The 1950s, 1960s, and 1970s saw the transition of mechanical circulatory support (MCS) from the necessary extension of cardiopulmonary bypass to the development of durable devices. Within the last 20 years, enhanced pumps as well as surgical and medical experience have allowed MCS to become a routine part of the armamentarium for treating heart failure patients. Most recently, within the last 10 years, there has been a dramatic shift from the use of large, pulsatile left ventricular assist devices (LVADs) to smaller continuous flow devices. In this chapter, the current state of MCS for treating advanced heart failure as well as the detail of the surgically related issues with LVADs are reviewed.