Durable left ventricular assist devices (LVADs) have transformed care for patients with end-stage heart failure, functioning as both a bridge to transplantation and destination therapy. Advances in device technology, particularly magnetically levitated pumps, have improved survival and reduced complications. However, LVAD recipients remain prone to surgical emergencies related to device failure, anticoagulation, altered haemodynamics, and comorbidities. This chapter discusses the incidence, presentation, and management of urgent surgical scenarios in this population.