The prospects for long-term mechanical circulatory support are improving. Axial flow pumps are a promising competitor to pulsatile first-generation LVADs, although the two may serve different patient populations. Centrifugal pumps are in the development phase and seem to require less anticoagulation. Clinical experience has established the safety of diminished pulse pressure circulation, and mechanical unloading appears to promote recovery of the native left ventricle. Under these circumstances, true left ventricular assist is preferable to ventricular replacement and detailed medical management improves patient outcomes. Further clinical trials of destination therapy are indicated and must use more reliable blood pumps implanted before terminal decline into multiorgan failure.