The successes achieved in bridging patients to transplantation and to recovery of the native heart argue strongly for further development and wider application of mechanical circulatory assist devices. It is possible that even higher success rates can be achieved with earlier use of VADs, particularly in patients who cannot separate from cardiopulmonary bypass. There are several important questions and problems that must be addressed before the wider application of VADs in acute heart failure. How can one reliably and expeditiously distinguish patients who will separate from bypass and survive if given additional time on conventional cardiopulmonary bypass from patients who are destined to require mechanical assistance? How can the problems with post-bypass organ damage be minimized, and how can patients with irreversible organ injury be distinguished from patients with reversible dysfunction? How can the problems with post-implant bleeding, infection, and thromboembolism be minimized? Perhaps the most important problem is how to treat patients who survive VAD implantation, but whose hearts fail to recover. The only alternatives at the present time are removal of the device with almost certain death, or cardiac transplantation. The development of chronically implantable VADs (ie, expected duration of support 5 years or more) will provide an excellent alternative for patients who are not optimal transplant recipients or for whom there is not a donor heart available. The number of patients that will be in this category and the cost per patient year of survival are factors that will weight heavily in the decisions made by the federal government regarding clinical application of this technology.