Heart failure continues to be associated with high morbidity and mortality. Over the past decade, left ventricular assist devices have been shown to improve the survival and quality of life. However, it is quite clear that very sick patients do not do as well, and it is therefore imperative to select patients at the proper time. In this article, we review both the indications for considering left ventricular assist device therapy as well as discuss the considerations and therapy that should be done pre-operatively to possibly improve post-insertion outcomes.