Patient selection for durable mechanical circulatory support: contemporary statement

Advanced heart failure (HF) remains a growing clinical challenge, while the limited availability of donor organs has increased the importance of mechanical circulatory support (MCS) as a therapeutic option. Patient selection for MCS implantation, together with decisions regarding the optimal timing and choice of device, has become one of the most critical issues in contemporary heart failure management. Despite robust evidence demonstrating significant improvements in survival and quality of life following implantation of durable mechanical circulatory support (dMCS) devices, only a small proportion of eligible patients receive this therapy in many countries, including Bulgaria. The reasons are multifactorial and include death before referral, advanced irreversible end-organ dysfunction, socioeconomic barriers, and patient refusal. Decision-making is highly complex because every candidate presents unique clinical characteristics requiring comprehensive diagnostic evaluation and preoperative optimization. Final patient selection should be based on structured multidisciplinary discussion within a specialized advanced heart failure team, following clearly defined principles and evidence-based recommendations. The aim of this review is to provide a practical framework for clinicians involved in the management of advanced heart failure, enabling appropriate assessment of individual patient characteristics, definition of the therapeutic intent of durable mechanical circulatory support, and determination of the optimal timing for device implantation.