Drakos [48] outlined the survival advantage of a heart transplant over a VAD in an editorial comment by matching International Society for Heart and Lung Transplantation survival data of adult patients receiving transplants in 2010–2012 with survival curves from the study ‘Results of the Destination Therapy Post-Food and Drug Administration Approval Study With a Continuous Flow Left Ventricular Assist Device’ (Fig. 4). The included VAD data (mainly derived from early generation VAD trials) are followed by better data from the next-generation LVAD—currently seen in the MOMENTUM-3 trial [13]. These new VAD data comprising more favourable adverse event-free survival and overall survival rates are comparable with survival rates in the first 2 years after a heart transplant. But these results still neglect the constant threats associated with an MCS (e.g. bleeding, thrombosis and infection) especially in the following years in which the adverse event rate after the transplant is extremely beneficial. Thus, younger patients with missing contraindications definitely profit more from a heart transplant as destination therapy, whereas permanent MCS should be considered in older cohorts or in patients with limited prognoses [49].