BACKGROUND: Approximately one million individuals live with heart failure in the UK, and clinicians diagnose around 200 000 new cases each year. Although lifesaving treatments such as heart transplantation (HTx) and left ventricular assist device (LVAD) therapy exist, healthcare providers perform only about 325 of these procedures annually across the UK and Ireland. This gap suggests that many eligible patients do not receive appropriate referrals for HTx or LVAD. AIMS: The Transplant Cardiology Working Group conducted the inaugural UK and Ireland National Advanced Heart Failure Audit Report 2024 to promote quality improvement in caring for patients with advanced heart failure (AHF). This first international multicentre audit specifically examined referral patterns for HTx and LVAD therapies to the seven adult heart transplant centres across the UK and Ireland. RESULTS: The audit identified approximately 100 referrals per month for transplant or LVAD assessment. Adjusting for age eligibility, referral rates varied significantly by region, with some areas showing high referral levels and others substantially lower. The audit also found that a considerable number of referred patients had contraindications to HTx or LVAD therapy. Importantly, neither distance to the nearest transplant centre nor the deprivation level of the patient's postcode influenced referral likelihood, indicating that factors such as clinician awareness or local referral culture may drive variation. Additionally, women remain under-referred, comprising only one in three patients assessed for AHF therapies. CONCLUSION: This audit provides the first concrete evidence of widespread potential inequity in access to AHF therapies across the UK and Ireland. These findings have important implications for national healthcare planning, including workforce development and allocation of public health resources. Further work is required to investigate barriers to referral, enhance clinician awareness and optimise care pathways for patients in need of both life-prolonging and supportive therapies.