**1. Introduction**

Heart failure (HF) is a global pandemic that has been increasing in prevalence. It affects 3.6 million people in Europe and 5 million in the United States (US) annually. Left ventricular assist devices (LVADs) were first introduced as a bridge to orthotopic heart transplant (OHT) and subsequently progressed into a viable long-term therapeutic option [1]. With prevalence now approaching 2% in the US and Canada and

hospitalization rates as high as 3%, it comes as no surprise that \$30.7 billion was spent annually in the US alone managing this critical diagnosis. Further, the cost is expected to exceed \$70 billion by 2030 [2, 3].

Varying stages of HF come with progressively more severe disability for the patient and a progressively increasing need for more social support. End-stage heart failure leads to significantly higher morbidity with loss of autonomy and increasing societal costs [4]. OHT remains the gold standard for end-stage HF as it still boasts the most longevity when there is a favorable surgical outcome. Due to the limited availability of organs, many contraindications limit the eligible recipient pool greatly. Some of these include age greater than 70 years, severe pulmonary hypertension, severe lung disease, severe infection, viral infections with organ damage, a history of cancer, severe neurological deficits, psychiatric illness, current tobacco or recreational drug use, multisystem disease with poor long term survival, and many more [5]. For patients who are not ideal OHT candidates, LVAD remains an option, with a mean survival now surpassing 7.1 years [6]. For some patients, LVADs may serve as a bridge to transplantation, while for others it may be a final destination therapy. For those that are not LVAD candidates, those with severe right ventricular failure, restrictive or hypertrophic cardiomyopathy, left ventricular end-diastolic dimension <4.5 cm, or contraindications to anticoagulation, a palliative care referral is indicated [7].
