Advanced heart failure (HF) is a huge problem. First, advanced HF is highly prevalent, particularly in older age groups, the very groups that are now starting to dominate the populations of the developed world. Second, advanced HF is expensive, accounting for a significant proportion of GDP healthcare spending in developed counties. The majority of the cost is spent on a combination of medical therapy, hospital admissions and the dramatic increase in the use of biventricular pacemaker and defibrillators in HF. Third, this condition remains highly lethal despite medical and pacemaker/defibrillator therapy, with an estimated 1-year freedom from hospitalisation or death as low as 32.9% in one study.1

For decades, heart transplantation has remained the only long-term treatment option for a minority of patients with advanced HF. The REMATCH trial2 marked the emergence of left ventricular assist devices (LVAD). Groundbreaking as the trial was, it did not detract clinicians and patients from the ultimate goal of heart transplantation. The term ‘bridge-to-transplant (BTT)’ was coined to describe the intention to mechanically support a transplant-eligible patient to heart transplantation, typically within 6 months to a year. This time frame was relevant due to the limited durability of the most commonly used device, the HeartMate XVE (Thoratec, Pleasanton, California, USA), at that time, but has been rendered almost irrelevant as the current generation of LVAD (eg, HeartMate II by Thoratec) has supported patients for over 9 years without the need for pump exchange.

It was inevitable that the improving clinical outcomes would lead to the use of LVAD therapy as so-called ‘destination therapy’. This term was coined to describe the use of mechanical circulatory support in transplant-ineligible patients. …