Advanced heart failure (HF) is defined as the presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy. Although roughly 5–10% of all HF patients have chronic advanced HF, this group of patients is required more intensive medical treatment, frequent hospitalization, long hospital stay and sophisticated device therapy including noninvasive mechanical ventilation, short and long term mechanical support device or heart transplantation. There are many difficulties in clinical practice in the management of advanced HF patients, including resistant congestion, hyponatremia, worsening renal functions, pulmonary hypertension, frailty, cognitive impairment and comorbidities. Some complicated advanced HF patients are required to be referred to HF clinics for consideration of further therapeutic options. In this paper, commonly encountered problems and management strategies for advanced HF patients in real life clinical practice have been addressed in the form of expert opinions based on the available data in the literature.