**8. Ventricular assistant devices**

Despite multiple logistic challenges, Ventricular Assistant devices (VADs) as bridge to transplantation have been adopted in many countries across the Middle East region in parallel with other regions in the world. From the real-world data analysis, Heart pumps in Middle East and Africa region are expected to grow with the highest growth rate in the forecast period of 2022 to 2029 due to the upsurge of growing heart awareness campaigns. The heart pump segment in Saudi Arabia is dominating the Middle East and Africa's left ventricular assist device (LVAD) market due to the increasing implantation of mechanical circulatory support devices.

For example, mechanical circulatory support (MCS) program was launched at King Faisal Hospital in Saudi Arabia, 20 years ago. Along with the other two centers that have implanted durable MCS devices as destination therapy, reaching almost a total of 45 durable LVADs per year. Besides, it remains the main heart transplant center in the Middle East, reaching 35 transplants per year with 89% 1-year survival. Other Gulf countries namely Qatar & UAE surged to embrace VADs as treatment strategies as well [31].

In Lebanon, Beirut Cardiac Institute is considered the main local institute that has the widest experience in LVAD in Lebanon, from 2010 to December 2019, 78 patients had different types of VADs, a total of 82 pumps with 4 patients needed an exchange of the pump the reported 12-month survival was 80%, with 75% survival at 18months, an outcome like the IMACS (International Registry for Mechanically Assisted Circulatory Support) data [32].

Meanwhile, unique challenges complicating the flourishing of such programs also might affect the outcome is the fear of device management at home, on the other hand, in Europe and the US almost every patient is discharged from the hospital awaiting heart transplantation. Also, the burden of other health-related quality of life such as social interaction and Job stability are other important factors that impact decision-making and the future after VADs implantation [33].
