| Summary: | Background: New therapies with prognostic benefits have been recently introduced in heart failure with reduced ejection fraction (HFrEF) management. The aim of this study was to evaluate the prognostic power of current listing criteria for heart transplantation (HT) in an HFrEF cohort submitted to cardiopulmonary exercise testing (CPET) between 2009 and 2014 (group A) and between 2015 and 2018 (group B). Methods: Consecutive patients with HFrEF who underwent CPET were followed-up for cardiac death and urgent HT. Results: CPET was performed in 487 patients. The composite endpoint occurred in 19.4% of group A vs. 7.4% of group B in a 36-month follow-up. Peak VO<sub>2</sub> (pVO<sub>2</sub>) and VE/VCO<sub>2</sub> slope were the strongest independent predictors of mortality. International Society for Heart and Lung Transplantation (ISHLT) thresholds of pVO<sub>2</sub> ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers) and VE/VCO<sub>2</sub> slope > 35 presented a similar and lower Youden index, respectively, in group B compared to group A, and a lower positive predictive value. pVO<sub>2</sub> ≤ 10 mL/kg/min and VE/VCO<sub>2</sub> slope > 40 outperformed the traditional cut-offs. An ischemic etiology subanalysis showed similar results. Conclusion: ISHLT thresholds showed a lower overall prognostic effectiveness in a contemporary HFrEF population. Novel parameters may be needed to improve risk stratification.
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