SCIENTIFIC JOURNAL of the Hungarian Society of Cardiology

Therapeutic algorhytm of advanced heart failure – The role of early referral

█ Review

DOI: 10.26430/CHUNGARICA.2023.53.4.393

Sax Balázs, Assabiny Alexandra, Becker Dávid, Merkely Béla
Semmelweis Egyetem, Városmajori Szív- és Érgyógyászati Klinika, Budapest
Levelezési cím:
Dr. Sax Balázs. Semmelweis Egyetem Városmajori Szív- és Érgyógyászati Klinika
1122 Budapest, Városmajor u. 68. E-mail:


Advanced (or Stage D) heart failure is the final stage of the disease when subjective and objective signs of low exercise capacity, severe cardiac dysfunction are present and recurrent hospitalizations are needed despite optimal medical and non-pharmacological treatment (e.g. CRT). Gold standard therapy of advanced heart failure is still cardiac transplantation (HTX), in the absence of contraindications (e.g., pulmonary hypertension, active infection or malignant disease, severe renal or hepatic failure, cachexia, advanced age, unresolved psycho-social issues). HTX activity is limited by donor heart availability as well. In the presence of HTX contraindications or urgency, durable left ventricular assist device (LVAD) therapy may offer good long term outcome as a bridge or destination therapy. However, LVAD implantation is also limited by several contraindications (e.g. right ventricular failure, active infection, severe renal or hepatic failure, contraindications of long term anticoagulation, medical non-adherence). Both HTX and LVAD implantation carry high perioperative burden. When both therapies are contraindicated, patient should enter palliative care. Optimal long term outcome for both HTX and LVAD therapy relies on timely referral to the implanting center – before the development of end organ dysfunction and frailty. Guidelines help treating cardiologist to identify heart failure patients at risk for sliding into advanced heart failure, e.g. by using “I NEED HELP” acronym of red flags.


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