Left ventricular assist devices (LVADs) have become a cornerstone in the treatment of advanced heart failure. Recent outcomes demonstrate survival rates comparable to heart transplantation, enabling the synergistic use of both therapies to achieve significant life prolongation for patients. This chapter provides a comprehensive overview of LVAD implantation techniques, including methods for performing concomitant procedures and pump exchanges in cases of malfunction. Particular attention is given to the differences between traditional and thoracotomy approaches, highlighting the potential benefits of the latter. The thoracotomy technique has been associated with reduced blood transfusion requirements, a lower incidence of right heart failure, and improved heart transplantation outcomes following LVAD support. Furthermore, evidence suggests that patients with prior sternotomies, obesity, or those on mechanical circulatory support (MCS) achieve better outcomes with the thoracotomy approach.