Recommendations for concomitant cardiac condition including arrhythmias
Recommendation   Class   Level   References
Aortic valve and root diseases
Biological valve replacement in patients with more than mild aortic insufficiency should be considered.  IIa  B  [68, 69]
Application of a central leaflet coaptation stitch may be considered in patients with more than mild aortic insufficiency.  IIb  B  [68–70]
Closure of aortic valve in patients with more than mild aortic insufficiency is not recommended.  III  C  [68, 69]
It is recommended that a functional bioprosthesis be left in place.  I  C  [69, 71]
Replacement of a mechanical aortic valve with a biological valve is recommended.  I  C  [69, 71]
Closure of mechanical aortic valves is not recommended.  III  C  [68, 69]
Surgical correction of an ascending aorta aneurysm at the time of implantation of a ventricular assist device should be considered.  IIa  C  [70]
Mitral valve disease
Correction of moderate or severe mitral stenosis of any cause (including transcatheter interventions) is recommended.  I  C  [71, 72]
In selected patients, the repair of severe mitral insufficiency may be considered.  IIb  C  [73–75]
Exchange of a functional mitral mechanical or biological prosthesis at the time of long-term mechanical circulatory support device implantation is not recommended.  III  C  [71]
In patients previously treated with a MitraClip, a thorough evaluation to rule out the existence of mitral valve stenosis is recommended.  I  C
Tricuspid valve disease and right ventricular dysfunction
Correction of severe tricuspid stenosis at the time of long-term mechanical circulatory support implantation is recommended.  I  C
Re-evaluation of patients with moderate to severe tricuspid regurgitation after treatment with diuretic therapy, if condition permits, is recommended.  I  C  [76]
In carefully selected patients, tricuspid valve repair for moderate to severe tricuspid regurgitation at the time of long-term mechanical circulatory support implantation may be considered.  IIb  C  [77–80]
Implantation of a biventricular assist device or a total artificial heart in patients with severe tricuspid regurgitation and right ventricular dysfunction may be considered.  IIb  C  [81]
Intracardiac shunts
Closure of a patent foramen ovale, either percutaneously or at the time of LT-MCS implantation, is recommended.  I  C  [71]
Depending on the shunt volume, closure of an iatrogenic atrial septal defect after trans-septal intervention is recommended.  I  C
Intensive use of transoesophageal echocardiography in the operating room directly after LT-MCS implantation is recommended.  I  C  [71, 72]
Closure of a ventricular septal defect during LT-MCS implantation is recommended.  I  C
In patients with an unrepairable ventricular septal defect, LT-MCS implantation is not recommended.  III  C  [71]
Arrhythmia
Medical or surgical intervention (according to European Society of Cardiology/European Heart Rhythm Association, Heart Rhythm Society Guidelines) for atrial tachyarrhythmia is recommended.  I  C  [79, 82, 83]
Routine implantation of an implantable ICD for primary prophylaxis before long-term mechanical circulatory support implantation is not recommended.  III  C  [84]
In patients with an ICD, preoperative evaluation of a possible ventricular assist device–ICD interaction may be considered.  IIb  C  [85]
Concomitant VT ablation during long-term mechanical circulatory support device implantation in patients with a history of frequent VTs may be considered.  IIb  C  [86, 87]
In patients with refractory, recurrent VT/ventricular fibrillation in the presence of an untreatable arrhythmogenic substrate (e.g. giant cell myocarditis or sarcoidosis), implantation of a biventricular assist device or a total artificial heart should be considered.  IIa  C
Intracardiac thrombus
Echocardiography, computed tomography or magnetic resonance imaging in patients suspected of having an intracardiac thrombus is recommended.  I  C  [71]
In patients with atrial fibrillation, due to the increased risk of thromboembolism from the LAA, a transoesophageal echocardiogram should be considered.  IIa  C  [72]
In patients with atrial fibrillation, LAA closure may be considered.  IIb  C  [88]
If a left atrial or ventricular thrombus is present, inspection and removal of the thrombus are recommended.  I  C
If an LAA thrombus is present, occlusion of the LAA should be considered.  IIa  C
Although RV and RA thrombi are less common, cardiac imaging to exclude them, in particular before implantation of an RVAD, should be considered.  IIa  C  [71]
In case of implantation of a left ventricular assist device, removal of an RV thrombus may be considered.  IIb  C
In case of RVAD implantation in the RA, removal of an RV thrombus may be considered.  IIb  C
In case of RVAD implantation in the RA, removal of an RA thrombus is recommended.  I  C
In case of RVAD implantation in the RV, removal of an RV thrombus is recommended.  I  C
Miscellaneous conditions
A left thoracotomy approach may be considered in patients who have had prior cardiac surgery.  IIb  C  [89]
LT-MCS implantation in patients who have active infective endocarditis is not recommended.  III  C  [33]
Postponement of an LT-MCS implant may considered in patients who have had a recent myocardial infarction affecting the left ventricular apex if the situation allows.  IIb  C  [90]
Surgical or interventional revascularization at the time of LT-MCS implantation may be considered in patients with right ventricular ischaemia.  IIb  C
ICD: implantable cardioverter defibrillator; LAA: left atrial appendage; LT-MCS: long-term mechanical circulatory support; RA: right atrium; RV: right ventricle; RVAD: right ventricular assist device; VT: ventricular tachycardia.