Mechanical circulatory support (MCS) has revolutionized the management of heart failure over the decades, from its earliest predecessor, the cardiopulmonary bypass machine, to ventricular assist devices. With each generation of devices, there has been device revision and progression, which has served to improve quality of life and patient outcomes. Smaller drivelines have reduced the risk of infection, and more hemocompatible surfaces and other features of device design have reduced thrombotic complications, yet device complications continue to long-term use of devices and prevent MCS from becoming a true alternative to heart transplant. Current challenges include continued minimization of complications, such as bleeding, thrombosis/thromboembolism, infection, and late-onset right ventricular failure. To address these challenges, future innovation should be focused on device miniaturization, less invasive surgical insertion techniques, optimization of hemocompatibility based on pump design and blood flow, and determination of a durable and wireless device power source to allow full implantability. Durable biventricular support remains elusive but would be a significant advancement if achieved.