Systolic heart failure is a problem of substantial magnitude worldwide. Over the last 25 years great progress has been made in the medical management of heart failure with the recognition of the benefits of beta-adrenergic blockade, modulation of the renin-angiotensin and mineralocorticoid axes and judicious diuretic therapy. In addition, cardiac resynchronization therapy and prophylactic implantation of cardiac defibrillators have been responsible for measurable benefits in terms of functional status and dysrhythmia-related mortality, respectively. Unfortunately, progressive cardiac dysfunction often results in activity limitation, symptoms at rest, hospital admission, end-organ dysfunction and death despite maximal implementation of standard therapies. Heart transplantation has been a dramatic and effective therapy for end-stage heart failure, but it remains limited by a shortage of donor organs, strict criteria defining acceptable recipients and often unsatisfactory long-term success. Mechanical alternatives to support the failing circulation have been sought for the last 50 years. The history of device development has been marked in general by the slow progress achieved by a few dedicated and persevering pioneers. In the past decade, however, evolving technology has dramatically changed the field and broadened the options for the treatment of advanced heart failure. This review will detail the important milestones and the current state of the art, with an emphasis on implantable devices for intermediate to long term support.