While heart transplant still predominates as the gold standard final therapy for patients with end-stage heart failure in the United States, the idea of durable mechanical support as a bridge to transplant has gained considerable momentum. With the FDA approval of left ventricular assist devices in 1994 and the approval of total artificial heart in 2004 as a bridge to transplantation, the use of both types of devices is used in supporting end-stage heart failure patients to transplant. As a result, the concept of durable support for transplants has departed in two distinct pathways based on whether the patient requires univentricular or biventricular support to survive the transplant. Due to severe left ventricular failure being more prevalent than severe right ventricular failure or biventricular failure, the growth of the use of univentricular support as a bridge to transplant has surpassed the use of biventricular support. However, the development of right ventricular failure and its associated mortality post left ventricular assist device implant poses a significant concern, suggesting that our pre-implant ability to identify the presence or absence of biventricular failure is, at best, limited. Furthermore, with rapid technological advances, the idea of these two devices becoming serious contenders to take the gold standard spot from heart transplant to offer a final therapy can become a reality. With the additional evolution of xenotransplantation, we are at a pivotal period in establishing more reliable treatment options for patients with end-stage heart failure. Whether univentricular support, biventricular support, or xenotransplantation becomes an alternative for orthotopic heart transplantation remains to be seen. This chapter explores the clinical situations where biventricular support as a bridge to transplantation may be warranted as an option. It analyses the difficulties and challenges in making sound decisions that benefit patients requiring advanced therapies.