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