Adult patients with advanced heart failure

Inclusion Criteria:

1. Advanced HF (Stage D or advanced Stage C HF) with:

   symptoms of dyspnea at rest or with minimal exertion systolic dysfunction or preserved systolic function ("diastolic heart failure") Outpatient care setting (office, clinic or home hospice).

2. Patient already receiving optimal medical therapy per ACC/AHA guidelines (ACEI or ARB + β-blocker +aldosterone antagonist) for at least 1 month or explanation of intolerance of specific medication. We will exclude those not on optimized medications with no notation of intolerance; however, we will keep a tally to quantify patients who are considered "advanced Heart Failure" but are not on recommended medications.
3. Can be awaiting LVAD, transplantation or other procedure
4. Age > 18 years and able to sign informed consent to participate

Exclusion Criteria:

1. Cognitive or other impairment which prevents accurate assessment of symptoms or ability to provide informed consent.
2. Heart failure due to recent onset of acute viral myocarditis, peripartum myocarditis.
3. Patient on hemodialysis or receiving mechanical ventilation
4. Patients receiving investigational agents or devices.
5. Patients who have received heart transplant or a destination Left Ventricular Assist Device