Advanced heart failure requires a different evaluation from routine heart-failure care. When symptoms, recurrent decompensation or organ dysfunction remain severe despite optimized treatment, a specialist center may assess whether mechanical circulatory support, heart-transplant evaluation or another advanced strategy is appropriate. LVAD implantation and heart transplantation are related but distinct pathways: a ventricular assist device may be used as a bridge to recovery, decision, candidacy or transplantation, or as long-term destination therapy, while transplantation requires a separate multidisciplinary assessment and possible registration on the Eurotransplant waiting list.
Referral should happen before irreversible deterioration
The 2026 ESC heart-failure guidance treats advanced heart failure as a dedicated stage requiring timely specialist referral. Evaluation is not triggered by a single ejection-fraction value alone. Recurrent hospitalizations, persistent severe symptoms despite guideline-directed treatment, progressive kidney or liver dysfunction, intolerance of therapy, low output, escalating support needs and other markers can prompt referral to an advanced-heart-failure center.
- Recent echocardiography and cardiac imaging
- History of heart-failure admissions and decompensations
- Current heart-failure medication with doses and tolerability
- Rhythm history, ICD/CRT records and device interrogations when relevant
- Coronary, valve and cardiomyopathy investigations
- Kidney, liver and pulmonary function
- Functional capacity such as exercise testing when available
Mechanical circulatory support and transplantation answer different questions
A durable ventricular assist device supports circulation mechanically. German centers describe several possible goals, including bridge to recovery, bridge to decision, bridge to candidacy, bridge to transplant and destination therapy. Heart transplantation replaces the failing heart with a donor organ and therefore depends on transplant eligibility, donor-organ availability and allocation rules in addition to surgical suitability. An advanced-heart-failure team should compare these pathways rather than presenting them as interchangeable packages.
LVAD evaluation includes anatomy, organ function and the ability to manage long-term device care
LVAD candidacy is individualized. Teams assess the pattern of ventricular failure, right-heart function, valve disease, infection risk, bleeding and thrombotic risk, kidney and liver function, frailty, neurological status and the patient's ability to manage the device and follow-up. Implantation creates an ongoing care pathway involving device checks, wound and driveline care, medication management and rapid access to experienced clinicians if alarms or complications occur.
Heart-transplant evaluation is not the same as joining the waiting list
A transplant center first determines whether transplantation is medically appropriate and whether contraindications are present. DHZC describes a broad work-up including cardiac testing, other-organ assessment, infection screening, tumor screening, vaccination and psychosocial evaluation. The center then decides whether a patient can be registered. Evaluation therefore does not guarantee listing, and listing does not guarantee that a donor heart will become available.
Eurotransplant allocation cannot be treated as a self-pay booking
Germany participates in Eurotransplant. Transplant centers register eligible patients in the central system, and when a donor organ becomes available Eurotransplant generates a match list using medical and allocation criteria. Eurotransplant states that a patient from outside its member region who needs a transplant must be referred by the treating physician to a transplant center in a member country; that center assesses the patient and decides whether registration on the waiting list is appropriate. The ability to pay for treatment does not replace these eligibility and allocation steps.
Documents for an international advanced-heart-failure review
The first useful goal is a specialist review of the existing disease course rather than travel for a predetermined operation. Send records through the official secure route requested by the center.
- Concise cardiology summary and exact referral question
- Recent echocardiography and cardiac MRI or CT when available
- Coronary angiography or other coronary assessment when performed
- Right-heart catheterization and exercise-test results when available
- Current medication list and previous intolerance or contraindications
- ICD, CRT, pacemaker or prior mechanical-support records
- Recent kidney, liver, blood-count and relevant infection results
- Previous cardiac surgery or intervention reports
- Current functional status and recent hospital-discharge summaries
Long-term care must be feasible after the German evaluation or procedure
Both LVAD therapy and transplantation require intensive long-term follow-up. LVAD patients need device and anticoagulation or antithrombotic management according to the implanted system and individual plan. Transplant recipients require lifelong immunosuppression and close surveillance for rejection, infection and other complications. International patients should confirm who will provide routine and emergency follow-up after returning home before committing to an advanced pathway in Germany.
Sources and review
Sources last reviewed 2026-09-11.
- 2026 ESC Guidelines for the management of heart failure — European Society of Cardiology ↗
- Before heart transplant – indication, diagnostics and listing evaluation — German Heart Center at Charité (DHZC) ↗
- Artificial hearts and ventricular assist devices — German Heart Center at Charité (DHZC) ↗
- Heart-support systems – bridge and destination strategies — Heidelberg University Hospital ↗
- Transplant and artificial-heart outpatient clinic — Hannover Medical School (MHH) ↗
- Eurotransplant allocation and waiting-list process — Eurotransplant ↗
- Eurotransplant guidance for patients outside the member region — Eurotransplant ↗