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Evolution of Left Ventricular Assist Device Therapy for Advanced Heart Failure: A Review. Importance: The mortality rate for the most advanced forms of heart failure with medical therapy alone remains unacceptably high at 30% to 80% at 1 year. In the past decade, left ventricular assist devices have assumed an increasingly prominent role in the management of these patients. This review included all English-language articles published over the past 15 years on left ventricular assist devices. Search topics focused on advanced heart failure and ventricular assist devices, including volume of implantations, patient selection, complications, cost, and recovery of function. The search also included all published clinical trials or reports of cohort studies as well as registry data. Observations: There has been significant progress in nearly all aspects of left ventricular assist device therapy, from patient selection to device design and postoperative management. Percutaneous devices have been developed to facilitate rapid deployment and provide short-term hemodynamic support. The devices have transitioned from pulsatile to continuous flow design and are now smaller, with enhanced durability more suited for long-term support. The mean survival following left ventricular assist device implantation is nearly 5 years. However, some complications, including bleeding, infection, pump thrombosis, and stroke, limit the potential of the therapy. There are many innovations now under investigation that promise to further improve outcomes and enhance patient satisfaction. Conclusions and Relevance: Advanced or end-stage heart failure remains a major health care problem in terms of both patient morbidity and mortality as well as cost. Physicians and health care professionals need to become aware of the significant progress in the field of mechanical support of circulation with the use of ventricular assist devices.