Over the past four decades, the field of advanced heart failure/transplant cardiology (AHFTC) has undergone remarkable transformation in both clinical practice and fellowship training. Driven by a combination of technological innovation, evidence-based therapeutics and deepened understanding of HF pathophysiology, graduate medical education in this subspecialty now faces unprecedented opportunities alongside complex challenges. Despite these advances, a persistent shortage of trainees pursuing AHFTC fellowships underscores the urgent need to reassess how we structure and promote training in this vital field.

The therapeutic landscape for heart failure with reduced ejection fraction (HFrEF) has dramatically expanded. Thirty years ago, treatment was largely limited to diuretics, digoxin and select vasodilators. The landmark CONSENSUS and SOLVD trials established the mortality benefit of ACE inhibitors, followed by compelling evidence supporting beta-blockers, mineralocorticoid receptor antagonists and ICDs.^1,2 More recently, angiotensin receptor-neprilysin inhibitors, SGLT2 inhibitors and vericiguat have added to this therapeutic armamentarium.³

This expanding complexity demands that advanced training programs evolve beyond simply teaching the administration and monitoring of guideline-directed medical therapy. Contemporary fellowship education must emphasize evidence-based protocol development, quality improvement methodologies and personalized patient care strategies to prepare trainees for managing increasingly complex patient populations.

Expanding Etiological Understanding, Diagnostic Modalities

Our understanding of nonischemic cardiomyopathies has also evolved substantially, moving away from the oversimplified categorization of "idiopathic" cardiomyopathy toward precise phenotyping using advanced diagnostic modalities. The advent of cardiac MRI has revolutionized tissue characterization, enabling clinicians to differentiate among myocarditis, sarcoidosis, hypertrophic and infiltrative cardiomyopathies such as amyloidosis.⁴

The diagnostic armamentarium has expanded further with technetium-99m pyrophosphate (PYP) scanning for transthyretin cardiac amyloidosis and cardiac PET for inflammatory cardiomyopathies.⁵ Moreover, the increasing availability of genetic testing has opened new frontiers in familial and heritable cardiomyopathies, facilitating family screening and paving the way for targeted therapies.⁶

Mastery of these diagnostic modalities – understanding not only their technical aspects but also their appropriate clinical application – has become essential for the next generation of AHFTC specialists.

Growth in Heart Transplantation, MCS

The number of heart transplants performed annually in the U.S. has increased steadily, exceeding 4,500 in 2024.⁷ This expansion, coupled with the evolution of the heart allocation system, demands that training programs continuously adapt their curricula. Contemporary fellowship training must emphasize sophisticated immunosuppressive management, nuanced allograft rejection surveillance, and comprehensive post-transplant complication management.

Equally transformative has been the evolution of mechanical circulatory support (MCS) technology. Durable left ventricular assist devices (LVADs) have progressed through multiple generations – from pulsatile to continuous flow designs – with current iterations demonstrating superior durability and reduced complication rates.⁸ The temporary MCS landscape has similarly expanded, with devices including Impella, TandemHeart and extracorporeal membrane oxygenation, serving as critical bridges to decision, recovery or transplant across the entire spectrum of cardiogenic shock presentations.

Fellowships in AHFTC must provide comprehensive training encompassing patient selection, device management, troubleshooting and the ethical complexities surrounding MCS utilization. In addition, simulation-based education and a focus on the value of an interdisciplinary care team approach have emerged as cornerstone elements of contemporary training.

Addressing the Fellowship Recruitment Crisis

Despite these exciting advancements, an unfortunate trend has emerged: the continued difficulty in filling AHFTC fellowship positions. According to the National Resident Matching Program, in 2024 only 48% of offered positions were filled.⁹ This recruitment challenge stems from multiple interconnected factors.

First, the perceived emotional and logistical burdens of managing critically ill patients – particularly those on MCS or awaiting transplant – may deter potential candidates. Second, procedural subspecialties within cardiology, such as interventional cardiology and electrophysiology, may appear more financially lucrative or procedurally appealing to trainees. Third and perhaps more critically, limited exposure to AHFTC mentorship during general cardiology training may limit fellows from discovering their passion for this field.

Strategies to Turn the Tide

Addressing this workforce gap requires multifaceted intervention strategies. Early and meaningful exposure to AHFTC through dedicated rotations, case conferences and simulation experiences during general cardiology fellowship could spark interest among trainees. Incorporating structured mentorship programs that pair fellows with HF faculty and transplant recipients may demystify the specialty while highlighting its profound impact on patient's lives.

Training programs must also evolve to emphasize areas of the field outside of inpatient care. Contemporary curricula should incorporate robust education in outpatient HF management, remote monitoring technologies, palliative care integration and health care policy affecting transplant and MCS allocation. This comprehensive approach better reflects the full spectrum of modern HF practice.

Professional societies have crucial roles to play. Expanding career development resources, offering travel scholarships for HF conferences and creating dedicated research opportunities for trainees can help cultivate the next generation of HF specialists.

The persistent under-recruitment threatens our ability to meet the growing burden of HF in an aging population. The path forward requires bold action from training programs, professional societies and current practitioners. By reimagining fellowship structure, expanding mentorship opportunities and showcasing the intellectual rigor and clinical impact of AHFTC practice, we can inspire a new generation of specialists to embrace this challenging yet deeply rewarding field. The future of our patients with AHF depends on our collective commitment to nurturing and developing the workforce that will care for them.

This article was authored by Michael Francke, MD, interventional cardiology fellow at the Kaiser Permanente - Los Angeles Medical Center in CA, who completed his AHFTC fellowship at Cedars-Sinai in Los Angeles.

References

1. CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med 1987;316:429-35.
2. SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991;325:293-302.
3. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;42:3599-3726.
4. Ferreira VM, Schulz-Menger J, Holmvang G, et al. Cardiovascular magnetic resonance in nonischemic myocardial inflammation: Expert recommendations. JACC 2018;72:3158-76.
5. Gillmore JD, Maurer MS, Falk RH, et al. Nonbiopsy diagnosis of cardiac transthyretin amyloidosis. Circulation 2016;133:2404-12.
6. Hershberger RE, Givertz MM, Ho CY, et al. Genetic evaluation of cardiomyopathy: a clinical practice resource of the American College of Medical Genetics and Genomics. Genet Med 2018;20:899-909.
7. United Network for Organ Sharing (UNOS). Data reports. Accessed August 2025. Available here.
8. Mehra MR, Uriel N, Naka Y, et al. A fully magnetically levitated left ventricular assist device;  final report. N Engl J Med 2019;380:1618-27.
9. National Resident Matching Program. Results and data: 2024 appointment year. Accesssed August 2025. Available here.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant

Keywords: Cardiology Magazine, ACC Publications, Fellowships and Scholarships, Heart Transplantation, Education, Medical, Graduate, Heart Failure