Advanced heart failure — viva

Stem

Practice viva. The examiner asks how you recognise advanced heart failure, when you refer, and what the advanced HF centre can offer, working through the definition, the screening criteria, inotropes, durable MCS, transplantation and palliative care.^[1]

Branch A — What is advanced heart failure?

Examiner: Define advanced heart failure.^[1]

Strong answer:

• ESC 2026 Table 14: all four criteria must be present despite FMT, AMT and GDIT.^[1]
• Severe and persistent symptoms of HF (NYHA class III or IV), and severe cardiac dysfunction defined by at least one of: LVEF ≤30%, isolated RV failure, non-operable severe valve or congenital abnormalities, or persistently high (or increasing) natriuretic peptides with severe LV diastolic dysfunction or structural abnormalities.^[1]
• Episodes of congestion needing high-dose i.v. diuretics or malignant arrhythmias causing ≥2 unplanned visits or hospitalizations in 12 months, or ≥1 episode of low output requiring inotropes or vasoactive drugs.^[1]
• Severe impairment of exercise capacity: 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]

Follow-up: Does the LVEF have to be low?^[1]

• No: ESC 2026 says a severely reduced LVEF is common but not required, as advanced HF may develop in HFpEF or other structural abnormalities.^[1]

Branch B — When do you refer?

Examiner: How do you pick up the patient who needs referral?^[1]

Strong answer:

• ESC 2026 calls systematic assessment with the Rule of three or I NEED HELP criteria essential for timely referral; one item from either list marks high risk.^[1]
• 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 recommends early consultation with an advanced HF centre in patients with advanced HF or at risk of it, 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]
• AHA/ACC/HFSA 2022 recommends timely referral for HF specialty care in advanced HF when consistent with the patient’s goals of care (COR 1, LOE C-LD), and warns that after end-organ dysfunction or cardiogenic shock patients may no longer qualify.^[2]

Follow-up: Is I-Need-Help the same in both guidelines?^[2]

• No: ESC 2026 uses EF <20% or poor RV function and low blood pressure with high heart rate; AHA/ACC/HFSA 2022 uses EF ≤35% and low systolic BP ≤90 with high heart rate.^[1][2]

Branch C — Inotropes

Examiner: When would you use inotropes in advanced HF?^[1][2]

Strong answer:

• ESC 2026: 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).^[1]
• AHA/ACC/HFSA 2022: bridge therapy in stage D HF refractory to GDMT and device therapy in patients eligible for and awaiting MCS or transplantation is reasonable (COR 2a, LOE B-NR); in select stage D patients despite optimal GDMT and device therapy who are ineligible for both, continuous intravenous inotropic support may be considered as palliative therapy for symptom control and improvement in functional status (COR 2b, LOE B-NR).^[2]
• Long-term continuous or intermittent intravenous inotropes, for reasons other than palliative care or as a bridge to advanced therapies, are potentially harmful (AHA/ACC/HFSA 2022, COR 3: Harm, LOE B-R).^[2]
• ESC 2026: because inotropic therapy may exacerbate or induce myocardial ischaemia and/or tachyarrhythmias, it should only be used in the lowest required dose and for as short a period as possible.^[1]

Follow-up: What is inotrope dependence?^[1]

• ESC 2026 Table S18: failure to wean intravenous inotropic support within 72 h without symptomatic hypotension, worsening renal or hepatic function, or worsening congestion leading to or upholding NYHA class IV symptoms (in the absence of reduction in loop diuretic dose); not diagnosed during introduction or uptitration of beta-blockers or RAS inhibitors.^[1]

Branch D — Durable MCS

Examiner: Who gets an LVAD?^[1]

Strong answer:

• ESC 2026 Table 16: HF with severely reduced LVEF and one of: INTERMACS 1–2 with neurological and other end-organ recovery but no cardiac recovery on temporary MCS; 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: 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).^[1]
• Absolute contraindications in ESC 2026 include severe RV dysfunction despite euvolaemic status, severe irreversible end-organ or neurological disease, severe pulmonary disease and contraindication to long-term oral anticoagulation.^[1]
• MOMENTUM 3 (randomised; 1028 patients with advanced HF, centrifugal-flow vs axial-flow LVAD): survival at 2 years free of disabling stroke or reoperation to replace or remove a malfunctioning device 76.9% vs 64.8%.^[6]

Follow-up: Aspirin with an LVAD?^[8]

• ARIES-HM3 (randomised, double-blind, placebo-controlled; 628 patients with advanced HF and a fully magnetically levitated LVAD on a VKA, aspirin 100 mg/d vs placebo, median follow-up 14 months): placebo was noninferior for survival free of haemocompatibility events at 12 months, and aspirin avoidance was associated with reduced nonsurgical bleeding.^[8]

Branch E — Transplantation

Examiner: What are the contraindications to heart transplantation?^[1]

Strong answer:

• ESC 2026 Table 17 absolute contraindications: inability to comply with the therapeutic regimen (e.g. dementia), and serious comorbidities with poor prognosis, not reversible with heart transplantation.^[1]
• Other contraindications include active infection (relative; an infected LVAD may be an indication), pharmacologically irreversible pulmonary vascular resistance (LVAD as bridge to candidacy should be considered), cancer (highly selected cases may be eligible, to be discussed with an oncologist), irreversible liver or kidney dysfunction (combined heart–liver or heart–kidney transplantation may be considered), BMI >35 kg/m² or severe cachexia, and alcohol or substance abuse or active smoking within 6 months.^[1]
• ESC 2026: 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]

Branch F — Palliative care

Examiner: Where does palliative care fit?^[1]

Strong answer:

• 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]
• ESC 2026 recommends access to an integrated HF palliative care multidisciplinary team for patients in an advanced HF stage to improve QoL and reduce symptom burden (Class I, Level B2).^[1]
• Patients with contraindications to MCS or transplantation should receive palliative care (ESC 2026).^[1]
• NHFA/CSANZ 2018: referral to palliative care should be considered in advanced HF, and involvement should be considered early in the trajectory towards end-stage HF (strong recommendation for, high quality of evidence).^[3]
• Discuss ICD deactivation (ESC 2026 Table S20); AHA/ACC/HFSA 2022 says every form of MCS will eventually be turned off, and that this should be addressed with patients before discussions about MCS.^[1][2]
• ESC 2022 VA/SCD gives the formal ICD row: 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]