Severe systolic dysfunction combined with symptoms of heart failure has a high rate of morbidity and mortality. Medical management remains the mainstay of therapy but mechanical circulatory support (MCS) is one of the treatment options for end-stage heart failure. The left ventricular assist device (LVAD) is the most common type of device used for durable MCS. There have been significant improvements in the technology, surgical technique, and patient management. There is not a single model that is able to accurately assess risk in these patients due to the variety of variables. It is essential to assess all risk in the decision-making process.