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Background Heart failure (HF) is the commonest cause of pleural effusions, and up to 10% are resistant to medical therapy. The current standard care for resistant effusions is recurrent therapeutic thoracentesis (TT). Indwelling pleural catheters (IPCs) plus talc improve pleurodesis rates in malignant pleural effusions. This is the first randomised study to examine daily drainage and talc instillation via IPC in cardiogenic pleural effusions.Aims To assess the feasibility of a full-scale trial of recurrent TT vs IPC insertion, daily drainage and talc instillation across 12 UK centres. The primary outcome was feasibility, defined as recruitment of 80% of the target of 40 patients and ≥50% eligible patients.Methods Adult patients with a resistant HF-related pleural effusion were eligible for randomisation. Participants were randomised 1:1 in a non-blinded fashion to receive recurrent TT or IPC, daily drainage, and talc. The follow-up period was 12 weeks.Results Of the 231 patients screened, 43 met eligibility criteria. Furosemide up titration and SGLT2i addition were the most common changes in the 47 patients deemed ineligible due to medical optimisation. 18 (42%) patients were randomised, with a median age of 79 (IQR 70–83) and a median Clinical Frailty Score of 6 (IQR 5–7). Eight patients completed follow-up, with five deaths and five withdrawals. Pleurodesis was reported in 3/8 (38%) in the IPC group and 0/10 in the TT group. Total pleural procedure numbers were lower in the IPC group (1.0:2.2, p<0.001). Median reduction of dyspnoea at 4 weeks (on 100 mm scale) was 58 mm in the IPC group; 40 mm in TT(p=0.247). A higher complication rate was observed in the IPC arm.Abstract S150 Figure 1Conclusions The study did not meet the feasibility threshold. Patients with resistant HF effusions are elderly and frail, with limited life expectancy. Advances in medical HF management may have reduced the incidence of symptomatic HF effusions requiring recurrent drainage - a notable proportion of screened patients in this study were managed successfully with medical approaches. In persistently symptomatic patients, IPC/talc was a potentially beneficial management strategy; however, medical management with TT remains standard care.