Taking care of patients with LT-MCS as a destination therapy can be more difficult than taking care of HTx candidates or HTx patients [501–504]. Factors that can complicate advanced HF management such as ageing-related comorbidities, end-organ damage, cognitive impairment, frailty and limited social support are compounded by risk of MCS failure and MCS-related complications such as bleeding, infection and stroke. As a result, LT-MCS is associated with repeated hospitalizations and a high rate of caregiver burnout. The unpredictable course of advanced HF, differences among LT-MCS devices and a limited evidence base can further complicate shared decision-making, preparedness planning and EOL care [503].