Ivan Netuka, MD, PhD, chair of the department of cardiovascular surgery at the Institute for Clinical and Experimental Medicine in Prague, explains how and when to bridge to decision or left ventricular assist device (LVAD). He explains that what is needed in the bridge to decision strategy is adequate or even supra-maximal blood flow, a sufficient time window of opportunity, verstatility across uni- and biventricular support across phenotypes, efficient left ventricular unloading, timely and active rehabilitation, and right ventricular optimization and assessment for chronic LVAD physiology.