From innovation to implementation: expanding global access to mechanical circulatory support and heart transplantation.

Mechanical circulatory support (MCS) and heart transplantation are established therapies for advanced heart failure and cardiogenic shock. Technological advances have improved outcomes, including randomized evidence supporting the use of temporary MCS, such as percutaneous ventricular assist devices, in selected patients with ST-elevation myocardial infarction-related cardiogenic shock, alongside substantial gains in survival with contemporary durable left ventricular assist devices (LVADs). Despite this progress, access remains highly inequitable. Although global transplant activity has increased in recent years, heart transplantation remains concentrated in a small number of regions; historically, approximately 90% of procedures have been performed in North America and Western Europe. Similarly, temporary MCS use is largely limited to tertiary care centers, while durable LVAD use is concentrated in high-income settings. These disparities reflect differences in health system capacity across infrastructure, workforce, regulation, financing, culture, ethics, longitudinal follow-up, and data systems, as well as variation in health-system investment, language access, health literacy, and the completeness of registry-based data capture. In many resource-limited settings, fragmented care pathways lead to a "bridge to nowhere," where temporary support is initiated without access to definitive therapy. In this narrative review with scoping methods, we examine global variation in access to MCS and heart transplantation, map patient care pathways, and organize barriers into key system domains. We further synthesize potential solutions and propose a practical implementation roadmap spanning regionalized shock systems, durable MCS referral and follow-up networks, donor management infrastructure, workforce development, health financing strategies, and registry-based quality improvement.