• Persistent severe symptoms of heart failure and low exercise capacity (NYHA class III-IV) despite optimal therapy
• Multiple hospitalizations per year for heart failure (> 2 per year)
• Increasing required daily dose of diuretics
• Persistent signs of fluid retention refractory to maximal therapy
• Having to taper off heart failure therapy due to symptomatic hypotension
• Increasing dysfunction of the heart with deterioration of LVEF, severe secondary mitral valve insufficiency , development of low cardiac output, right ventricular dysfunction,...
• Increasing multi-organ failure (renal insufficiency, liver failure and ascites, etc.)
• Admission to intensive care requiring intravenous inotropes and/or vasopressors
• A negative answer to the “surprise question”: Would you be surprised if your patient died in the next 12 months?

**Definition of terminal heart failure: End-stage heart failure with poor general or functional condition of the patient (NYHA class III to IV) and limited therapeutic options, without the patient still being eligible for LVAD (left ventricular assist device) and heart transplantation.