Surgical support in end-stage heart failure, either MCS or a heart transplant, will remain an ongoing topic in cardiology [7]. However, current management is not often guided by the best medical option but rather by feasibility because human donors are ‘limited’ and grafts are scarce. Additionally, a heart transplant requires international coordination, established transplant centres with considerable experience and close collaboration with practicing cardiologists. Because of the scarcity of organs in some areas, there has been a recent structural shift in the indication towards MCS in the management of end-stage heart failure.