Training in heart failure can be segregated into 3 distinct and ascending or tiered levels of intensity. Level 1 represents the basic training and competency that every cardiology fellowship trainee must experience and demonstrate. Level 2 training represents a significant intensification of training, so that a trainee can subsequently focus some of his or her subsequent clinical activities on heart failure patients or research. Level 3 training offers competencies required for individuals specializing in advanced heart failure cardiology. Such competency includes advanced training in such areas as cardiac transplantation, ventricular assist devices, and heart failure disease management. Many programs will offer exposure sufficient to qualify the trainee for the UNOS designation of heart transplant physician in the Level 3 curriculum. Within this rapidly evolving field, in which new diagnostic and treatment modalities are emerging, over time, additional competencies may be warranted to supplement present training and competency standards. © 2008 American College of Cardiology Foundation.