Aims Management of advanced heart failure (HF) remains challenging despite specific sections in the 2021 European Society of Cardiology/Heart Failure Association (ESC/HFA) guidelines, with delays in referrals exacerbating the issue. This study aimed to evaluate the awareness and implementation of these guidelines among cardiologists and identify barriers to effective referral. Methods and results From June to October 2023, an online survey was disseminated through the ESC mailing list, targeting cardiologists across Europe. The survey investigated four areas: guideline awareness, healthcare network organization, clinical case management, and perceptions of mechanical circulatory support (MCS) outcomes. Respondents were categorized into heart failure cardiologists (HFCs), general cardiologists (GCs), and other participants (OPs). Among 497 respondents, 25% were heart HFCs, 40% were GCs, and 35% were OPs. A total of 84% of HFCs reported a high level of guideline knowledge, compared to 57% of GCs and 62% of OPs ( p < 0.001). Additionally, 76% of HFCs ‘regularly or always’ used ESC/HFA criteria to identify advanced HF, compared to 44% of GCs and 48% of OPs ( p < 0.001). Correct responses regarding the recommendation class for heart transplantation were 84%, 55%, and 60% ( p < 0.0001), and for MCS as a bridge to transplantation, 69%, 65%, and 55% ( p = 0.018) among HFCs, GCs, and OPs, respectively. Referring patients with severe HF to a tertiary centre team was found to be ‘very difficult’ or ‘difficult’ by 8.4% of HFCs, 19.6% of GCs, and 18.2% of OPs ( p = 0.0005). Conclusion The study highlights significant disparities in knowledge and application of advanced HF guidelines among cardiologists, revealing an opportunity for educational initiatives. The difficulty in referring patients to tertiary centres underscores the need to improve the referral pathway for advanced HF patients.