1|Page
ABIM Advanced Heart Failure &
Transplant Cardiology (AHFTC)
Board Exam Review 2026
Comprehensive ABIM AHFTC review for the Advanced
Heart Failure & Transplant Cardiology certification and
MOC exams. Covers heart failure management (HFrEF,
HFpEF), mechanical circulatory support, heart
transplantation, pulmonary hypertension, and
cardiomyopathies. Includes board-style questions,
rationales, and high-yield topics aligned with the ABIM
blueprint. Ideal for cardiology fellows and physicians
preparing for the 2026 exam.
Q1. A 58-year-old man with non-ischemic cardiomyopathy (LVEF 25%) on optimal
GDMT presents with BP 85/50 mmHg, HR 110 bpm, cool extremities, and elevated
JVP. Which hemodynamic profile is most likely?
A) Profile A (warm and dry)
B) Profile B (warm and wet)
C) Profile C (cold and wet)
D) Profile L (cold and dry)
,2|Page
Correct Answer: C) Profile C (cold and wet)
Rationale: The presence of congestion (elevated JVP) and hypoperfusion (cool
extremities, narrow pulse pressure, hypotension) defines the wet-cold or "cardiogenic
shock" profile according to the Forrester and Stevenson classification. Profile C carries
the highest risk and often requires inotropes or mechanical circulatory support.
Q2. A 72-year-old woman with HFrEF (EF 30%) has a normal serum sodium,
creatinine 1.1 mg/dL, and BNP 850 pg/mL. Which additional biomarker provides the
strongest prognostic information for sudden cardiac death?
A) High-sensitivity troponin T
B) Galectin-3
C) Soluble ST2
D) Growth differentiation factor-15
Correct Answer: C) Soluble ST2
Rationale: Soluble ST2, a marker of myocardial fibrosis and ventricular remodeling,
independently predicts mortality and sudden cardiac death in HFrEF. While elevated
troponin also confers risk, ST2 has stronger additive prognostic value for sudden death
prediction, making it valuable for risk stratification.
Q3. A patient with advanced HF and QRS duration 170 ms with LBBB morphology on
ECG is receiving optimal medical therapy but remains NYHA III. What is the most
appropriate next therapy?
A) Implantable cardioverter-defibrillator (ICD) only
B) Cardiac resynchronization therapy with defibrillator (CRT-D)
C) Permanent pacemaker without defibrillation capability
D) Continued medical therapy optimization alone
Correct Answer: B) Cardiac resynchronization therapy with defibrillator (CRT-D)
Rationale: CRT improves survival and symptoms in HFrEF patients with LBBB and QRS
≥150 ms who remain symptomatic on GDMT. The addition of ICD capability (CRT-D) is
indicated for patients with NYHA II-III symptoms and EF ≤35%. Multiple trials
(COMPANION, CARE-HF, REVERSE) established CRT benefit.
,3|Page
Q4. Which hemodynamic finding on right heart catheterization is most characteristic
of constrictive pericarditis rather than restrictive cardiomyopathy?
A) E/A ratio >2 with deceleration time <150 ms
B) Discordant ventricular filling pressures with RVEDP > LVEDP or respiratory
discordance
C) Pulmonary vein systolic filling reversal with inspiration
D) Equalization of diastolic pressures with "square root sign"
Correct Answer: B) Discordant ventricular filling pressures with RVEDP > LVEDP
or respiratory discordance
Rationale: Discordant filling patterns (RVEDP > LVEDP by >5 mmHg) or respiratory
discordance where LV and RV pressures move in opposite directions during respiration
is classic for constriction. Equalization alone can occur in restrictive cardiomyopathy.
Annulus reversus (medial e' < lateral e') on tissue Doppler is a specific echo finding for
constriction.
Q5. A 55-year-old with a HeartMate 3 LVAD presents with new intermittent audible
"beeping" and low flow alarms. What is the most urgent initial step?
A) Assess the pulsatility index and auscultate for abnormal rotor sounds
B) Obtain a stat echocardiogram
C) Increase pump speed by 500 RPM
D) Administer intravenous fluids
Correct Answer: A) Assess the pulsatility index and auscultate for abnormal
rotor sounds
Rationale: Low flow alarms in LVAD patients may indicate suction events, hypovolemia,
or pump thrombosis. Auscultation for abnormal rotor sounds and checking the
pulsatility index (low in thrombosis, high in suction events) guides the next steps. Speed
changes without diagnosis can worsen thrombosis or suction events.
Q6. Which endomyocardial biopsy finding is diagnostic of antibody-mediated
rejection (AMR) following heart transplantation?
, 4|Page
A) Grade 2R cellular rejection
B) C4d positivity on immunofluorescence with microvascular inflammation and
endothelial swelling
C) Quilty effect
D) Isolated myocyte necrosis without inflammatory infiltrate
Correct Answer: B) C4d positivity on immunofluorescence with microvascular
inflammation and endothelial swelling
Rationale: Antibody-mediated rejection is defined by complement fragment C4d
deposition in capillaries plus histologic evidence of microvascular injury (endothelial
swelling, macrophages). Cellular rejection grades are separate and based on
lymphocytic infiltration and myocyte necrosis. AMR requires specific treatment
including plasmapheresis and IVIG.
Q7. A patient with advanced HF has a peak VO₂ of 12 mL/kg/min on
cardiopulmonary exercise testing. What does this finding suggest?
A) Mild HF with excellent prognosis
B) Consideration for transplant evaluation
C) No therapy change needed
D) Contraindication to beta-blocker therapy
Correct Answer: B) Consideration for transplant evaluation
Rationale: Peak VO₂ <14 mL/kg/min (or <12 mL/kg/min if on beta-blockers) is a
threshold for advanced therapy referral and transplant evaluation. Peak VO₂ is the
most useful prognostic CPET variable in HF and guides transplant listing decisions.
Q8. Which medication class has been shown to improve survival and reduce
hospitalizations in HFpEF patients with LVEF ≥60% and obesity (BMI >35 kg/m²)?
A) Spironolactone
B) Semaglutide
C) Sacubitril/valsartan
D) Sildenafil
Correct Answer: B) Semaglutide
ABIM Advanced Heart Failure &
Transplant Cardiology (AHFTC)
Board Exam Review 2026
Comprehensive ABIM AHFTC review for the Advanced
Heart Failure & Transplant Cardiology certification and
MOC exams. Covers heart failure management (HFrEF,
HFpEF), mechanical circulatory support, heart
transplantation, pulmonary hypertension, and
cardiomyopathies. Includes board-style questions,
rationales, and high-yield topics aligned with the ABIM
blueprint. Ideal for cardiology fellows and physicians
preparing for the 2026 exam.
Q1. A 58-year-old man with non-ischemic cardiomyopathy (LVEF 25%) on optimal
GDMT presents with BP 85/50 mmHg, HR 110 bpm, cool extremities, and elevated
JVP. Which hemodynamic profile is most likely?
A) Profile A (warm and dry)
B) Profile B (warm and wet)
C) Profile C (cold and wet)
D) Profile L (cold and dry)
,2|Page
Correct Answer: C) Profile C (cold and wet)
Rationale: The presence of congestion (elevated JVP) and hypoperfusion (cool
extremities, narrow pulse pressure, hypotension) defines the wet-cold or "cardiogenic
shock" profile according to the Forrester and Stevenson classification. Profile C carries
the highest risk and often requires inotropes or mechanical circulatory support.
Q2. A 72-year-old woman with HFrEF (EF 30%) has a normal serum sodium,
creatinine 1.1 mg/dL, and BNP 850 pg/mL. Which additional biomarker provides the
strongest prognostic information for sudden cardiac death?
A) High-sensitivity troponin T
B) Galectin-3
C) Soluble ST2
D) Growth differentiation factor-15
Correct Answer: C) Soluble ST2
Rationale: Soluble ST2, a marker of myocardial fibrosis and ventricular remodeling,
independently predicts mortality and sudden cardiac death in HFrEF. While elevated
troponin also confers risk, ST2 has stronger additive prognostic value for sudden death
prediction, making it valuable for risk stratification.
Q3. A patient with advanced HF and QRS duration 170 ms with LBBB morphology on
ECG is receiving optimal medical therapy but remains NYHA III. What is the most
appropriate next therapy?
A) Implantable cardioverter-defibrillator (ICD) only
B) Cardiac resynchronization therapy with defibrillator (CRT-D)
C) Permanent pacemaker without defibrillation capability
D) Continued medical therapy optimization alone
Correct Answer: B) Cardiac resynchronization therapy with defibrillator (CRT-D)
Rationale: CRT improves survival and symptoms in HFrEF patients with LBBB and QRS
≥150 ms who remain symptomatic on GDMT. The addition of ICD capability (CRT-D) is
indicated for patients with NYHA II-III symptoms and EF ≤35%. Multiple trials
(COMPANION, CARE-HF, REVERSE) established CRT benefit.
,3|Page
Q4. Which hemodynamic finding on right heart catheterization is most characteristic
of constrictive pericarditis rather than restrictive cardiomyopathy?
A) E/A ratio >2 with deceleration time <150 ms
B) Discordant ventricular filling pressures with RVEDP > LVEDP or respiratory
discordance
C) Pulmonary vein systolic filling reversal with inspiration
D) Equalization of diastolic pressures with "square root sign"
Correct Answer: B) Discordant ventricular filling pressures with RVEDP > LVEDP
or respiratory discordance
Rationale: Discordant filling patterns (RVEDP > LVEDP by >5 mmHg) or respiratory
discordance where LV and RV pressures move in opposite directions during respiration
is classic for constriction. Equalization alone can occur in restrictive cardiomyopathy.
Annulus reversus (medial e' < lateral e') on tissue Doppler is a specific echo finding for
constriction.
Q5. A 55-year-old with a HeartMate 3 LVAD presents with new intermittent audible
"beeping" and low flow alarms. What is the most urgent initial step?
A) Assess the pulsatility index and auscultate for abnormal rotor sounds
B) Obtain a stat echocardiogram
C) Increase pump speed by 500 RPM
D) Administer intravenous fluids
Correct Answer: A) Assess the pulsatility index and auscultate for abnormal
rotor sounds
Rationale: Low flow alarms in LVAD patients may indicate suction events, hypovolemia,
or pump thrombosis. Auscultation for abnormal rotor sounds and checking the
pulsatility index (low in thrombosis, high in suction events) guides the next steps. Speed
changes without diagnosis can worsen thrombosis or suction events.
Q6. Which endomyocardial biopsy finding is diagnostic of antibody-mediated
rejection (AMR) following heart transplantation?
, 4|Page
A) Grade 2R cellular rejection
B) C4d positivity on immunofluorescence with microvascular inflammation and
endothelial swelling
C) Quilty effect
D) Isolated myocyte necrosis without inflammatory infiltrate
Correct Answer: B) C4d positivity on immunofluorescence with microvascular
inflammation and endothelial swelling
Rationale: Antibody-mediated rejection is defined by complement fragment C4d
deposition in capillaries plus histologic evidence of microvascular injury (endothelial
swelling, macrophages). Cellular rejection grades are separate and based on
lymphocytic infiltration and myocyte necrosis. AMR requires specific treatment
including plasmapheresis and IVIG.
Q7. A patient with advanced HF has a peak VO₂ of 12 mL/kg/min on
cardiopulmonary exercise testing. What does this finding suggest?
A) Mild HF with excellent prognosis
B) Consideration for transplant evaluation
C) No therapy change needed
D) Contraindication to beta-blocker therapy
Correct Answer: B) Consideration for transplant evaluation
Rationale: Peak VO₂ <14 mL/kg/min (or <12 mL/kg/min if on beta-blockers) is a
threshold for advanced therapy referral and transplant evaluation. Peak VO₂ is the
most useful prognostic CPET variable in HF and guides transplant listing decisions.
Q8. Which medication class has been shown to improve survival and reduce
hospitalizations in HFpEF patients with LVEF ≥60% and obesity (BMI >35 kg/m²)?
A) Spironolactone
B) Semaglutide
C) Sacubitril/valsartan
D) Sildenafil
Correct Answer: B) Semaglutide
