias (AHA/ACC/HFSA 2022).^[2]
Why long-term use harms: with currently available agents, the benefit of haemodynamic support may be compromised by increased myocardial oxygen demand and increased arrhythmic burden (AHA/ACC/HFSA 2022).^[2]
Choice of agent: AHA/ACC/HFSA 2022 finds a continued lack of robust evidence to suggest the clear benefit of one inotrope over another.^[2]
Dose and review: lower doses are preferred to minimize adverse effects, tachyphylaxis should be acknowledged, the agent may need to change during longer support, and the ongoing need for support and the possibility of discontinuation should be regularly assessed (AHA/ACC/HFSA 2022).^[2]

Inotrope dependence

ESC 2026 supplementary Table S18 defines inotrope dependency as failure to wean intravenous inotropic support within 72 h without one of three events.^[1]

(i) development of symptomatic arterial hypotension, or^[1]
(ii) worsening renal or hepatic function, defined as eGFR decrease >30%, or clinically important elevation in liver enzymes or INR, or^[1]
(iii) worsening congestion leading to or upholding NYHA class IV symptoms, in the absence of reduction in loop diuretic dose.^[1]

The table footnotes set the details.^[1] The inotropic support covered is epinephrine, norepinephrine, dopamine, dobutamine or milrinone.^[1] After continuous intravenous inotropic support for >7 days, dependence is failure to reduce the infusion rate at 72 h after each attempt to reduce; with levosimendan, it is the need for a new infusion <10 days after the former.^[1] The diagnosis should not be made during simultaneous introduction or uptitration of beta-blockers or RAS inhibitors.^[1]

Dobutamine and milrinone

AHA/ACC/HFSA 2022 Table 20: Intravenous Inotropic Agents Used in the Management of HF (selected rows)

Agent	Bolus	Infusion (mcg/kg/min)	Half-life; metabolism	CO, HR, SVR, PVR	Adverse effects	Special considerations
Dobutamine (adrenergic agonist)	NA (not applicable)	2.5–20	2–3 min; hepatic	↑, ↑, ↔, ↔	↑/↓BP, headache, tachyarrhythmias, nausea, fever, hypersensitivity	Caution: MAO-I; contraindication: sulfite allergy
Milrinone (PDE 3 inhibitor)	NR (not recommended)	0.125–0.75	2.5 h; hepatic	↑, ↑, ↓, ↓	Tachyarrhythmias, ↓BP	Accumulation may occur in setting of renal failure; monitor kidney function and LFTs

^[2]

Read the effect columns: milrinone lowers SVR and PVR in this table, while dobutamine leaves both unchanged.^[2] Milrinone may accumulate in renal failure.^[2]

Home infusion is mentioned in the Australian guideline under acute HF.^[3] NHFA/CSANZ 2018 says continuous home ambulatory infusions of inotropes may improve quality of life in patients who cannot be weaned from inotropic support and would otherwise be unable to be discharged from hospital, as a bridging strategy to transplantation or as palliation.^[3]

ESC 2026 strengthened its inotrope row from the 2021 edition; its Table 6 (revised recommendations) pairs the two.^[1]

2021 row (dated history): continuous inotropes and/or vasopressors may be considered in patients with low cardiac output and evidence of organ hypoperfusion as bridge to MCS or heart transplantation (2021: Class IIb, Level C).^[1]
2026 row that replaces it: the Recommendation Table 12 continuous inotrope row above (2026: Class IIa, Level C).^[1]

Durable mechanical circulatory support

ESC 2026 says MCS can improve survival and symptoms of patients with advanced HF.^[1] Durable MCS is indicated to prolong life and improve QoL in selected patients when FMT and GDIT are insufficient, or when temporary MCS has not led to cardiac recovery or clinical improvement.^[1] An LVAD is by far the most common and reliable type; a total artificial heart or implantable biventricular assist device is occasionally used for biventricular failure or special anatomical situations.^[1]

The strategy labels

ESC 2026 supplementary Table S19: Terms describing various indications for mechanical circulatory support (all terms)

Term	ESC 2026 definition
Bridge to decision/bridge to bridge	Use of temporary MCS in patients with cardiogenic shock until haemodynamic parameters and end-organ perfusion are stabilized, contraindications for durable MCS are excluded, and additional therapeutic options, including durable MCS therapy or heart transplantation, can be evaluated
Bridge to surgery	Use of temporary MCS in patients with cardiogenic shock with an indication to surgery as a bridge to surgery
Bridge to candidacy	Use of durable and temporary MCS (usually LVAD) to improve end-organ function and/or to make an ineligible patient eligible for heart transplantation
Bridge to transplantation	Use of durable and temporary MCS to keep a patient alive who is otherwise at high risk of death before transplantation until a donor organ becomes available
Bridge to recovery	Use of MCS to keep a patient alive until cardiac function recovers sufficiently to remove MCS
Destination therapy	Use of durable MCS as an alternative to transplantation in patients with end-stage HF ineligible for transplantation

^[1]

Labels are not fixed.^[3] NHFA/CSANZ 2018 notes that patients may move from BTT to DT, for example after a disabling stroke or high immune sensitisation from repeated transfusion, and from DT to BTT after marked improvement in functional class and reversal of frailty.^[3] In 2018 the Australian guideline stated that approved indications for VAD implantation in Australia (and New Zealand) fell into the first three of its four categories (BTT, bridge to candidacy and bridge to recovery), while globally destination therapy had become the most common indication.^[3]

ESC 2026 LVAD candidacy

ESC 2026 Table 16: Indications and contraindications for implantation of a left ventricular assist device (all entries)

Group	ESC 2026 wording
Indications (footnote: indication by transplantation centre includes assessment of HF severity by RHC and/or CPET)	HF with severely reduced LVEF and one of the following:
Indication option	INTERMACS 1–2 with neurological and other end-organ recovery but no cardiac recovery on temporary MCS, OR
Indication option	INTERMACS 2–4, OR
Indication option	Severe symptoms and signs (NYHA class III/IV; INTERMACS >4) despite optimal FMT and GDIT, and at least one of: unable to exercise due to HF or, if able to perform CPET, pVO₂ <12–14 mL/kg/min and/or <50% predicted value; end-organ dysfunction (worsening kidney and/or hepatic function, group 2 pulmonary hypertension, cardiac cachexia) due to reduced perfusion as indicated by cardiac index ≤2 L/min/m² despite euvolaemic or therapy-resistant hypervolaemic status; repeated HFH within the previous 12 months without an obvious precipitating cause.
Absolute contraindications	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
Relative contraindications	Obesity or malnutrition; musculoskeletal disease that impairs rehabilitation; malignancy (depending on type and prognosis); severe peripheral arterial disease; systemic infection; alcohol or substance abuse within the past 6 months, or active smoking; impaired cognitive function; frailty

^[1] ^[1]

AHA/ACC/HFSA 2022 durable support criteria

AHA/ACC/HFSA 2022 Table 19: Indications and Contraindications to Durable Mechanical Support (all entries)

Group	AHA/ACC/HFSA 2022 wording
Indications (combination of these)	Frequent hospitalizations for HF; NYHA class IIIb to IV functional limitations despite maximal therapy; intolerance of neurohormonal antagonists; increasing diuretic requirement; symptomatic despite CRT; inotrope dependence; low peak VO₂ (<14–16); end-organ dysfunction attributable to low cardiac output
Absolute contraindications	Irreversible hepatic disease; irreversible renal disease; irreversible neurological disease; medical nonadherence; severe psychosocial limitations
Relative contraindications	Age >80 y for destination therapy; obesity or malnutrition; musculoskeletal disease that impairs rehabilitation; active systemic infection or prolonged intubation; untreated malignancy; severe PVD; active substance abuse; impaired cognitive function; unmanaged psychiatric disorder; lack of social support

^[2]

Compare the two lists before the exam.^[1]^[2] ESC 2026 places severe RV dysfunction despite euvolaemia, severe pulmonary disease and a contraindication to long-term oral anticoagulation among its absolute contraindications; AHA/ACC/HFSA 2022 Table 19 lists none of the three, and gives age >80 y for destination therapy as a relative contraindication.^[1]^[2]

The durable MCS rows

Durable MCS rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 13)	Durable MCS (LVAD) is recommended in selected patients (eligibility criteria in Table 16) with advanced HFrEF, despite FMT and GDIT, as BTT, BTC, BTR, or as destination therapy to improve symptoms and reduce the risk of death.	Class I, Level C
AHA/ACC/HFSA 2022 (section 8.4, row 1)	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
AHA/ACC/HFSA 2022 (section 8.4, row 2)	In select patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT, durable MCS can be beneficial to improve symptoms, improve functional class, and reduce mortality.	COR 2a, LOE B-R
AHA/ACC/HFSA 2022 (section 8.4, value statement 3)	In patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT, durable MCS devices provide low to intermediate economic value based on current costs and outcomes.	Value statement: uncertain value (B-NR)
NHFA/CSANZ 2018 (section 9.5)	Implantation of a VAD as a bridge to transplant should be considered in patients actively listed for heart transplantation who become inotrope-dependent or who progress to needing acute mechanical circulatory support.	Strong recommendation FOR; low quality of evidence

^[1] ^[2] ^[3]

ESC 2026 lists its LVAD row as a revision of two 2021 rows; its Table 6 lists both against the single 2026 row (2026: Class I, Level C).^[1]

2021 row (dated history): long-term MCS should be considered in patients with advanced HFrEF despite optimal medical and device therapy, not eligible for heart transplantation or other surgical options, and without severe RV dysfunction, to reduce the risk of death and improve symptoms (2021: Class IIa, Level A).^[1]
2021 row (dated history): long-term MCS should be considered in patients with advanced HFrEF refractory to optimal medical and device therapy as a bridge to cardiac transplantation (2021: Class IIa, Level B).^[1]
Who suits a device: AHA/ACC/HFSA 2022 says anatomic and physiologic criteria make durable MCS inappropriate for some patients, and it is most appropriate for HFrEF with a dilated ventricle.^[2]
Too sick and too well: implantation in INTERMACS profile 1 has been associated with poorer outcome, while ambulatory patients in profiles 5 to 7 might be too well to have large significant benefit, depending on their symptom burden (AHA/ACC/HFSA 2022).^[2]
Risk markers: there is no clear single risk model, but factors such as elevated central venous pressure, pulmonary hypertension and coagulopathy have been linked to poorer outcomes (AHA/ACC/HFSA 2022).^[2]
Anticoagulation: in patients unable to tolerate anticoagulation after repeated challenges, durable MCS is associated with excess morbidity (AHA/ACC/HFSA 2022).^[2]
Bridge to candidacy: for patients first considered transplant ineligible because of pulmonary hypertension, obesity, overall frailty or other reasons, MCS can provide time to reverse or modify these conditions (AHA/ACC/HFSA 2022).^[2]
Drugs after implant: AHA/ACC/HFSA 2022 supportive text says continuing and uptitrating GDMT in patients with durable MCS is recommended.^[2]
Secondary mitral regurgitation: in its valvular heart disease section, ESC 2026 says that in advanced HF, LVAD or heart transplantation is recommended as first choice and TEER may be considered for symptom improvement in patients not suitable or waiting for these therapies.^[1]
ICD in NYHA class IV: ESC 2026 does not recommend ICD implantation in patients in NYHA class IV with severe symptoms refractory to pharmacological therapy unless they are candidates for CRT, a ventricular assist device, or heart transplantation (Class III, Level C); see ICD and CRT indications in heart failure.^[1]

ICD and wearable defibrillator rows before transplantation and with an LVAD, by body and year

Body and year	Row	Strength
ESC 2022 VA/SCD (Recommendation Table 48, prior to heart transplant, row 1)	In patients awaiting heart transplantation, ICD implantation for primary prevention should be considered.	Class IIa, Level C
ESC 2022 VA/SCD (Recommendation Table 48, prior to heart transplant, row 2)	In patients awaiting heart transplantation, WCD (wearable cardioverter defibrillator) may be considered.	Class IIb, Level C
ESC 2026 HF (Recommendation Table 6)	A wearable cardioverter-defibrillator may be considered in patients with HF who are at risk of sudden cardiac death for a limited period in order to increase survival as a bridge to decision for permanent ICD implantation or while listed for heart transplantation.	Class IIb, Level C
ESC 2022 VA/SCD (Recommendation Table 19)	ICD implantation should be considered in LVAD recipients with symptomatic sustained VAs (ventricular arrhythmias).	Class IIa, Level B

^[16] ^[1]

For patients with HF who are listed for heart transplantation, the ESC 2026 heart failure row is the newer ESC row on the wearable defibrillator, so the ESC 2022 row on it is dated for that population.^[1]^[16] The ESC 2022 ventricular arrhythmia rows on ICD implantation while awaiting heart transplantation and in LVAD recipients with symptomatic sustained VAs are given with their year.^[16] Recommendation Table 48 also has a post heart transplant row, outside this topic: in selected transplanted patients with cardiac allograft vasculopathy or treated rejection, ICD implantation may be considered (Class IIb, Level C).^[16]

Temporary MCS as the bridge

ESC 2026 says temporary MCS devices are indicated in selected patients to reverse critical end-organ hypoperfusion and hypoxia in the setting of cardiogenic shock.^[1] The aim is to support cerebral and end-organ perfusion, reverse acidosis and multiorgan failure, and support the patient until the trajectory clarifies towards recovery, durable MCS or transplantation, or a palliative pathway.^[1] ESC 2026 narrative says temporary MCS should be considered in INTERMACS profiles 1 or 2 as a bridge to decision, bridge to recovery, or bridge to either durable MCS or urgent heart transplantation (no class or level given).^[1]

ESC 2026 Recommendation Table 10: Recommendations for the use of temporary mechanical circulatory support in patients with cardiogenic shock (selected rows)

ESC 2026 Recommendation Table 10 row	Class, Level
A multidisciplinary Shock Team is recommended in potential candidates for temporary MCS to guide the device selection (modality and type) based on patient and HF characteristics.	I, C
Advanced HF cardiogenic shock: temporary MCS should be considered in selected patients with HF-related haemodynamic instability as a BTR, BTD, BTB (bridge to bridge), BTC, or BTT.	IIa, C

^[1]

AHA/ACC/HFSA 2022: in patients with advanced HFrEF and hemodynamic compromise and shock, temporary MCS, including percutaneous and extracorporeal ventricular assist devices, are reasonable as a "bridge to recovery" or "bridge to decision" (COR 2a, LOE B-NR).^[2] AHA/ACC/HFSA 2022 says these patients often present in cardiogenic shock that cannot be managed solely with intravenous inotropes and in whom other organ function is at risk.^[2] Device choice and shock staging are covered in Cardiogenic shock: staging, MCS selection and outcomes.

^[1]

Outcomes and the trials

REMATCH

N Engl J Med

PMID 11794191

2001

Randomised: LVAD (68 patients) vs optimal medical management (61)

Population: 129 patients with end-stage HF ineligible for cardiac transplantation; all had NYHA class IV symptoms

Key finding

Risk of death from any cause reduced by 48% (relative risk 0.52); survival 52% vs 25% at one year and 23% vs 8% at two years (P=0.09)

^[5]

Serious adverse events were 2.35 times as frequent with the device, mainly infection, bleeding and device malfunction (REMATCH abstract).^[5] ESC 2026 reports REMATCH as the only RCT comparing an LVAD as destination therapy with optimal medical therapy in advanced HF, now dated: it showed lower all-cause death with an earlier device (HeartMate XVE), but mortality at 2 years was high in both arms.^[1]

MOMENTUM 3

N Engl J Med

PMID 30883052

2019

Randomised: fully magnetically levitated centrifugal-flow LVAD vs axial-flow LVAD; primary end point survival at 2 years free of disabling stroke or reoperation to replace or remove a malfunctioning device

Population: 1028 patients with advanced HF, randomised irrespective of intended goal (bridge to transplantation or destination therapy)

Key finding

Primary end point met in 76.9% vs 64.8% (relative risk 0.84; P<0.001 for superiority); pump replacement 2.3% vs 11.3%

^[6]

The 5-year report was an observational follow-up of MOMENTUM 3 in 69 US centres; of 1020 patients in the per-protocol population, 536 were still receiving LVAD support at 2 years.^[7] Its 10 end points were evaluated at 5 years in the per-protocol population.^[7] The 5-year report abstract gives a 5-year Kaplan-Meier estimate of survival to transplant, recovery or LVAD support free of debilitating stroke or reoperation to replace the pump of 54.0% vs 29.7%, and overall Kaplan-Meier survival of 58.4% vs 43.7%, centrifugal-flow vs axial-flow.^[7]

ESC 2026 summarises the same trial differently.^[1] ESC 2026 reports 2-year and 5-year survival of 79% and 58.4% with the fully magnetically levitated LVAD in MOMENTUM 3, and says current 2-year survival with the latest LVADs is comparable to that after heart transplantation.^[1] ESC 2026 adds that >85% of patients in MOMENTUM 3 were in INTERMACS 1–3 at the time of LVAD implantation.^[1] AHA/ACC/HFSA 2022 reports that the survival benefit of durable LVAD support in advanced NYHA class IV patients has progressively improved, with a 2-year survival >80% in recent trials with newer generation LVADs, approaching the early survival after cardiac transplantation.^[2] AHA/ACC/HFSA 2022 also cites a 2020 INTERMACS report in which 87.6% of recent durable LVAD recipients were INTERMACS 1 to 3 before implant.^[2]

Living with an LVAD

ESC 2026 says adverse events may negatively affect QoL after LVAD.^[1] Pump thrombosis has become extremely rare, but driveline infections remain similar to those with older devices.^[1] Right HF and arrhythmias may cause readmissions, and bleeding events can be minimized by avoiding antiplatelet therapy in addition to anticoagulation.^[1] AHA/ACC/HFSA 2022 notes that most patients require rehospitalization within the first year after implant.^[2] ESC 2026: cardiac rehabilitation (either comprehensive or exercise-based) is recommended in patients with an LVAD to improve functional capacity and QoL (Class I, Level B1).^[1] The ESC 2026 cardiac rehabilitation guideline recommends CR in patients with advanced HF and LVAD and in patients after heart transplantation to improve physical functioning (VO₂ peak, 6MWD) (Class I, Level B1).^[10] The same guideline recommends exercise training, as part of CR, in ventricular assist device recipients to improve physical functioning (VO₂ peak or walking capacity) and HRQoL (Class I, Level B1).^[10] The ESC 2026 cardiac rehabilitation guideline also recommends exercise training, as part of CR, in heart transplantation recipients to improve physical functioning (VO₂ peak) (Class I, Level B1).^[10]

ARIES-HM3

JAMA

PMID 37950897

2023

Randomised, double-blind, placebo-controlled: aspirin 100 mg/d vs placebo with VKA therapy; noninferiority primary end point at 12 months

Population: 628 patients with advanced HF implanted with a fully magnetically levitated LVAD, 51 centres in 9 countries; median follow-up 14 months

Key finding

Alive and free of haemocompatibility events at 12 months: 74% placebo vs 68% aspirin, noninferior; aspirin avoidance associated with reduced nonsurgical bleeding (relative risk 0.66) with no increase in stroke or other thromboembolic events

^[8]

AHA/ACC/HFSA 2022 says appropriate patient selection for LVAD benefits from review by a multidisciplinary team that typically includes an HF cardiologist, surgeon, social worker, nurse, pharmacist, dietician and a palliative medicine specialist.^[2]

ESC 2026 Recommendation Table 13: Recommendations for durable mechanical circulatory support in advanced heart failure (all rows)

ESC 2026 Recommendation Table 13 row	Class, Level
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.	I, C
Histopathological examination of explanted heart tissue from LVAD or heart transplantation surgery should be considered in patients with non-ischaemic HF to identify an aetiological diagnosis that may be treatable or facilitate family screening.	IIa, C

^[1]

ESC 2026 explains the second row: histology after LVAD implantation or transplantation can identify potentially treatable or genetic causes of HF, is valuable for family screening, and helps judge the potential for myocardial recovery in LVAD patients.^[1]

Heart transplantation

ESC 2026 calls heart transplantation, although never evaluated in RCTs, the gold-standard treatment for advanced HF in the absence of contraindications.^[1] Post-transplant 1-year survival is 80%–90% and median survival is around 12.5 years.^[1] Transplantation significantly improves QoL and functional status; the main challenge afterwards is balancing the efficacy and side effects of immunosuppression, and organ donor shortage remains the main limitation.^[1] Several countries have started donation after circulatory death programmes, besides donation after brain death, with comparable mid-term results.^[1]

Careful recipient selection remains essential, based on pre-transplant and post-transplant life expectancy (ESC 2026).^[1]

ESC 2026 Table 17: Indications and contraindications for heart transplantation (all entries)

Group	ESC 2026 wording
Indication (footnote a: indication by heart transplantation centre includes assessment of HF severity by RHC and/or CPET)	Advanced HF and no other therapeutic option (except for durable MCS as BTT)
Absolute contraindications	Inability to comply with the therapeutic regimen (e.g. dementia)
Absolute contraindications	Serious comorbidities with poor prognosis, not reversible with heart transplantation
Other contraindications	Active infection (footnote b: active infection is a relative contraindication to transplantation, but infected LVAD may be an indication)
Other contraindications	Severe peripheral arterial or cerebrovascular disease
Other contraindications	Elevated pulmonary vascular resistance (if pharmacologically irreversible) (footnote c: LVAD as bridge to candidacy should be considered)
Other contraindications	Cancer (footnote d: highly selected cases may be eligible, to be discussed with an oncologist)
Other contraindications	Irreversible liver dysfunction (cirrhosis) or irreversible kidney dysfunction (footnote e: combined heart–liver or heart–kidney transplantation may be considered)
Other contraindications	Systemic disease with multiorgan involvement
Other contraindications	BMI >35 kg/m² or severe cachexia
Other contraindications	Alcohol or substance abuse or active smoking within the past 6 months
Other contraindications	Psychological instability
Other contraindications	Insufficient social support to achieve compliant care in the outpatient setting

^[1]

ESC 2026 weighs age against life expectancy and biological age.^[1] Patients younger than 65 years might be more appropriate candidates because of their overall life expectancy, but most programmes accept patients up to 70 years, and biological as well as chronological age must be taken into account.^[1] Surgical complexity (previous sternotomies, mediastinal radiation, adult congenital heart disease) should also be considered, and the decision pathway to transplantation or LVAD is rarely straightforward and is unique to each patient.^[1] Some younger patients prefer to remain on LVAD for a prolonged period, rather than proceeding to transplantation immediately, to increase the potential number of life years gained.^[1]

Transplantation rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 14)	Heart transplantation is recommended in selected patients (eligibility criteria in Table 17) with advanced HF refractory to FMT and GDIT, and without contraindications, to improve QoL and survival.	Class I, Level C
AHA/ACC/HFSA 2022 (section 8.5, row 1)	For selected patients with advanced HF despite GDMT, cardiac transplantation is indicated to improve survival and QOL.	COR 1, LOE C-LD
AHA/ACC/HFSA 2022 (section 8.5, value statement 2)	In patients with stage D (advanced) HF despite GDMT, cardiac transplantation provides intermediate economic value.	Value statement: intermediate value (C-LD)
NHFA/CSANZ 2018 (section 9.6)	Referral for heart transplant assessment should be considered in patients with heart failure associated with intractable NYHA Class III–IV symptoms who have exhausted all alternative therapies and who do not have overt contraindications, to decrease mortality.	Strong recommendation FOR; low quality of evidence

^[1] ^[2] ^[3]

AHA/ACC/HFSA 2022 is explicit that the evidence for a mortality and morbidity benefit in selected stage D patients comes from observational cohorts.^[2] AHA/ACC/HFSA 2022 reports a median survival of adult transplant recipients now >12 years, against <2 years for stage D HF without advanced therapies.^[2] Adult recipients transplanted between 2011 and 2013 had survival of 90.3%, 84.7% and 79.6% at 1, 3 and 5 years.^[2] For comparison, the risk of death becomes greater than survival between 3 and 4 years on an LVAD, regardless of implant strategy (eg, bridge-to-transplant, bridge-to-decision, destination therapy).^[2]

In 2018 NHFA/CSANZ reported a median survival of about 15 years for heart transplant recipients in Australia and New Zealand.^[3]

Obesity can be the barrier.^[1] The 2026 AHA/ACC/ADA/ASN CKM guideline (section 6.3.1): in select adults with CKM syndrome stage 4, obesity, and symptomatic HFrEF, treatment of obesity may be considered to improve functional capacity and facilitate heart transplantation in otherwise eligible patients (COR 2b, LOE B-NR).^[11]

AHA/ACC/HFSA 2022 refers listing criteria, evaluation and management of transplant candidates to the International Society for Heart and Lung Transplantation.^[2] The ISHLT 2024 guidelines for the evaluation and care of cardiac transplant candidates update and replace the 2006 and 2016 ISHLT listing criteria (abstract); the full text was not held for this topic, so no ISHLT criterion is taught here.^[4]

^[1]

Cardiomyopathies, including hypertrophic cardiomyopathy

The 2023 ESC cardiomyopathies guideline and the 2024 AHA/ACC hypertrophic cardiomyopathy (HCM) guideline each carry rows on transplantation and MCS in their own populations.^[14]^[15]

Cardiomyopathy and HCM rows on transplantation and MCS, by body and year (selected rows)

Body and year	Row	Strength
ESC 2023 cardiomyopathies (Recommendation Table 9)	Orthotopic cardiac transplantation is recommended for eligible cardiomyopathy patients with advanced heart failure (NYHA class III–IV) or intractable ventricular arrhythmia refractory to medical/invasive/device therapy, and who do not have absolute contraindications.	Class I, Level C
ESC 2023 cardiomyopathies (Recommendation Table 10, row 1)	Mechanical circulatory support therapy should be considered in selected cardiomyopathy patients with advanced heart failure (NYHA class III–IV) despite optimal pharmacological and device treatment, who are otherwise suitable for heart transplantation, to improve symptoms and reduce the risk of heart failure hospitalization from worsening heart failure and premature death while awaiting a transplant.	Class IIa, Level B
ESC 2023 cardiomyopathies (Recommendation Table 10, row 2)	Mechanical circulatory support therapy should be considered in selected cardiomyopathy patients with advanced heart failure (NYHA class III–IV) despite optimal pharmacological and device therapy, who are not eligible for cardiac transplantation or other surgical options, and without severe right ventricular dysfunction, to reduce the risk of death and improve symptoms.	Class IIa, Level B
AHA/ACC 2024 HCM (section 6.7, exercise stress testing, row 2)	In patients with nonobstructive HCM and advanced HF (NYHA functional class III to class IV), cardiopulmonary exercise stress testing should be performed to quantify the degree of functional limitation and aid in selection of patients for heart transplantation or mechanical circulatory support.	COR 1, LOE B-NR
AHA/ACC 2024 HCM (section 8.3, row 3)	In patients with nonobstructive HCM and advanced HF (NYHA functional class III to class IV despite GDMT), CPET should be performed to quantify the degree of functional limitation and aid in selection of patients for heart transplantation or mechanical circulatory support.	COR 1, LOE B-NR
AHA/ACC 2024 HCM (section 8.3, row 4)	In patients with nonobstructive HCM and advanced HF (NYHA functional class III to class IV despite GDMT) or with life-threatening ventricular arrhythmias refractory to maximal GDMT, assessment for heart transplantation in accordance with current listing criteria is recommended.	COR 1, LOE B-NR
AHA/ACC 2024 HCM (section 8.3, row 7)	In patients with nonobstructive HCM and advanced HF (NYHA functional class III to class IV despite GDMT) who are candidates for heart transplantation, continuous-flow LVAD therapy is reasonable as a bridge to heart transplantation.	COR 2a, LOE B-NR
AHA/ACC 2024 HCM (section 8.5, ventricular arrhythmias, row 1)	In patients with HCM and recurrent, poorly tolerated life-threatening ventricular tachyarrhythmias refractory to maximal antiarrhythmic drug therapy and ablation, heart transplantation assessment is indicated in accordance with current listing criteria.	COR 1, LOE B-NR

^[14] ^[15]

ESC 2023 text says orthotopic cardiac transplantation should be considered in patients with moderate-to-severe drug-refractory symptoms (NYHA functional class III–IV) who meet standard eligibility criteria, for which it cites the 2021 ESC heart failure guideline (no class or level given).^[14] The same ESC 2023 text adds that this may include patients with restrictive cardiomyopathy (RCM) and HCM with normal LVEF but severe drug-refractory symptoms (NYHA functional class III–IV) caused by diastolic dysfunction.^[14] AHA/ACC 2024 HCM supportive text says 20% to 50% of patients with HCM who have advanced HF have preserved EF with restrictive physiology, so transplant referral for HCM does not require a reduced EF (no class or level given).^[15]

Currency goes by population: for cardiomyopathy patients with advanced HF, the newer ESC 2026 heart failure transplant row applies.^[1] ESC 2026 Recommendation Table 14: heart transplantation is recommended in selected patients with advanced HF refractory to FMT and GDIT, and without contraindications, to improve QoL and survival (Class I, Level C).^[1] For those with advanced HFrEF, the newer ESC 2026 durable MCS row also applies.^[1] ESC 2026 Recommendation Table 13: 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 (Class I, Level C).^[1] The ESC 2023 rows are given with their year for the cardiomyopathy populations they name, such as eligible patients with intractable ventricular arrhythmia refractory to medical/invasive/device therapy and no absolute contraindications.^[14] The AHA/ACC 2024 HCM rows are newer than the 2022 AHA/ACC/HFSA heart failure guideline and are specific to HCM; they sit beside its general rows.^[15]

Adults with congenital heart disease

ESC 2026 lists adult congenital heart disease among the sources of surgical complexity to weigh before transplantation or LVAD.^[1] ACC/AHA 2025 and ESC 2020, the two adult congenital heart disease guidelines held for this topic, each address referral for advanced therapies.^[12]^[13]

In patients with ACHD, ACC/AHA 2025 (section 3.6.2) says heart failure–related hospital admissions, as well as the development of systemic ventricular dysfunction and protein-losing enteropathy, are associated with worse outcomes.^[12] ACC/AHA 2025 says these would be appropriate triggers for evaluation for advanced heart failure therapies, including transplantation (no class or level given).^[12] ACC/AHA 2025 adds that patients with ACHD who undergo heart transplant evaluation may not be candidates because of delays in referral that result in prohibitive risk from extracardiac organ dysfunction and, even when listed, have high waitlist-period mortality (no class or level given).^[12]

Adult congenital heart disease rows and text by body and year

Body and year	Row	Strength
ACC/AHA 2025 ACHD (section 3.6.2, row 1)	In patients with ACHD and heart failure, evaluation by specialists with medical and surgical experience in ACHD, as well as by specialists with expertise in advanced heart failure, is recommended to assess appropriateness for advanced heart failure therapies, such as heart transplantation or MCS.	COR 1, LOE B-NR
ACC/AHA 2025 ACHD (section 3.6.2, row 2)	In patients with ACHD who are considered for heart transplantation, multiorgan transplantation (heart–lung, heart–kidney, or heart–liver) is reasonable based on center-specific assessment of the degree of respective lung, kidney, or liver dysfunction.	COR 2a, LOE B-NR
ACC/AHA 2025 ACHD (section 3.6.2, row 3)	In patients with ACHD and advanced heart failure that is refractory to optimal medical and device-based therapy, the use of durable MCS devices is reasonable to improve quality of life or as a bridge to transplantation.	COR 2a, LOE B-NR
ACC/AHA 2025 ACHD (section 4.4.1.1, d-TGA and atrial switch, row 5)	For adults with d-TGA and atrial switch, biomarkers and validated disease-specific risk scores can be useful to identify patients at high risk for adverse cardiac events, prompting closer follow-up and referral to specialized heart failure transplant centers.	COR 2a, LOE B-NR
ACC/AHA 2025 ACHD (section 4.4.1.1, d-TGA and atrial switch, row 11)	Adults with d-TGA and atrial switch who have worsening symptoms of exercise intolerance, heart failure, or arrhythmia refractory to treatment should be referred to a heart failure program for assessment for mechanical support and transplantation in consultation with an ACHD cardiologist, to improve quality of life and prolong survival.	COR 1, LOE C-LD
ACC/AHA 2025 ACHD (section 4.4.5, Fontan, row 1)	In adults with Fontan circulation and evidence of progressive Fontan circulatory failure, formal evaluation by a heart failure/transplant cardiologist with experience in heart transplantation in the adult Fontan population is recommended.	COR 1, LOE B-NR
ACC/AHA 2025 ACHD (section 4.4.5, Fontan, row 16)	Adults with Fontan circulation referred for cardiac transplantation should undergo pretransplantation review by a committee with broad multidisciplinary representation to improve patient selection and posttransplant outcomes.	COR 1, LOE C-EO
ESC 2020 ACHD (section 4.15, unoperated and palliated univentricular heart; patients after Fontan operation are in section 4.16)	Heart transplantation and heart-lung transplantation should be considered when there is no conventional surgical option in patients with poor clinical status.	Class IIa, Level C
ESC 2020 ACHD (section 3.4.1, Heart failure, text)	In all cases, timely evaluation for transplantation by ACHD heart failure specialists in a transplant centre with ACHD expertise is recommended.	(no class or level given)

^[12] ^[13]

ESC 2020 adds that the increased use of ventricular assist devices can bridge patients to transplantation, and in selected patients it may be an option as destination therapy (no class or level given).^[13] ESC 2020 is the ESC adult congenital heart disease guideline held for this topic, so its rows are given with their year.^[13]

Palliative care and the end of life

ESC 2026 describes the usual course: a generalizable pattern of gradual decline, punctuated by episodes of acute deterioration leading to death.^[1] ESC 2026 defines palliative care as patient- and family-centred care aimed at optimizing health-related QoL by anticipating, preventing and alleviating suffering, which should be integrated into the management of patients with HF in an advanced stage.^[1] ESC 2026 says the role of palliative and supportive care spans the entire course of HF, beginning early, intensifying as the condition progresses and extending into caregiver bereavement.^[1]

ESC 2026 says patients with contraindications to MCS or heart transplantation should receive palliative care, and advance care planning should be discussed in all patients with advanced HF regardless of treatment strategy.^[1] Evidence supports multidisciplinary palliative care in advanced HF to improve patient-reported outcomes (symptom burden, depression, functional status, QoL), but trials do not identify who would benefit most from specialist palliative referral.^[1]

Palliative care and advance care planning rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 26)	Proactive discussion regarding HF trajectory, goals of care, and advance care planning is recommended in patients with advanced HF to facilitate communication on end of life and QoL.	Class I, Level B1
ESC 2026 (Recommendation Table 26)	Access to an integrated HF palliative care multidisciplinary team is recommended for patients in an advanced HF stage to improve QoL and reduce symptom burden.	Class I, Level B2
AHA/ACC/HFSA 2022 (section 13.1, row 1)	For all patients with HF, palliative and supportive care, including high-quality communication, conveyance of prognosis, clarifying goals of care, shared decision-making, symptom management, and caregiver support, should be provided to improve QOL and relieve suffering.	COR 1, LOE C-LD
AHA/ACC/HFSA 2022 (section 13.1, row 2)	For patients with HF being considered for, or treated with, life-extending therapies, the option for discontinuation should be anticipated and discussed through the continuum of care, including at the time of initiation, and reassessed with changing medical conditions and shifting goals of care.	COR 1, LOE C-LD
AHA/ACC/HFSA 2022 (section 13.1, row 3)	For patients with HF, particularly stage D HF patients being evaluated for advanced therapies, patients requiring inotropic support or temporary mechanical support, patients experiencing uncontrolled symptoms, major medical decisions, or multimorbidity, frailty, and cognitive impairment, specialist palliative care consultation can be useful to improve QOL and relieve suffering.	COR 2a, LOE B-R
AHA/ACC/HFSA 2022 (section 13.1, row 4)	For patients with HF, execution of advance care directives can be useful to improve documentation of treatment preferences, delivery of patient-centered care, and dying in preferred place.	COR 2a, LOE C-LD
AHA/ACC/HFSA 2022 (section 13.1, row 5)	In patients with advanced HF with expected survival <6 months, timely referral to hospice can be useful to improve QOL.	COR 2a, LOE C-LD
NHFA/CSANZ 2018 (section 14)	Referral to palliative care should be considered in patients with advanced heart failure to alleviate end-stage symptoms, improve quality of life, and decrease rehospitalisation. Involvement of palliative care should be considered early in the trajectory towards end-stage heart failure.	Strong recommendation FOR; high quality of evidence

^[1] ^[2] ^[3]

ESC 2026 defines advance care planning as a structured process to explore and communicate the patient’s values, life goals and preferences for future care.^[1] ESC 2026 says advance care planning may include preferences for place of death and resuscitation, which may include deactivating devices such as an ICD or durable MCS.^[1] ESC 2026 recommends it in parallel to advanced HF treatments to determine goals of care and improve QoL along the disease trajectory.^[1] NHFA/CSANZ 2018 practice advice is that patients with heart failure should be encouraged to have an advanced care plan, regardless of clinical status and soon after diagnosis.^[3]

Recognising the end of life

ESC 2026 supplementary Table S20 lists how to recognise the end of life in HF.^[1]

Frequent hospitalizations or emergency visits due to decompensated HF.^[1]
Increasing ICD shocks.^[1]
Progressive functional decline (physical and mental), dependence in most activities of daily living.^[1]
Progressive decline in quality of life.^[1]
Heart transplantation and durable MCS ruled out.^[1]
Refractory symptoms despite optimal medical and device management.^[1]
Signs of advanced HF: end-organ dysfunction, cardiac cachexia, frailty, hypotension.^[1]
Clinically judged to be close to the end of life.^[1]

ESC 2026 says end-of-life care focuses on symptom management (including breathlessness, pain, and anxiety and depression), patient comfort and maintaining QoL.^[1] The core components in Table S20 include the following.^[1]

Initiate advance care planning early in the HF trajectory, and discuss the difference between palliative care and end-of-life care and when to integrate each.^[1]
Optimize diuretics for fluid management, individualize changes to HF FMT, and adjust therapies to those that alleviate symptoms or prevent distress.^[1]
Use oxygen if indicated for symptom relief; give advice on position, fans and breathing techniques; relax previously introduced fluid and sodium restrictions in appropriate patients.^[1]
Consider hospice referral when shifting to comfort-orientated care.^[1]

Devices at the end of life

ICD: ESC 2026 Table S20 says discuss the option of deactivating ICDs to prevent unnecessary shocks; NHFA/CSANZ 2018 practice advice is that deactivation discussions should occur between the patient and family and their cardiologist.^[1]^[3]
ICD, the formal row: ESC 2022 VA/SCD Recommendation Table 21: informed discussion with patient and family about ICD deactivation options and shared decision-making is indicated prior to implantation and in case of significant health status deterioration (Class I, Level C).^[16]
Durable MCS: ESC 2026 says patients may request withdrawal because the treatment no longer matches their goals, because of poor QoL or new serious comorbidities such as cancer; the MCS may be deactivated after careful evaluation of the patient’s wish, by or under the supervision of a specialized team, and the decision has to take national laws into account.^[1]
Plan it up front: AHA/ACC/HFSA 2022 says every form of MCS will eventually be turned off, and this should be addressed with patients before discussions about MCS.^[2]
Why it matters: failure to proactively address topics such as deactivation of ICD and LVAD therapies can lead to suffering at the end of life (AHA/ACC/HFSA 2022).^[2]

PAL-HF

J Am Coll Cardiol

PMID 28705314

2017

Randomised: usual care vs usual care plus an interdisciplinary palliative care intervention; primary end points KCCQ overall summary and FACIT-Pal at 6 months

Population: 150 patients with advanced HF at a single centre, randomised 2012–2015

Key finding

KCCQ difference 9.49 points and FACIT-Pal difference 11.77 points in favour of the intervention at 6 months; no effect on rehospitalization or mortality

^[9]

AHA/ACC/HFSA 2022 cites PAL-HF as showing greater benefits in QOL, anxiety, depression and spiritual well-being, but notes that other trials have been mixed and many negative, so formal palliative care interventions should be tailored to patient and caregiver wants and needs.^[2]

Evidence, guidelines and regional differences

Europe (ESC)

2026 heart failure guideline

Early consultation with an advanced HF centre is recommended in advanced HF or at risk of it, in motivated patients without absolute contraindications to transplantation or durable MCS, to evaluate candidacy: Class I, Level A
Durable MCS (LVAD) is recommended in selected patients with advanced HFrEF despite FMT and GDIT, as BTT, BTC, BTR or destination therapy, to improve symptoms and reduce the risk of death: Class I, Level C
Continuous inotropes should be considered in advanced HFrEF with low cardiac output and evidence of hypoperfusion or end-organ dysfunction, as BTD, BTT or bridge to durable MCS, to increase cardiac output and improve symptoms: Class IIa, Level C
Heart transplantation is recommended in selected patients with advanced HF refractory to FMT and GDIT, without contraindications, to improve QoL and survival: Class I, Level C
Access to an integrated HF palliative care multidisciplinary team is recommended in an advanced HF stage to improve QoL and reduce symptom burden: Class I, Level B2

United States (AHA/ACC/HFSA)

2022 heart failure guideline

In advanced HF, when consistent with the patient’s goals of care, timely referral for HF specialty care is recommended: COR 1, LOE C-LD
Durable LVAD implantation is effective in select patients with advanced HFrEF with NYHA class IV symptoms deemed dependent on continuous intravenous inotropes or temporary MCS, to improve functional status, QOL and survival: COR 1, LOE A
Long-term continuous or intermittent intravenous inotropes, for reasons other than palliative care or as a bridge to advanced therapies, are potentially harmful: COR 3: Harm, LOE B-R
Cardiac transplantation is indicated for selected patients with advanced HF despite GDMT to improve survival and QOL: COR 1, LOE C-LD
Timely referral to hospice can be useful in advanced HF with expected survival <6 months to improve QOL: COR 2a, LOE C-LD

Australia and New Zealand (NHFA/CSANZ)

2018 heart failure guideline

Referral to a specialist centre for consideration of VAD implantation should be considered in intractable, severe heart failure despite guideline-directed medical and pacemaker therapy, without major comorbidities, to decrease mortality: strong recommendation for, moderate quality of evidence
Referral for heart transplant assessment should be considered with intractable NYHA Class III–IV symptoms after all alternative therapies have been exhausted, without overt contraindications, to decrease mortality: strong recommendation for, low quality of evidence
Referral to palliative care should be considered in advanced heart failure to alleviate end-stage symptoms, improve quality of life and decrease rehospitalisation, with involvement considered early in the trajectory: strong recommendation for, high quality of evidence

^[1] ^[2] ^[3]

Guidelines checked for this topic

ESC: the 2026 heart failure guideline and its supplementary data (section 8, section 11.6.2, Tables 5, 6 and 14 to 17, Recommendation Table 6 (the NYHA class IV ICD row and the wearable defibrillator row), Recommendation Tables 10 (two rows), 11 to 14, 24 (the LVAD row) and 26, its secondary mitral regurgitation text, and supplementary Tables S18 to S20).^[1]
United States: the 2022 AHA/ACC/HFSA heart failure guideline (take-home message 8, sections 4.1, 4.7, 8.1 to 8.5 and 13.1, Tables 3 and 16 to 20).^[2]
Other same-month or newer guidelines quoted: the 2026 ESC cardiac rehabilitation guideline (Recommendation Tables 5 and 17) and the 2026 AHA/ACC/ADA/ASN cardiovascular-kidney-metabolic syndrome guideline (section 6.3.1).^[10]^[11]
Australia and New Zealand: the 2018 NHFA/CSANZ heart failure guideline (sections 6.7, 9.5, 9.6 and 14), dated.^[3]
Adult congenital heart disease: the 2025 ACC/AHA/HRS/ISACHD/SCAI guideline (sections 3.6.2, 4.4.1.1 and 4.4.5) and the 2020 ESC guideline (section 3.4.1 and the section 4.15 univentricular heart table), each given with its year.^[12]^[13]
Cardiomyopathies: the 2023 ESC cardiomyopathies guideline (section 6.10.2.2 text and Recommendation Tables 9 and 10) and the 2024 AHA/ACC hypertrophic cardiomyopathy guideline (section 6.7 row 2, section 8.3 rows 3, 4 and 7 with supportive text, and section 8.5 row 1), each given with its year.^[14]^[15]
Ventricular arrhythmias: the 2022 ESC ventricular arrhythmias and sudden cardiac death guideline (Recommendation Tables 19 and 21, and the two pre-transplant rows of Recommendation Table 48), given with its year.^[16]
ISHLT: the 2024 guidelines for the evaluation and care of cardiac transplant candidates, PubMed abstract only.^[4]
Trials: REMATCH, MOMENTUM 3 (2-year and 5-year reports), ARIES-HM3 and PAL-HF, from their PubMed abstracts.^[5]^[6]^[7]^[8]^[9]

The 2026 ESC and 2022 AHA/ACC/HFSA heart failure guidelines are the newest ESC and ACC/AHA heart failure guidelines in the census for this topic (2026-10-09). The NHFA/CSANZ 2018 guideline is the newest Australian heart failure guideline in the census for this topic, so its rows are given with their year.^[3]

Not held as text for this topic (none of their recommendations is used): the 2024 ISHLT cardiac transplant candidate guidelines (abstract only), the 2023 ISHLT mechanical circulatory support guidelines, the 2023 ISHLT/HFSA acute mechanical circulatory support guideline, the 2016 ISHLT listing criteria, the 2026 ESC cardiovascular disease and chronic kidney disease guideline (not held in its version of record), the 2026 AHA/ACC perioperative guideline (abstract only) and the 2025 NHFA/CSANZ acute coronary syndromes guideline (not held as text in its version of record).
Checked, not used: the 2025 ESC/EACTS valvular heart disease guideline (its secondary mitral regurgitation rows and text; the topic uses the newer ESC 2026 heart failure text on the same point); the 2025 ESC myocarditis and pericarditis guideline (its Shock Team and temporary MCS rows are specific to myocarditis; temporary MCS is covered in the linked cardiogenic shock topic); the 2025 ESC pregnancy guideline (pregnancy-specific rows, including pregnancy after heart transplantation; this topic does not teach pregnancy); the 2022 ESC/ERS pulmonary hypertension guideline (its MCS and palliative care text concerns pulmonary hypertension populations); and the 2020 ESC sports cardiology guideline (exercise after heart transplantation; the topic uses the newer ESC 2026 cardiac rehabilitation rows).^[1]^[10]
Checked, not used: the other held guidelines listed for the currency sweep in the evidence pack; their candidate rows concern other populations, such as acute coronary syndromes, valve disease, pacing, endocarditis, pulmonary embolism and non-cardiac surgery.

Pitfalls

Common errors

Waiting for LVEF ≤30% before calling HF advanced: ESC 2026 says a severely reduced LVEF is common but not required, and advanced HF may develop in HFpEF or other structural abnormalities; AHA/ACC 2024 HCM says transplant referral for HCM does not require a reduced EF.^[1]^[15]
Reciting I NEED HELP without the source: E is EF <20% or poor RV function in ESC 2026 but EF ≤35% in AHA/ACC/HFSA 2022.^[1]^[2]
Referring only after end-organ failure: AHA/ACC/HFSA 2022 warns that after end-organ dysfunction or cardiogenic shock, patients may no longer qualify for advanced therapies.^[2]
Leaving a patient on long-term continuous or intermittent intravenous inotropes for reasons other than palliative care or as a bridge to advanced therapies: AHA/ACC/HFSA 2022 calls this potentially harmful (COR 3: Harm, LOE B-R).^[2]
Calling active infection an absolute bar to transplantation: ESC 2026 lists it among other contraindications and calls it relative, and an infected LVAD may be an indication.^[1]
Diagnosing inotrope dependence while starting or uptitrating beta-blockers or RAS inhibitors: ESC 2026 Table S18 says it should not be made then.^[1]

Exam pearls

ESC 2026 Table 14: all four criteria must be present despite FMT, AMT and GDIT; the exercise criterion is inability to exercise, 6-min walk <300 m, or pVO₂ <12–14 mL/kg/min (12 for patients on beta-blocker) or <50% predicted, estimated to be of cardiac origin.^[1]
ESC 2026 Rule of three: HFH (≥2 or ≥1 requiring inotropes within the last year), diuretic resistance, intolerance to neurohormonal drugs with onset of cardiorenal syndrome.^[1]
ESC 2026 LVAD indication: HF with severely reduced LVEF plus INTERMACS 1–2 with neurological and other end-organ recovery but no cardiac recovery on temporary MCS, or INTERMACS 2–4, or NYHA class III/IV (INTERMACS >4) despite optimal FMT and GDIT with at least one of: unable to exercise due to HF or, if able to perform CPET, pVO₂ <12–14 mL/kg/min and/or <50% predicted; end-organ dysfunction due to reduced perfusion (cardiac index ≤2 L/min/m² despite euvolaemic or therapy-resistant hypervolaemic status); or repeated HFH within the previous 12 months without an obvious precipitating cause.^[1]
ESC 2026 transplant: 1-year survival 80%–90%, median around 12.5 years; most programmes accept patients up to 70 years; BMI >35 kg/m² or severe cachexia is among the other contraindications.^[1]
AHA/ACC/HFSA 2022 Table 19 lists age >80 y for destination therapy as a relative contraindication to durable mechanical support.^[2]
Inotrope dependence (ESC 2026 Table S18): failure to wean intravenous inotropic support within 72 h without symptomatic arterial hypotension, worsening renal or hepatic function (eGFR decrease >30%, or clinically important elevation in liver enzymes or INR), or worsening congestion leading to or upholding NYHA class IV symptoms (in the absence of reduction in loop diuretic dose); after continuous support for >7 days, it is failure to reduce the infusion rate at 72 h after each attempt to reduce, and with levosimendan the need for a new infusion <10 days after the former; it should not be diagnosed during simultaneous introduction or uptitration of beta-blockers or RAS inhibitors.^[1]
REMATCH (randomised; 129 transplant-ineligible patients with NYHA class IV end-stage HF, LVAD vs optimal medical management): survival 52% vs 25% at one year.^[5]
MOMENTUM 3 (randomised; 1028 patients with advanced HF, centrifugal-flow vs axial-flow LVAD, 2 years): primary end point 76.9% vs 64.8%; pump replacement 2.3% vs 11.3%.^[6]
ARIES-HM3 (randomised, double-blind, placebo-controlled; 628 patients with advanced HF and a fully magnetically levitated LVAD, aspirin 100 mg/d vs placebo with VKA, 12 months): placebo noninferior, and aspirin avoidance associated with reduced nonsurgical bleeding.^[8]

Say it this way at the viva

"I screen with the ESC 2026 Rule of three or I NEED HELP, and one positive item is enough to think about referral.^[1] ESC 2026 recommends early consultation with an advanced HF centre in a motivated patient with advanced HF, or at risk of it, without absolute contraindications to transplantation or durable MCS, in order to evaluate candidacy (Class I, Level A).^[1] In advanced HF, ESC 2026 recommends CPET and right heart catheterization as part of the evaluation for heart transplantation and durable MCS (each Class I, Level C); patients with contraindications to MCS or heart transplantation should receive palliative care.^[1] Whatever the plan, I start advance care planning now: ESC 2026 recommends proactive discussion of HF trajectory, goals of care and advance care planning in advanced HF to facilitate communication on end of life and QoL (Class I, Level B1)."^[1]

References16Show

[1]Køber L, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J, 2026.PMID 42661420
[2]Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022.PMID 35363499
[3]Atherton JJ, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ, 2018.PMID 30077227
[4]Peled Y, et al. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant, 2024.PMID 39115488
[5]Rose EA, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med, 2001.PMID 11794191
[6]Mehra MR, et al. A Fully Magnetically Levitated Left Ventricular Assist Device - Final Report. N Engl J Med, 2019.PMID 30883052
[7]Mehra MR, et al. Five-Year Outcomes in Patients With Fully Magnetically Levitated vs Axial-Flow Left Ventricular Assist Devices in the MOMENTUM 3 Randomized Trial. JAMA, 2022.PMID 36074476
[8]Mehra MR, et al. Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial. JAMA, 2023.PMID 37950897
[9]Rogers JG, et al. Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial. J Am Coll Cardiol, 2017.PMID 28705314
[10]Bäck M, et al. 2026 ESC Guidelines on cardiac rehabilitation. Eur Heart J, 2026.PMID 42661418
[11]Ndumele CE, et al. 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2026.PMID 42265997
[12]Gurvitz M, et al. 2025 ACC/AHA/HRS/ISACHD/SCAI Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2026.PMID 41411375
[13]Baumgartner H, et al. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J, 2021.PMID 32860028
[14]Arbelo E, et al. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J, 2023.PMID 37622657
[15]Ommen SR, et al. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2024.PMID 38727647
[16]Zeppenfeld K, et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J, 2022.PMID 36017572

Key answer

ESC 2026 defines advanced HF by four criteria that must all be present despite FMT, AMT and GDIT: severe and persistent symptoms (NYHA class III or IV); severe cardiac dysfunction; episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic combinations) or malignant arrhythmias causing ≥2 unplanned visits or hospitalizations in the last 12 months, or ≥1 episode of low output requiring inotropes or vasoactive drugs; and severe impairment of exercise capacity estimated to be of cardiac origin.^[1]
ESC 2026: early consultation with an advanced HF centre 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 (Class I, Level A).^[1]
ESC 2026 uses the Rule of three or I NEED HELP criteria (at least one of either list) to flag high risk of advanced HF; the AHA/ACC/HFSA 2022 I-Need-Help list differs in its NYHA (class IIIB to IV), EF (≤35%) and blood pressure (low systolic BP ≤90) items.^[1]^[2]
ESC 2026: 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 (Class I, Level C); heart transplantation is recommended in selected patients with advanced HF refractory to FMT and GDIT, and without contraindications, to improve QoL and survival (Class I, Level C).^[1]
ESC 2026: access to an integrated HF palliative care multidisciplinary team is recommended for patients in an advanced HF stage to improve QoL and reduce symptom burden (Class I, Level B2).^[1]

Foundational and additional drug therapy for HFrEF: Heart failure with reduced ejection fraction.
ICD and CRT before advanced therapies are considered: ICD and CRT indications in heart failure.
Temporary MCS and the SCAI shock stages: Cardiogenic shock: staging, MCS selection and outcomes.
Frailty, cachexia, iron deficiency and kidney disease: HF comorbidities: iron deficiency, CKD, gout and cachexia.

What advanced heart failure is

ESC 2026 Table 14: Criteria for definition of advanced heart failure (all criteria; all must be present despite FMT, AMT and GDIT)

Criterion	ESC 2026 wording
1	Severe and persistent symptoms of HF (NYHA class III or IV).
2	Severe cardiac dysfunction defined by at least one of: LVEF ≤30%; isolated RV failure (e.g. ARVC); non-operable severe valve abnormalities; non-operable severe congenital abnormalities; persistently high (or increasing) BNP or NT-proBNP values and severe LV diastolic dysfunction or structural abnormalities (i.e. HFpEF [footnote a: see ESC 2026 Table 10, simplified echocardiographic criteria for supporting objective evidence of HFpEF], hypertrophic or restrictive cardiomyopathies).
3	Episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic combinations) or malignant arrhythmias causing ≥2 unplanned visits or hospitalizations in the last 12 months, or ≥1 episode of low output requiring inotropes or vasoactive drugs.
4	Severe impairment of exercise capacity with inability to exercise, or low 6-min walk test distance (<300 m), or pVO₂ <12–14 mL/kg/min (footnote: the cut-off 12 mL/kg/min refers to patients on beta-blocker), or <50% predicted value, estimated to be of cardiac origin.

^[1]

When to refer

The ESC 2026 high-risk screens

ESC 2026 calls systematic assessment with the Rule of three or I NEED HELP criteria essential for timely referral to an advanced HF centre.^[1] One criterion from either list is enough.^[1]

ESC 2026 Table 15: Criteria for high risk of advanced heart failure (all criteria)

Group	Criterion
Rule of three (at least 1)	HFH (≥2 or ≥1 requiring inotropes within the last year)
Rule of three (at least 1)	Diuretic resistance
Rule of three (at least 1)	Intolerance to neurohormonal drugs with onset of cardiorenal syndrome
I NEED HELP (at least 1)	I: Inotropes
I NEED HELP (at least 1)	N: NYHA class III/IV or persistently high natriuretic peptides
I NEED HELP (at least 1)	E: End-organ dysfunction (liver, kidney)
I NEED HELP (at least 1)	E: EF <20% or poor RV function
I NEED HELP (at least 1)	D: Defibrillator shocks
I NEED HELP (at least 1)	H: HFH >1
I NEED HELP (at least 1)	E: Escalating diuretics
I NEED HELP (at least 1)	L: Low blood pressure, high heart rate
I NEED HELP (at least 1)	P: Prognostic medication intolerance or the need to downtitrate

^[1]

The AHA/ACC/HFSA 2022 version of I-Need-Help

ESC 2026 Table 15

I NEED HELP

N: NYHA class III/IV or persistently high natriuretic peptides
E: EF <20% or poor RV function
E: Escalating diuretics
L: Low blood pressure, high heart rate
P: Prognostic medication intolerance or the need to downtitrate

AHA/ACC/HFSA 2022

I-Need-Help

N: NYHA class IIIB to IV or persistently elevated natriuretic peptides
E: EF ≤35%
E: Edema despite escalating diuretics
L: Low systolic BP ≤90, high heart rate
P: Prognostic medication; progressive intolerance or down-titration of GDMT

^[1] ^[2]

AHA/ACC/HFSA 2022 clinical indicators

AHA/ACC/HFSA 2022 Table 18: Clinical Indicators of Advanced HF (all indicators)

Indicator
Repeated hospitalizations or emergency department visits for HF in the past 12 mo.
Need for intravenous inotropic therapy.
Persistent NYHA functional class III to IV symptoms despite therapy.
Severely reduced exercise capacity (peak VO₂ <14 mL/kg/min or <50% predicted, 6-min walk test distance <300 m, or inability to walk 1 block on level ground because of dyspnea or fatigue).
Intolerance to RAASi because of hypotension or worsening renal function.
Intolerance to beta blockers as a result of worsening HF or hypotension.
Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose >160 mg/d or use of supplemental metolazone therapy.
Refractory clinical congestion.
Progressive deterioration in renal or hepatic function.
Worsening right HF or secondary pulmonary hypertension.
Frequent SBP ≤90 mm Hg.
Cardiac cachexia.
Persistent hyponatremia (serum sodium <134 mEq/L).
Refractory or recurrent ventricular arrhythmias; frequent ICD shocks.
Increased predicted 1-year mortality (eg, >20%) according to HF survival models (eg, MAGGIC, SHFM).

^[2]

The referral rows

Referral rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 11)	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.	Class I, Level A
AHA/ACC/HFSA 2022 (section 8.1)	In patients with advanced HF, when consistent with the patient’s goals of care, timely referral for HF specialty care is recommended to review HF management and assess suitability for advanced HF therapies (eg, LVAD, cardiac transplantation, palliative care, and palliative inotropes).	COR 1, LOE C-LD
NHFA/CSANZ 2018 (section 9.5)	Referral to a specialist centre for consideration of VAD implantation should be considered in patients with intractable, severe heart failure despite guideline-directed medical and pacemaker therapy, and who do not suffer from major comorbidities, to decrease mortality.	Strong recommendation FOR; moderate quality of evidence
NHFA/CSANZ 2018 (section 9.6)	Referral for heart transplant assessment should be considered in patients with heart failure associated with intractable NYHA Class III–IV symptoms who have exhausted all alternative therapies and who do not have overt contraindications, to decrease mortality.	Strong recommendation FOR; low quality of evidence

^[1] ^[2] ^[3]

Do not wait for a full work-up: AHA/ACC/HFSA 2022 says a complete assessment is not required before referral, because comprehensive multidisciplinary assessment is routinely performed when evaluating patients for advanced therapies.^[2]
Down-titration is a trigger: ESC 2026 says any of these down-titrations of neurohormonal therapy should prompt contact with, or referral to, an advanced HF centre if there are no absolute contraindications for MCS or heart transplantation, and AMT implementation should not delay early referral.^[1]
Transplant timing: NHFA/CSANZ 2018 says timing of referral can be difficult to judge, but recommends early referral because these patients are at high risk of complications that may exclude them from transplant consideration, such as fixed pulmonary hypertension or multiorgan failure.^[3]
Who gets missed: ESC 2026 says women and sociocultural minority groups are less likely to receive MCS and heart transplantation for reasons not explained by medical factors or social determinants of health, and deserve extra attention for timely referral and patient communication.^[1]
Networks: ESC 2026 calls a Hub and Spoke network between centres with different levels of care complexity key to good patient management.^[1]
NHFA/CSANZ 2018 practice advice: clinicians are advised to contact the specialist centres about any patient with heart failure who is responding poorly to conventional medical or device therapy.^[3]

^[1]

Assessment at the advanced HF centre

ESC 2026 Recommendation Table 11: Recommendations for diagnosis and evaluation of advanced heart failure (all rows)

ESC 2026 Recommendation Table 11 row	Class, Level
Early consultation with an advanced HF centre 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.	I, A
Cardiopulmonary exercise testing is recommended in patients with advanced HF, as part of the evaluation for heart transplantation and durable MCS.	I, C
Right heart catheterization is recommended in patients with advanced HF, as part of the evaluation for heart transplantation and durable MCS.	I, C

^[1]

INTERMACS profiles

AHA/ACC/HFSA 2022 Table 17: INTERMACS Profiles (all profiles; features abridged for profiles 4, 6 and 7)

Profile	Description	Features (AHA/ACC/HFSA 2022 wording)
1	Critical cardiogenic shock	Life-threatening hypotension and rapidly escalating inotropic/pressor support, with critical organ hypoperfusion often confirmed by worsening acidosis and lactate levels.
2	Progressive decline	"Dependent" on inotropic support but nonetheless shows signs of continuing deterioration in nutrition, renal function, fluid retention, or other major status indicator; can also apply to a patient with refractory volume overload, perhaps with evidence of impaired perfusion, in whom inotropic infusions cannot be maintained because of tachyarrhythmias, clinical ischemia, or other intolerance.
3	Stable but inotrope dependent	Clinically stable on mild-moderate doses of intravenous inotropes (or has a temporary circulatory support device) after repeated documentation of failure to wean without symptomatic hypotension, worsening symptoms, or progressive organ dysfunction (usually renal).
4	Resting symptoms on oral therapy at home	At home on oral therapy but frequently has symptoms of congestion at rest or with activities of daily living (dressing or bathing).
5	Exertion intolerant	Comfortable at rest but unable to engage in any activity, living predominantly within the house or housebound.
6	Exertion limited	Comfortable at rest without evidence of fluid overload but able to do some mild activity.
7	Advanced NYHA class III	Clinically stable with a reasonable level of comfortable activity, despite a history of previous decompensation that is not recent.

^[2]

Frailty and nutrition

Medical therapy when GDMT is failing

Hypotension with a high arrhythmic burden: the ACE-I dose can be reduced so that beta-blockers can be prioritized (ESC 2026 example).^[1]
Hypoperfusion with persistently low stroke volume despite therapy: reduction or cessation of beta-blockers may be the first step to maintaining cardiac output, and amiodarone may be better tolerated than beta-blockers when arrhythmias occur (ESC 2026 example).^[1]

ESC 2026 Recommendation Table 12: Recommendations for medical management of advanced heart failure (all rows)

ESC 2026 Recommendation Table 12 row	Class, Level
Down-titration or discontinuation of beta-blockers or ivabradine should be considered in selected patients with advanced HFrEF and evidence of organ hypoperfusion, despite initial treatment, to increase cardiac output and improve symptoms.	IIa, C
Continuous inotropes should be considered in patients with advanced HFrEF, low cardiac output, and evidence of hypoperfusion or end-organ dysfunction, as BTD (bridge to decision), BTT (bridge to transplantation) or as bridge to durable MCS, to increase cardiac output and improve symptoms.	IIa, C
Kidney replacement therapy should be considered in patients with refractory volume overload and end-stage kidney failure to improve symptoms.	IIa, C
Ultrafiltration may be considered in patients with refractory volume overload unresponsive to escalation of diuretic therapy to reduce the risk of rehospitalization.	IIb, C

^[1]

Inotropes

Inotrope rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 12)	Continuous inotropes should be considered in patients with advanced HFrEF, low cardiac output, and evidence of hypoperfusion or end-organ dysfunction, as BTD, BTT or as bridge to durable MCS, to increase cardiac output and improve symptoms.	Class IIa, Level C
AHA/ACC/HFSA 2022 (section 8.3, row 1)	In patients with advanced (stage D) HF refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation, continuous intravenous inotropic support is reasonable as "bridge therapy."	COR 2a, LOE B-NR
AHA/ACC/HFSA 2022 (section 8.3, row 2)	In select patients with stage D HF, despite optimal GDMT and device therapy who are ineligible for either MCS or cardiac transplantation, continuous intravenous inotropic support may be considered as palliative therapy for symptom control and improvement in functional status.	COR 2b, LOE B-NR
AHA/ACC/HFSA 2022 (section 8.3, row 3)	In patients with HF, long-term use of either continuous or intermittent intravenous inotropic agents, for reasons other than palliative care or as a bridge to advanced therapies, is potentially harmful.	COR 3: Harm, LOE B-R

^[1] ^[2]

Why bridge: AHA/ACC/HFSA 2022 says more prolonged use of inotropes as bridge therapy for those awaiting transplantation or MCS may have benefit in reducing pulmonary hypertension and maintaining end-organ perfusion beyond initial stabilization.^[2]
Palliative inotropes carry risk: arrhythmias and catheter-related infections, although an ICD does decrease the mortality associated with arrhythmias (AHA/ACC/HFSA 2022).^[2]
Why long-term use harms: with currently available agents, the benefit of haemodynamic support may be compromised by increased myocardial oxygen demand and increased arrhythmic burden (AHA/ACC/HFSA 2022).^[2]
Choice of agent: AHA/ACC/HFSA 2022 finds a continued lack of robust evidence to suggest the clear benefit of one inotrope over another.^[2]
Dose and review: lower doses are preferred to minimize adverse effects, tachyphylaxis should be acknowledged, the agent may need to change during longer support, and the ongoing need for support and the possibility of discontinuation should be regularly assessed (AHA/ACC/HFSA 2022).^[2]

Inotrope dependence

ESC 2026 supplementary Table S18 defines inotrope dependency as failure to wean intravenous inotropic support within 72 h without one of three events.^[1]

(i) development of symptomatic arterial hypotension, or^[1]
(ii) worsening renal or hepatic function, defined as eGFR decrease >30%, or clinically important elevation in liver enzymes or INR, or^[1]
(iii) worsening congestion leading to or upholding NYHA class IV symptoms, in the absence of reduction in loop diuretic dose.^[1]

Dobutamine and milrinone

AHA/ACC/HFSA 2022 Table 20: Intravenous Inotropic Agents Used in the Management of HF (selected rows)

Agent	Bolus	Infusion (mcg/kg/min)	Half-life; metabolism	CO, HR, SVR, PVR	Adverse effects	Special considerations
Dobutamine (adrenergic agonist)	NA (not applicable)	2.5–20	2–3 min; hepatic	↑, ↑, ↔, ↔	↑/↓BP, headache, tachyarrhythmias, nausea, fever, hypersensitivity	Caution: MAO-I; contraindication: sulfite allergy
Milrinone (PDE 3 inhibitor)	NR (not recommended)	0.125–0.75	2.5 h; hepatic	↑, ↑, ↓, ↓	Tachyarrhythmias, ↓BP	Accumulation may occur in setting of renal failure; monitor kidney function and LFTs

^[2]

Read the effect columns: milrinone lowers SVR and PVR in this table, while dobutamine leaves both unchanged.^[2] Milrinone may accumulate in renal failure.^[2]

ESC 2026 strengthened its inotrope row from the 2021 edition; its Table 6 (revised recommendations) pairs the two.^[1]

2021 row (dated history): continuous inotropes and/or vasopressors may be considered in patients with low cardiac output and evidence of organ hypoperfusion as bridge to MCS or heart transplantation (2021: Class IIb, Level C).^[1]
2026 row that replaces it: the Recommendation Table 12 continuous inotrope row above (2026: Class IIa, Level C).^[1]

Durable mechanical circulatory support

The strategy labels

ESC 2026 supplementary Table S19: Terms describing various indications for mechanical circulatory support (all terms)

Term	ESC 2026 definition
Bridge to decision/bridge to bridge	Use of temporary MCS in patients with cardiogenic shock until haemodynamic parameters and end-organ perfusion are stabilized, contraindications for durable MCS are excluded, and additional therapeutic options, including durable MCS therapy or heart transplantation, can be evaluated
Bridge to surgery	Use of temporary MCS in patients with cardiogenic shock with an indication to surgery as a bridge to surgery
Bridge to candidacy	Use of durable and temporary MCS (usually LVAD) to improve end-organ function and/or to make an ineligible patient eligible for heart transplantation
Bridge to transplantation	Use of durable and temporary MCS to keep a patient alive who is otherwise at high risk of death before transplantation until a donor organ becomes available
Bridge to recovery	Use of MCS to keep a patient alive until cardiac function recovers sufficiently to remove MCS
Destination therapy	Use of durable MCS as an alternative to transplantation in patients with end-stage HF ineligible for transplantation

^[1]

ESC 2026 LVAD candidacy

ESC 2026 Table 16: Indications and contraindications for implantation of a left ventricular assist device (all entries)

Group	ESC 2026 wording
Indications (footnote: indication by transplantation centre includes assessment of HF severity by RHC and/or CPET)	HF with severely reduced LVEF and one of the following:
Indication option	INTERMACS 1–2 with neurological and other end-organ recovery but no cardiac recovery on temporary MCS, OR
Indication option	INTERMACS 2–4, OR
Indication option	Severe symptoms and signs (NYHA class III/IV; INTERMACS >4) despite optimal FMT and GDIT, and at least one of: unable to exercise due to HF or, if able to perform CPET, pVO₂ <12–14 mL/kg/min and/or <50% predicted value; end-organ dysfunction (worsening kidney and/or hepatic function, group 2 pulmonary hypertension, cardiac cachexia) due to reduced perfusion as indicated by cardiac index ≤2 L/min/m² despite euvolaemic or therapy-resistant hypervolaemic status; repeated HFH within the previous 12 months without an obvious precipitating cause.
Absolute contraindications	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
Relative contraindications	Obesity or malnutrition; musculoskeletal disease that impairs rehabilitation; malignancy (depending on type and prognosis); severe peripheral arterial disease; systemic infection; alcohol or substance abuse within the past 6 months, or active smoking; impaired cognitive function; frailty

^[1] ^[1]

AHA/ACC/HFSA 2022 durable support criteria

AHA/ACC/HFSA 2022 Table 19: Indications and Contraindications to Durable Mechanical Support (all entries)

Group	AHA/ACC/HFSA 2022 wording
Indications (combination of these)	Frequent hospitalizations for HF; NYHA class IIIb to IV functional limitations despite maximal therapy; intolerance of neurohormonal antagonists; increasing diuretic requirement; symptomatic despite CRT; inotrope dependence; low peak VO₂ (<14–16); end-organ dysfunction attributable to low cardiac output
Absolute contraindications	Irreversible hepatic disease; irreversible renal disease; irreversible neurological disease; medical nonadherence; severe psychosocial limitations
Relative contraindications	Age >80 y for destination therapy; obesity or malnutrition; musculoskeletal disease that impairs rehabilitation; active systemic infection or prolonged intubation; untreated malignancy; severe PVD; active substance abuse; impaired cognitive function; unmanaged psychiatric disorder; lack of social support

^[2]

The durable MCS rows

Durable MCS rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 13)	Durable MCS (LVAD) is recommended in selected patients (eligibility criteria in Table 16) with advanced HFrEF, despite FMT and GDIT, as BTT, BTC, BTR, or as destination therapy to improve symptoms and reduce the risk of death.	Class I, Level C
AHA/ACC/HFSA 2022 (section 8.4, row 1)	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
AHA/ACC/HFSA 2022 (section 8.4, row 2)	In select patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT, durable MCS can be beneficial to improve symptoms, improve functional class, and reduce mortality.	COR 2a, LOE B-R
AHA/ACC/HFSA 2022 (section 8.4, value statement 3)	In patients with advanced HFrEF who have NYHA class IV symptoms despite GDMT, durable MCS devices provide low to intermediate economic value based on current costs and outcomes.	Value statement: uncertain value (B-NR)
NHFA/CSANZ 2018 (section 9.5)	Implantation of a VAD as a bridge to transplant should be considered in patients actively listed for heart transplantation who become inotrope-dependent or who progress to needing acute mechanical circulatory support.	Strong recommendation FOR; low quality of evidence

^[1] ^[2] ^[3]

ESC 2026 lists its LVAD row as a revision of two 2021 rows; its Table 6 lists both against the single 2026 row (2026: Class I, Level C).^[1]

2021 row (dated history): long-term MCS should be considered in patients with advanced HFrEF despite optimal medical and device therapy, not eligible for heart transplantation or other surgical options, and without severe RV dysfunction, to reduce the risk of death and improve symptoms (2021: Class IIa, Level A).^[1]
2021 row (dated history): long-term MCS should be considered in patients with advanced HFrEF refractory to optimal medical and device therapy as a bridge to cardiac transplantation (2021: Class IIa, Level B).^[1]
Who suits a device: AHA/ACC/HFSA 2022 says anatomic and physiologic criteria make durable MCS inappropriate for some patients, and it is most appropriate for HFrEF with a dilated ventricle.^[2]
Too sick and too well: implantation in INTERMACS profile 1 has been associated with poorer outcome, while ambulatory patients in profiles 5 to 7 might be too well to have large significant benefit, depending on their symptom burden (AHA/ACC/HFSA 2022).^[2]
Risk markers: there is no clear single risk model, but factors such as elevated central venous pressure, pulmonary hypertension and coagulopathy have been linked to poorer outcomes (AHA/ACC/HFSA 2022).^[2]
Anticoagulation: in patients unable to tolerate anticoagulation after repeated challenges, durable MCS is associated with excess morbidity (AHA/ACC/HFSA 2022).^[2]
Bridge to candidacy: for patients first considered transplant ineligible because of pulmonary hypertension, obesity, overall frailty or other reasons, MCS can provide time to reverse or modify these conditions (AHA/ACC/HFSA 2022).^[2]
Drugs after implant: AHA/ACC/HFSA 2022 supportive text says continuing and uptitrating GDMT in patients with durable MCS is recommended.^[2]
Secondary mitral regurgitation: in its valvular heart disease section, ESC 2026 says that in advanced HF, LVAD or heart transplantation is recommended as first choice and TEER may be considered for symptom improvement in patients not suitable or waiting for these therapies.^[1]
ICD in NYHA class IV: ESC 2026 does not recommend ICD implantation in patients in NYHA class IV with severe symptoms refractory to pharmacological therapy unless they are candidates for CRT, a ventricular assist device, or heart transplantation (Class III, Level C); see ICD and CRT indications in heart failure.^[1]

ICD and wearable defibrillator rows before transplantation and with an LVAD, by body and year

Body and year	Row	Strength
ESC 2022 VA/SCD (Recommendation Table 48, prior to heart transplant, row 1)	In patients awaiting heart transplantation, ICD implantation for primary prevention should be considered.	Class IIa, Level C
ESC 2022 VA/SCD (Recommendation Table 48, prior to heart transplant, row 2)	In patients awaiting heart transplantation, WCD (wearable cardioverter defibrillator) may be considered.	Class IIb, Level C
ESC 2026 HF (Recommendation Table 6)	A wearable cardioverter-defibrillator may be considered in patients with HF who are at risk of sudden cardiac death for a limited period in order to increase survival as a bridge to decision for permanent ICD implantation or while listed for heart transplantation.	Class IIb, Level C
ESC 2022 VA/SCD (Recommendation Table 19)	ICD implantation should be considered in LVAD recipients with symptomatic sustained VAs (ventricular arrhythmias).	Class IIa, Level B

^[16] ^[1]

Temporary MCS as the bridge

ESC 2026 Recommendation Table 10: Recommendations for the use of temporary mechanical circulatory support in patients with cardiogenic shock (selected rows)

ESC 2026 Recommendation Table 10 row	Class, Level
A multidisciplinary Shock Team is recommended in potential candidates for temporary MCS to guide the device selection (modality and type) based on patient and HF characteristics.	I, C
Advanced HF cardiogenic shock: temporary MCS should be considered in selected patients with HF-related haemodynamic instability as a BTR, BTD, BTB (bridge to bridge), BTC, or BTT.	IIa, C

^[1]

Outcomes and the trials

REMATCH

N Engl J Med

PMID 11794191

2001

Randomised: LVAD (68 patients) vs optimal medical management (61)

Population: 129 patients with end-stage HF ineligible for cardiac transplantation; all had NYHA class IV symptoms

Key finding

Risk of death from any cause reduced by 48% (relative risk 0.52); survival 52% vs 25% at one year and 23% vs 8% at two years (P=0.09)

^[5]

MOMENTUM 3

N Engl J Med

PMID 30883052

2019

Population: 1028 patients with advanced HF, randomised irrespective of intended goal (bridge to transplantation or destination therapy)

Key finding

Primary end point met in 76.9% vs 64.8% (relative risk 0.84; P<0.001 for superiority); pump replacement 2.3% vs 11.3%

^[6]

Living with an LVAD

ARIES-HM3

JAMA

PMID 37950897

2023

Randomised, double-blind, placebo-controlled: aspirin 100 mg/d vs placebo with VKA therapy; noninferiority primary end point at 12 months

Population: 628 patients with advanced HF implanted with a fully magnetically levitated LVAD, 51 centres in 9 countries; median follow-up 14 months

Key finding

^[8]

ESC 2026 Recommendation Table 13: Recommendations for durable mechanical circulatory support in advanced heart failure (all rows)

ESC 2026 Recommendation Table 13 row	Class, Level
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.	I, C
Histopathological examination of explanted heart tissue from LVAD or heart transplantation surgery should be considered in patients with non-ischaemic HF to identify an aetiological diagnosis that may be treatable or facilitate family screening.	IIa, C

^[1]

Heart transplantation

Careful recipient selection remains essential, based on pre-transplant and post-transplant life expectancy (ESC 2026).^[1]

ESC 2026 Table 17: Indications and contraindications for heart transplantation (all entries)

Group	ESC 2026 wording
Indication (footnote a: indication by heart transplantation centre includes assessment of HF severity by RHC and/or CPET)	Advanced HF and no other therapeutic option (except for durable MCS as BTT)
Absolute contraindications	Inability to comply with the therapeutic regimen (e.g. dementia)
Absolute contraindications	Serious comorbidities with poor prognosis, not reversible with heart transplantation
Other contraindications	Active infection (footnote b: active infection is a relative contraindication to transplantation, but infected LVAD may be an indication)
Other contraindications	Severe peripheral arterial or cerebrovascular disease
Other contraindications	Elevated pulmonary vascular resistance (if pharmacologically irreversible) (footnote c: LVAD as bridge to candidacy should be considered)
Other contraindications	Cancer (footnote d: highly selected cases may be eligible, to be discussed with an oncologist)
Other contraindications	Irreversible liver dysfunction (cirrhosis) or irreversible kidney dysfunction (footnote e: combined heart–liver or heart–kidney transplantation may be considered)
Other contraindications	Systemic disease with multiorgan involvement
Other contraindications	BMI >35 kg/m² or severe cachexia
Other contraindications	Alcohol or substance abuse or active smoking within the past 6 months
Other contraindications	Psychological instability
Other contraindications	Insufficient social support to achieve compliant care in the outpatient setting

^[1]

Transplantation rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 14)	Heart transplantation is recommended in selected patients (eligibility criteria in Table 17) with advanced HF refractory to FMT and GDIT, and without contraindications, to improve QoL and survival.	Class I, Level C
AHA/ACC/HFSA 2022 (section 8.5, row 1)	For selected patients with advanced HF despite GDMT, cardiac transplantation is indicated to improve survival and QOL.	COR 1, LOE C-LD
AHA/ACC/HFSA 2022 (section 8.5, value statement 2)	In patients with stage D (advanced) HF despite GDMT, cardiac transplantation provides intermediate economic value.	Value statement: intermediate value (C-LD)
NHFA/CSANZ 2018 (section 9.6)	Referral for heart transplant assessment should be considered in patients with heart failure associated with intractable NYHA Class III–IV symptoms who have exhausted all alternative therapies and who do not have overt contraindications, to decrease mortality.	Strong recommendation FOR; low quality of evidence

^[1] ^[2] ^[3]

In 2018 NHFA/CSANZ reported a median survival of about 15 years for heart transplant recipients in Australia and New Zealand.^[3]

^[1]

Cardiomyopathies, including hypertrophic cardiomyopathy

The 2023 ESC cardiomyopathies guideline and the 2024 AHA/ACC hypertrophic cardiomyopathy (HCM) guideline each carry rows on transplantation and MCS in their own populations.^[14]^[15]

Cardiomyopathy and HCM rows on transplantation and MCS, by body and year (selected rows)

Body and year	Row	Strength
ESC 2023 cardiomyopathies (Recommendation Table 9)	Orthotopic cardiac transplantation is recommended for eligible cardiomyopathy patients with advanced heart failure (NYHA class III–IV) or intractable ventricular arrhythmia refractory to medical/invasive/device therapy, and who do not have absolute contraindications.	Class I, Level C
ESC 2023 cardiomyopathies (Recommendation Table 10, row 1)	Mechanical circulatory support therapy should be considered in selected cardiomyopathy patients with advanced heart failure (NYHA class III–IV) despite optimal pharmacological and device treatment, who are otherwise suitable for heart transplantation, to improve symptoms and reduce the risk of heart failure hospitalization from worsening heart failure and premature death while awaiting a transplant.	Class IIa, Level B
ESC 2023 cardiomyopathies (Recommendation Table 10, row 2)	Mechanical circulatory support therapy should be considered in selected cardiomyopathy patients with advanced heart failure (NYHA class III–IV) despite optimal pharmacological and device therapy, who are not eligible for cardiac transplantation or other surgical options, and without severe right ventricular dysfunction, to reduce the risk of death and improve symptoms.	Class IIa, Level B
AHA/ACC 2024 HCM (section 6.7, exercise stress testing, row 2)	In patients with nonobstructive HCM and advanced HF (NYHA functional class III to class IV), cardiopulmonary exercise stress testing should be performed to quantify the degree of functional limitation and aid in selection of patients for heart transplantation or mechanical circulatory support.	COR 1, LOE B-NR
AHA/ACC 2024 HCM (section 8.3, row 3)	In patients with nonobstructive HCM and advanced HF (NYHA functional class III to class IV despite GDMT), CPET should be performed to quantify the degree of functional limitation and aid in selection of patients for heart transplantation or mechanical circulatory support.	COR 1, LOE B-NR
AHA/ACC 2024 HCM (section 8.3, row 4)	In patients with nonobstructive HCM and advanced HF (NYHA functional class III to class IV despite GDMT) or with life-threatening ventricular arrhythmias refractory to maximal GDMT, assessment for heart transplantation in accordance with current listing criteria is recommended.	COR 1, LOE B-NR
AHA/ACC 2024 HCM (section 8.3, row 7)	In patients with nonobstructive HCM and advanced HF (NYHA functional class III to class IV despite GDMT) who are candidates for heart transplantation, continuous-flow LVAD therapy is reasonable as a bridge to heart transplantation.	COR 2a, LOE B-NR
AHA/ACC 2024 HCM (section 8.5, ventricular arrhythmias, row 1)	In patients with HCM and recurrent, poorly tolerated life-threatening ventricular tachyarrhythmias refractory to maximal antiarrhythmic drug therapy and ablation, heart transplantation assessment is indicated in accordance with current listing criteria.	COR 1, LOE B-NR

^[14] ^[15]

Adults with congenital heart disease

Adult congenital heart disease rows and text by body and year

Body and year	Row	Strength
ACC/AHA 2025 ACHD (section 3.6.2, row 1)	In patients with ACHD and heart failure, evaluation by specialists with medical and surgical experience in ACHD, as well as by specialists with expertise in advanced heart failure, is recommended to assess appropriateness for advanced heart failure therapies, such as heart transplantation or MCS.	COR 1, LOE B-NR
ACC/AHA 2025 ACHD (section 3.6.2, row 2)	In patients with ACHD who are considered for heart transplantation, multiorgan transplantation (heart–lung, heart–kidney, or heart–liver) is reasonable based on center-specific assessment of the degree of respective lung, kidney, or liver dysfunction.	COR 2a, LOE B-NR
ACC/AHA 2025 ACHD (section 3.6.2, row 3)	In patients with ACHD and advanced heart failure that is refractory to optimal medical and device-based therapy, the use of durable MCS devices is reasonable to improve quality of life or as a bridge to transplantation.	COR 2a, LOE B-NR
ACC/AHA 2025 ACHD (section 4.4.1.1, d-TGA and atrial switch, row 5)	For adults with d-TGA and atrial switch, biomarkers and validated disease-specific risk scores can be useful to identify patients at high risk for adverse cardiac events, prompting closer follow-up and referral to specialized heart failure transplant centers.	COR 2a, LOE B-NR
ACC/AHA 2025 ACHD (section 4.4.1.1, d-TGA and atrial switch, row 11)	Adults with d-TGA and atrial switch who have worsening symptoms of exercise intolerance, heart failure, or arrhythmia refractory to treatment should be referred to a heart failure program for assessment for mechanical support and transplantation in consultation with an ACHD cardiologist, to improve quality of life and prolong survival.	COR 1, LOE C-LD
ACC/AHA 2025 ACHD (section 4.4.5, Fontan, row 1)	In adults with Fontan circulation and evidence of progressive Fontan circulatory failure, formal evaluation by a heart failure/transplant cardiologist with experience in heart transplantation in the adult Fontan population is recommended.	COR 1, LOE B-NR
ACC/AHA 2025 ACHD (section 4.4.5, Fontan, row 16)	Adults with Fontan circulation referred for cardiac transplantation should undergo pretransplantation review by a committee with broad multidisciplinary representation to improve patient selection and posttransplant outcomes.	COR 1, LOE C-EO
ESC 2020 ACHD (section 4.15, unoperated and palliated univentricular heart; patients after Fontan operation are in section 4.16)	Heart transplantation and heart-lung transplantation should be considered when there is no conventional surgical option in patients with poor clinical status.	Class IIa, Level C
ESC 2020 ACHD (section 3.4.1, Heart failure, text)	In all cases, timely evaluation for transplantation by ACHD heart failure specialists in a transplant centre with ACHD expertise is recommended.	(no class or level given)

^[12] ^[13]

Palliative care and the end of life

Palliative care and advance care planning rows by body and year

Body and year	Row	Strength
ESC 2026 (Recommendation Table 26)	Proactive discussion regarding HF trajectory, goals of care, and advance care planning is recommended in patients with advanced HF to facilitate communication on end of life and QoL.	Class I, Level B1
ESC 2026 (Recommendation Table 26)	Access to an integrated HF palliative care multidisciplinary team is recommended for patients in an advanced HF stage to improve QoL and reduce symptom burden.	Class I, Level B2
AHA/ACC/HFSA 2022 (section 13.1, row 1)	For all patients with HF, palliative and supportive care, including high-quality communication, conveyance of prognosis, clarifying goals of care, shared decision-making, symptom management, and caregiver support, should be provided to improve QOL and relieve suffering.	COR 1, LOE C-LD
AHA/ACC/HFSA 2022 (section 13.1, row 2)	For patients with HF being considered for, or treated with, life-extending therapies, the option for discontinuation should be anticipated and discussed through the continuum of care, including at the time of initiation, and reassessed with changing medical conditions and shifting goals of care.	COR 1, LOE C-LD
AHA/ACC/HFSA 2022 (section 13.1, row 3)	For patients with HF, particularly stage D HF patients being evaluated for advanced therapies, patients requiring inotropic support or temporary mechanical support, patients experiencing uncontrolled symptoms, major medical decisions, or multimorbidity, frailty, and cognitive impairment, specialist palliative care consultation can be useful to improve QOL and relieve suffering.	COR 2a, LOE B-R
AHA/ACC/HFSA 2022 (section 13.1, row 4)	For patients with HF, execution of advance care directives can be useful to improve documentation of treatment preferences, delivery of patient-centered care, and dying in preferred place.	COR 2a, LOE C-LD
AHA/ACC/HFSA 2022 (section 13.1, row 5)	In patients with advanced HF with expected survival <6 months, timely referral to hospice can be useful to improve QOL.	COR 2a, LOE C-LD
NHFA/CSANZ 2018 (section 14)	Referral to palliative care should be considered in patients with advanced heart failure to alleviate end-stage symptoms, improve quality of life, and decrease rehospitalisation. Involvement of palliative care should be considered early in the trajectory towards end-stage heart failure.	Strong recommendation FOR; high quality of evidence

^[1] ^[2] ^[3]

Recognising the end of life

ESC 2026 supplementary Table S20 lists how to recognise the end of life in HF.^[1]

Frequent hospitalizations or emergency visits due to decompensated HF.^[1]
Increasing ICD shocks.^[1]
Progressive functional decline (physical and mental), dependence in most activities of daily living.^[1]
Progressive decline in quality of life.^[1]
Heart transplantation and durable MCS ruled out.^[1]
Refractory symptoms despite optimal medical and device management.^[1]
Signs of advanced HF: end-organ dysfunction, cardiac cachexia, frailty, hypotension.^[1]
Clinically judged to be close to the end of life.^[1]

Initiate advance care planning early in the HF trajectory, and discuss the difference between palliative care and end-of-life care and when to integrate each.^[1]
Optimize diuretics for fluid management, individualize changes to HF FMT, and adjust therapies to those that alleviate symptoms or prevent distress.^[1]
Use oxygen if indicated for symptom relief; give advice on position, fans and breathing techniques; relax previously introduced fluid and sodium restrictions in appropriate patients.^[1]
Consider hospice referral when shifting to comfort-orientated care.^[1]

Devices at the end of life

ICD: ESC 2026 Table S20 says discuss the option of deactivating ICDs to prevent unnecessary shocks; NHFA/CSANZ 2018 practice advice is that deactivation discussions should occur between the patient and family and their cardiologist.^[1]^[3]
ICD, the formal row: ESC 2022 VA/SCD Recommendation Table 21: informed discussion with patient and family about ICD deactivation options and shared decision-making is indicated prior to implantation and in case of significant health status deterioration (Class I, Level C).^[16]
Durable MCS: ESC 2026 says patients may request withdrawal because the treatment no longer matches their goals, because of poor QoL or new serious comorbidities such as cancer; the MCS may be deactivated after careful evaluation of the patient’s wish, by or under the supervision of a specialized team, and the decision has to take national laws into account.^[1]
Plan it up front: AHA/ACC/HFSA 2022 says every form of MCS will eventually be turned off, and this should be addressed with patients before discussions about MCS.^[2]
Why it matters: failure to proactively address topics such as deactivation of ICD and LVAD therapies can lead to suffering at the end of life (AHA/ACC/HFSA 2022).^[2]

PAL-HF

J Am Coll Cardiol

PMID 28705314

2017

Randomised: usual care vs usual care plus an interdisciplinary palliative care intervention; primary end points KCCQ overall summary and FACIT-Pal at 6 months

Population: 150 patients with advanced HF at a single centre, randomised 2012–2015

Key finding

KCCQ difference 9.49 points and FACIT-Pal difference 11.77 points in favour of the intervention at 6 months; no effect on rehospitalization or mortality

^[9]

Evidence, guidelines and regional differences

Europe (ESC)

2026 heart failure guideline

Early consultation with an advanced HF centre is recommended in advanced HF or at risk of it, in motivated patients without absolute contraindications to transplantation or durable MCS, to evaluate candidacy: Class I, Level A
Durable MCS (LVAD) is recommended in selected patients with advanced HFrEF despite FMT and GDIT, as BTT, BTC, BTR or destination therapy, to improve symptoms and reduce the risk of death: Class I, Level C
Continuous inotropes should be considered in advanced HFrEF with low cardiac output and evidence of hypoperfusion or end-organ dysfunction, as BTD, BTT or bridge to durable MCS, to increase cardiac output and improve symptoms: Class IIa, Level C
Heart transplantation is recommended in selected patients with advanced HF refractory to FMT and GDIT, without contraindications, to improve QoL and survival: Class I, Level C
Access to an integrated HF palliative care multidisciplinary team is recommended in an advanced HF stage to improve QoL and reduce symptom burden: Class I, Level B2

United States (AHA/ACC/HFSA)

2022 heart failure guideline

In advanced HF, when consistent with the patient’s goals of care, timely referral for HF specialty care is recommended: COR 1, LOE C-LD
Durable LVAD implantation is effective in select patients with advanced HFrEF with NYHA class IV symptoms deemed dependent on continuous intravenous inotropes or temporary MCS, to improve functional status, QOL and survival: COR 1, LOE A
Long-term continuous or intermittent intravenous inotropes, for reasons other than palliative care or as a bridge to advanced therapies, are potentially harmful: COR 3: Harm, LOE B-R
Cardiac transplantation is indicated for selected patients with advanced HF despite GDMT to improve survival and QOL: COR 1, LOE C-LD
Timely referral to hospice can be useful in advanced HF with expected survival <6 months to improve QOL: COR 2a, LOE C-LD

Australia and New Zealand (NHFA/CSANZ)

2018 heart failure guideline

Referral to a specialist centre for consideration of VAD implantation should be considered in intractable, severe heart failure despite guideline-directed medical and pacemaker therapy, without major comorbidities, to decrease mortality: strong recommendation for, moderate quality of evidence
Referral for heart transplant assessment should be considered with intractable NYHA Class III–IV symptoms after all alternative therapies have been exhausted, without overt contraindications, to decrease mortality: strong recommendation for, low quality of evidence
Referral to palliative care should be considered in advanced heart failure to alleviate end-stage symptoms, improve quality of life and decrease rehospitalisation, with involvement considered early in the trajectory: strong recommendation for, high quality of evidence

^[1] ^[2] ^[3]

Guidelines checked for this topic

ESC: the 2026 heart failure guideline and its supplementary data (section 8, section 11.6.2, Tables 5, 6 and 14 to 17, Recommendation Table 6 (the NYHA class IV ICD row and the wearable defibrillator row), Recommendation Tables 10 (two rows), 11 to 14, 24 (the LVAD row) and 26, its secondary mitral regurgitation text, and supplementary Tables S18 to S20).^[1]
United States: the 2022 AHA/ACC/HFSA heart failure guideline (take-home message 8, sections 4.1, 4.7, 8.1 to 8.5 and 13.1, Tables 3 and 16 to 20).^[2]
Other same-month or newer guidelines quoted: the 2026 ESC cardiac rehabilitation guideline (Recommendation Tables 5 and 17) and the 2026 AHA/ACC/ADA/ASN cardiovascular-kidney-metabolic syndrome guideline (section 6.3.1).^[10]^[11]
Australia and New Zealand: the 2018 NHFA/CSANZ heart failure guideline (sections 6.7, 9.5, 9.6 and 14), dated.^[3]
Adult congenital heart disease: the 2025 ACC/AHA/HRS/ISACHD/SCAI guideline (sections 3.6.2, 4.4.1.1 and 4.4.5) and the 2020 ESC guideline (section 3.4.1 and the section 4.15 univentricular heart table), each given with its year.^[12]^[13]
Cardiomyopathies: the 2023 ESC cardiomyopathies guideline (section 6.10.2.2 text and Recommendation Tables 9 and 10) and the 2024 AHA/ACC hypertrophic cardiomyopathy guideline (section 6.7 row 2, section 8.3 rows 3, 4 and 7 with supportive text, and section 8.5 row 1), each given with its year.^[14]^[15]
Ventricular arrhythmias: the 2022 ESC ventricular arrhythmias and sudden cardiac death guideline (Recommendation Tables 19 and 21, and the two pre-transplant rows of Recommendation Table 48), given with its year.^[16]
ISHLT: the 2024 guidelines for the evaluation and care of cardiac transplant candidates, PubMed abstract only.^[4]
Trials: REMATCH, MOMENTUM 3 (2-year and 5-year reports), ARIES-HM3 and PAL-HF, from their PubMed abstracts.^[5]^[6]^[7]^[8]^[9]

Not held as text for this topic (none of their recommendations is used): the 2024 ISHLT cardiac transplant candidate guidelines (abstract only), the 2023 ISHLT mechanical circulatory support guidelines, the 2023 ISHLT/HFSA acute mechanical circulatory support guideline, the 2016 ISHLT listing criteria, the 2026 ESC cardiovascular disease and chronic kidney disease guideline (not held in its version of record), the 2026 AHA/ACC perioperative guideline (abstract only) and the 2025 NHFA/CSANZ acute coronary syndromes guideline (not held as text in its version of record).
Checked, not used: the 2025 ESC/EACTS valvular heart disease guideline (its secondary mitral regurgitation rows and text; the topic uses the newer ESC 2026 heart failure text on the same point); the 2025 ESC myocarditis and pericarditis guideline (its Shock Team and temporary MCS rows are specific to myocarditis; temporary MCS is covered in the linked cardiogenic shock topic); the 2025 ESC pregnancy guideline (pregnancy-specific rows, including pregnancy after heart transplantation; this topic does not teach pregnancy); the 2022 ESC/ERS pulmonary hypertension guideline (its MCS and palliative care text concerns pulmonary hypertension populations); and the 2020 ESC sports cardiology guideline (exercise after heart transplantation; the topic uses the newer ESC 2026 cardiac rehabilitation rows).^[1]^[10]
Checked, not used: the other held guidelines listed for the currency sweep in the evidence pack; their candidate rows concern other populations, such as acute coronary syndromes, valve disease, pacing, endocarditis, pulmonary embolism and non-cardiac surgery.

Pitfalls

Common errors

Waiting for LVEF ≤30% before calling HF advanced: ESC 2026 says a severely reduced LVEF is common but not required, and advanced HF may develop in HFpEF or other structural abnormalities; AHA/ACC 2024 HCM says transplant referral for HCM does not require a reduced EF.^[1]^[15]
Reciting I NEED HELP without the source: E is EF <20% or poor RV function in ESC 2026 but EF ≤35% in AHA/ACC/HFSA 2022.^[1]^[2]
Referring only after end-organ failure: AHA/ACC/HFSA 2022 warns that after end-organ dysfunction or cardiogenic shock, patients may no longer qualify for advanced therapies.^[2]
Leaving a patient on long-term continuous or intermittent intravenous inotropes for reasons other than palliative care or as a bridge to advanced therapies: AHA/ACC/HFSA 2022 calls this potentially harmful (COR 3: Harm, LOE B-R).^[2]
Calling active infection an absolute bar to transplantation: ESC 2026 lists it among other contraindications and calls it relative, and an infected LVAD may be an indication.^[1]
Diagnosing inotrope dependence while starting or uptitrating beta-blockers or RAS inhibitors: ESC 2026 Table S18 says it should not be made then.^[1]

Exam pearls

ESC 2026 Table 14: all four criteria must be present despite FMT, AMT and GDIT; the exercise criterion is inability to exercise, 6-min walk <300 m, or pVO₂ <12–14 mL/kg/min (12 for patients on beta-blocker) or <50% predicted, estimated to be of cardiac origin.^[1]
ESC 2026 Rule of three: HFH (≥2 or ≥1 requiring inotropes within the last year), diuretic resistance, intolerance to neurohormonal drugs with onset of cardiorenal syndrome.^[1]
ESC 2026 LVAD indication: HF with severely reduced LVEF plus INTERMACS 1–2 with neurological and other end-organ recovery but no cardiac recovery on temporary MCS, or INTERMACS 2–4, or NYHA class III/IV (INTERMACS >4) despite optimal FMT and GDIT with at least one of: unable to exercise due to HF or, if able to perform CPET, pVO₂ <12–14 mL/kg/min and/or <50% predicted; end-organ dysfunction due to reduced perfusion (cardiac index ≤2 L/min/m² despite euvolaemic or therapy-resistant hypervolaemic status); or repeated HFH within the previous 12 months without an obvious precipitating cause.^[1]
ESC 2026 transplant: 1-year survival 80%–90%, median around 12.5 years; most programmes accept patients up to 70 years; BMI >35 kg/m² or severe cachexia is among the other contraindications.^[1]
AHA/ACC/HFSA 2022 Table 19 lists age >80 y for destination therapy as a relative contraindication to durable mechanical support.^[2]
Inotrope dependence (ESC 2026 Table S18): failure to wean intravenous inotropic support within 72 h without symptomatic arterial hypotension, worsening renal or hepatic function (eGFR decrease >30%, or clinically important elevation in liver enzymes or INR), or worsening congestion leading to or upholding NYHA class IV symptoms (in the absence of reduction in loop diuretic dose); after continuous support for >7 days, it is failure to reduce the infusion rate at 72 h after each attempt to reduce, and with levosimendan the need for a new infusion <10 days after the former; it should not be diagnosed during simultaneous introduction or uptitration of beta-blockers or RAS inhibitors.^[1]
REMATCH (randomised; 129 transplant-ineligible patients with NYHA class IV end-stage HF, LVAD vs optimal medical management): survival 52% vs 25% at one year.^[5]
MOMENTUM 3 (randomised; 1028 patients with advanced HF, centrifugal-flow vs axial-flow LVAD, 2 years): primary end point 76.9% vs 64.8%; pump replacement 2.3% vs 11.3%.^[6]
ARIES-HM3 (randomised, double-blind, placebo-controlled; 628 patients with advanced HF and a fully magnetically levitated LVAD, aspirin 100 mg/d vs placebo with VKA, 12 months): placebo noninferior, and aspirin avoidance associated with reduced nonsurgical bleeding.^[8]

Say it this way at the viva

References16Show

[1]Køber L, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J, 2026.PMID 42661420
[2]Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022.PMID 35363499
[3]Atherton JJ, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ, 2018.PMID 30077227
[4]Peled Y, et al. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant, 2024.PMID 39115488
[5]Rose EA, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med, 2001.PMID 11794191
[6]Mehra MR, et al. A Fully Magnetically Levitated Left Ventricular Assist Device - Final Report. N Engl J Med, 2019.PMID 30883052
[7]Mehra MR, et al. Five-Year Outcomes in Patients With Fully Magnetically Levitated vs Axial-Flow Left Ventricular Assist Devices in the MOMENTUM 3 Randomized Trial. JAMA, 2022.PMID 36074476
[8]Mehra MR, et al. Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial. JAMA, 2023.PMID 37950897
[9]Rogers JG, et al. Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial. J Am Coll Cardiol, 2017.PMID 28705314
[10]Bäck M, et al. 2026 ESC Guidelines on cardiac rehabilitation. Eur Heart J, 2026.PMID 42661418
[11]Ndumele CE, et al. 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2026.PMID 42265997
[12]Gurvitz M, et al. 2025 ACC/AHA/HRS/ISACHD/SCAI Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2026.PMID 41411375
[13]Baumgartner H, et al. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J, 2021.PMID 32860028
[14]Arbelo E, et al. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J, 2023.PMID 37622657
[15]Ommen SR, et al. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2024.PMID 38727647
[16]Zeppenfeld K, et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J, 2022.PMID 36017572