Position Statement by the Saudi Heart Failure Working Group of the Saudi Heart Association on the Management of Advanced Heart Failure in Saudi Arabia.

Background: Heart failure (HF) is a leading cause of morbidity and mortality in Saudi Arabia. Despite remarkable progress in guideline-directed medical therapy, a significant proportion of patients progress to advanced HF and require evaluation for heart transplantation or mechanical circulatory support (MCS). In response to this growing burden, the Saudi Heart Association (SHA) developed recommendations to guide identification, timely referral, and optimal management of candidates for advanced HF therapies in Saudi Arabia. Methods: A multidisciplinary panel of 10 HF experts from Saudi Arabia convened for a series of structured virtual meetings to review local and international evidence. The panel integrated Saudi-specific clinical practice patterns and healthcare considerations into the deliberation process. Consensus was achieved through discussion and majority agreement. Recommendations were formulated using the SHA methodology, supported by a comprehensive literature review of published evidence. Results and conclusions: The SHA consensus establishes a structured, comprehensive framework for recognizing advanced HF, optimizing guideline-directed therapy, and determining candidacy for heart transplantation or MCS in tertiary and quaternary centers in Saudi Arabia. The document emphasizes timely prognostic stratification using clinical indicators and standardized tools such as INTERMACS and SCAI classifications. Referral pathways and multidisciplinary coordination are delineated to facilitate efficient evaluation and timely intervention. These recommendations aim to minimize delays in referral, expand access to advanced HF therapies and improve patient outcomes across Saudi Arabia.