The incidence of heart failure keeps rising in our aging population, with an estimated prevalence of 2% in American adults over 20 years of age. Left ventricular systolic failure carries a grim prognosis, with a 5-year survival rate of ~50%. In cases of end-stage heart failure in adult patients, the 1-year survival rate is <10%. In addition, the rate of heart donation has not kept up with the rising rate of new patients added to the transplant waitlist. This has necessitated the technology of mechanical circulatory support (MCS) to keep pushing the boundaries of durability and reliability, so that patients can survive successfully to a transplant. Multiple temporary or durable mechanical support devices (MCS)Multiple temporary or durable mechanical support devices (MCS) have emerged as viable bridge-to-transplant options in waitlisted patients. While temporary MCS devices are placed as a bridge to alternative therapy, traditionally, the durable left ventricular assist devices (LVAD) were implanted after defining the actual intent of implantation – as a bridge to transplant or as destination therapy. The intent could be maintenance of survival until other therapeutic options become available or possible, which would then replace the LVAD as the predominant means of survival. On other occasions, the LVAD is the destination and the means for survival. However, in the modern era, the intent of using LVAD is often dynamic and the strategy for treatment can change according to the patient’s response to the LVAD and medical therapy. The improvement in the durability of LVAD has improved the duration and quality of life for patients with advanced heart failure, further necessitating a more insightful conversation of therapies beyond LVAD with the patients. In the modern era of long-term durable mechanical unloading and introduction of new potent heart failure agents, the promise of myocardial recovery to LVAD explantation has become a more preferable and viable option. Reversal of the remodeling may be possible by changing the course of the pathological mechanisms set into action by the initial insult. It is being realized that the adverse hemodynamic and structural effects associated with end-stage heart failure can actually be reversed through astute use of mechanical unloading and targeted medical therapy. Patients have experienced significant overall recovery of myocardial function and ability to sustain their recovery through continued medical therapy alone. Such patients can return to a normalcy in their lives without requiring transplantation, thus, even questioning what truly comprises “end-stage” heart failure. Similarly, patients previously ineligible for transplant due to various medical or social reasons are now being offered the opportunity for heart transplant through valuable time afforded by the MCS devices to prove candidacy through interim correction of their limitations. All the above factors have resulted in a dynamic transformation in our understanding and utilization of MCS support recently. Even the definition of temporary circulatory support has undergone an overhaul. More MCS devices are being introduced that can provide ambulatory support through methods thought only for hospitalized patients. The distinction between durable and temporary support is becoming obscure as the technology keeps advancing. The patient demographics and acuity of presentation have also evolved over the years, which has resulted in a change in the distribution and characteristic of patient outcomes post-LVAD implantation. This chapter will detail the evolution of outcomes after MCS device therapy.