Abstract Objective To determine the impact, unmet needs and the role of left ventricular assist device (LVAD) treatment as destination therapy (DT) of heart failure (HF) in Belgium. At the moment, LVAD is only approved as “bridge to transplant” since health economical analysis calculated an unacceptable high price per QALY (84.00€). Design Retrospective epidemiological study on HF. Setting and parameters Parameters in advanced HF for Belgium, the UK (both non-DT adopters), Germany and the Netherlands (DT policies) are compared. Heart transplant (HTx) rates were consulted from (inter)national transplant organisations; implantation rates were requested from the 2 manufacturers.To quantify the impact of HF in Belgium, indirect measures on hospital admission were obtained by using the International Codes of Disease. Equity between HF and oncology was assessed by analysing approval of novel treatments. Timeframe is from 2009 till 2018. Results The last 10 years, mean HTx rates per million inhabitants are 6.8 in Belgium, 3.8 in Germany, 2.4 in the Netherlands and 2.5 in the UK. Transplant waiting lists are progressively exceeding the number of transplants – except in Germany. Combination of HTx and LVAD use show distinct patterns in advanced HF, with a 3-fold difference between the highest user (15,1: Germany in 2017) compared to the lowest user (4,9: UK in 2016). The need for advanced HF therapies is calculated at 14.9 per million. 8 additional LVAD implants were required in Belgium in 2018 to reach this goal. ICDcodings in Belgium show an upwards trend, indicating that the burden of HF is increasing in Belgium. Cardiovascular diseases are still the most important cause of death in Belgium according to the latest OECD report. From 2009 till 2016, 100 new cancer drugs were approved by the EMA. Only 18 of them showed a significant survival benefit as compared to standard treatment. From them, only 1 (trastuzumab) was evaluated in a health economical assessment for the Belgian health care system. Conclusions There is a ...