Over 30,000 ventricular assist devices (VADs) have been implanted worldwide in the past decade. Continuous-flow VAD therapy has realized greater durability and improved survival. Both axial and centrifugal flow devices are approved for the treatment of chronic and refractory advanced heart failure. Patients waiting for transplants that are ‘bridged’ and transplant-ineligible patients (destination therapy), receive VAD therapy. One-year survival rates are now approximately 80% and 70% at 2 years. The advent of continuous-flow VADs replaced volume displacement pulsatile VADs and numerous adverse events related to lack of circulatory pulsatility became recognized and prevalent as VAD therapy proliferated. Common adverse events include driveline infection, device infection, haemorrhagic and embolic stroke, bleeding, aortic insufficiency, and VAD thrombosis. Current VAD therapy requires systemic anticoagulation and antiplatelet therapy. A lack of donor hearts has resulted in prolonged and frequent VAD therapy in transplant candidates. Careful selection of VAD candidates is imperative and requires careful risk stratification. New VAD models with technological advances will enhance patient acceptance of VAD therapy and lead to further expansion in advanced heart failure patients.