Both prognosis and quality of life are poor for severely symptomatic patients with stage D heart failure, and treatment options are limited. Few individuals are eligible for cardiac transplantation, and ventricular resynchronization therapy provides only marginal benefit in select patients. The aim of this Review is to highlight the promise of blood pumps in this setting. Circulatory support devices were first developed to act as a bridge to recovery in patients who had failed to wean from cardiopulmonary bypass. As blood pumps developed, they were used to support patients with cardiogenic shock until a donor heart became available. Implantable left ventricular assist devices were then shown to relieve heart failure symptoms and prolong life in patients ineligible for transplant. The limitations of first-generation device technology have meant that the development of an 'off the shelf' solution for advanced heart failure has been slow to progress. New rotary blood pumps already show much promise in this regard but have not yet been subject to rigorous clinical trials. Anecdotal evidence from 7.5 years of event-free survival in the first patient to receive a 'destination' axial flow pump permits justifiable optimism about the future of this approach. It is now time for real progress.