While the term advanced HF has many definitions, to guide clinicians as to which patients should be considered for advanced HF management (such as but not limited to cardiac transplant, MCS, or palliative care) the following is a general guide. Cardiac transplant is well established in Canada and further guidance is available at http://www.ccs.ca/en/cctn-home.

Cardiac transplant assessment is typically done by a multispecialty, multidisciplinary team in a specialized setting, using Canadian and international guidance for appropriate work-up and eligibility.

Patients with advanced HF to be considered for advanced HF management strategies include those who, despite optimal treatment, continue to exhibit progressive/persistent NYHA III or IV HF symptoms and accompanied by more than one of the following:

• LVEF < 25% and, if measured, peak exercise oxygen consumption < 14 mL/kg/min (or less than 50% predicted).
• Evidence of progressive end organ dysfunction due to reduced perfusion and not to inadequate ventricular filling pressures.
• Recurrent HF hospitalizations (≥ 2 in 12 months) not due to a clearly reversible cause.
• Need to progressively reduce or eliminate evidence-based HF therapies such as ACEis, MRAs or beta-blockers, due to circulatory-renal limitations such as renal insufficiency or symptomatic hypotension.
• Diuretic refractoriness associated with worsening renal function.
• Requirement for inotropic support for symptomatic relief or to maintain end-organ function.
• Worsening right heart failure and secondary pulmonary hypertension.
• Six-minute walk distance less than 300 m.
• Increased 1-year mortality (e.g., > 20%–25%) predicted by HF risk scores
• Progressive renal or hepatic end-organ dysfunction.
• Persistent hyponatremia (serum sodium < 134 mEq/L).
• Cardiac cachexia.
• Inability to perform activities of daily living. It should be noted that most patients will have a number of the listed criteria and there is no single criterion that determines candidacy for cardiac transplant, mechanical circulatory support (MCS), or palliative care. Patient preferences should be incorporated into the decision process when assessing further choices.

It should be noted that most patients will have a number of the listed criteria and there is no single criterion that determines candidacy for cardiac transplant, MCS, or palliative care. Patient preferences should be incorporated into the decision process when assessing further choices.