Major advances in vascular assist device (VAD) technology and the clinical acceptance of destination therapy for patients with contraindications to transplant raise the questions of what patient benefit is necessary to recommend VAD implant for long-term support in patients who are transplant candidates. What are the appropriate indications for use and timing considerations for long-term VAD therapy in patients who qualify for transplant but are unlikely to obtain a donor? The authors suggest that VAD implantation for the indication of “maintenance therapy” where patients must remain on the VAD for two years before becoming transplant eligible, would constitute an appropriate clinical avenue to study these issues.