Despite extensive research and great strides over the past 40 years, the ideal permanent mechanical assist device remains elusive. The incidence of heart failure is increasing, and the number of heart transplants has remained constant. The HeartMate and Novacor are two pulsatile, long-term ventricular assist devices (VADs) commonly used as a bridge to transplantation. Randomized Evaluation of Mechanical Assistance in the Treatment of Congestive Heart Failure is a randomized study of device therapy in heart failure with treatment either with device (HeartMate) therapy or maximal medical therapy which was recently completed and demonstrated a Kaplan-Meier survival rate at 1 year of 52% for the device group compared to 25% in the medical therapy group. The TCI HeartMate is the only device approved for destination therapy, while others such as the Novacor device are in the process of evaluation. Most of these devices are still plagued by mechanical problems, bleeding, thromboembolism and infection. Other promising new devices include smaller VADs using impeller pump technology, such as the Arrow LionHeart, Micromed Debakey pump and Jarvik 2000 pump. The CardioVAD is an interesting chronically implantable balloon pump inserted into the descending thoracic aorta. While experience with the newer implantable pumps is growing, most of them require some manipulation of the heart perioperatively, in addition to anticoagulation postoperatively and careful monitoring for complications and infection.