Advanced heart failure is characterized by persistent severe symptoms and functional limitations despite optimal medical therapy and carries significant morbidity and mortality. This article discusses the key parameters of this clinical syndrome that should prompt referral by primary care providers and general cardiologists to advanced heart failure and transplantation centers, which is paramount to improving the quality of life and survival of these patients. It also aims to elucidate the evaluation process for determining candidacy for advanced therapies, including key indications and contraindications to left ventricular assist device implantation and heart transplantation.