Durable LVAD therapy in end-stage methamphetamine-associated heart failure: a case report of the bridge to opportunity and transplant candidacy.

Background: Methamphetamine-associated heart failure (MAHF) is an increasingly recognized cause of severe non-ischaemic cardiomyopathy with a 231% rise in hospital admissions from 2008 to 2020. MAHF is associated with high morbidity and mortality, and advanced therapy options are challenged by substance use and addiction. Case summary: A 40-year-old male with advanced MAHF and active substance use presented with out-of-hospital cardiac arrest requiring escalating temporary mechanical circulatory support and ultimately durable left ventricular assist device (LVAD) placement as a bridge to candidacy strategy. After 6 months of documented abstinence from substances and engagement in outpatient addiction medicine treatment, his Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) score had improved from 53 to 23, reclassifying him from a 'poor' to 'minimally acceptable' transplant candidate. He underwent successful cardiac transplantation and continues to be abstinent at 21 months post-transplantation. Discussion: This case demonstrates that active substance use represents a modifiable rather than absolute barrier to cardiac transplantation when addressed through a structured multidisciplinary framework, the bridge to opportunity. In the bridge to opportunity, durable LVAD implantation allowed for the haemodynamic support for a patient with end-stage MAHF to engage in outpatient addiction medicine care and demonstrate sustained sobriety. Ethical concerns regarding equitable organ allocation are best addressed through individualized psychosocial risk stratification using validated tools such as the SIPAT, rather than categorical exclusion of patients with substance use disorders. The bridge to opportunity is a reproducible model for appropriately resourced multidisciplinary transplant programmes and appropriately selected patients.