The need for mechanical assistance of the failing heart, whether acute after a myocardial infarction or permanent in patients with end-stage heart failure, has increased with improvements in medical therapy and a growing aged population. Over the past few decades, much progress has been made in the development and refinement of ventricular assist devices (VADs), medical devices capable of maintaining circulatory output of the diseased ventricle. Initially designed as a temporary support to allow ventricular recovery or as a bridge for patients to cardiac transplantation, these devices are now being used as a permanent form of "destination" therapy. Improvements in technological design, durability, and medical management have allowed individuals with VADs to be managed in their communities. Although these devices provide excellent hemodynamic support and enhance patient functional status, discharged individuals face many unique challenges. In this article, we discuss 1) the spectrum of VADs for outpatient therapy, including their basic physiology and hemodynamics; 2) the multidisciplinary approach required to care for a patient with such a device in the community; 3) routine general cardiac issues that are encountered; 4) associated long-term device and nondevice-related complications; and 5) the reported overall improvements in quality of life.