Left ventricular assist devices (LVAD) provide a durable option for patients with advanced hear failure. Axial and centrifugal pump physiology differs with regard to the relationship between pump inflow-outflow cannula pressure differential and flow, which results in device behavior that can vary drastically under different loading conditions. Ramp studies can aid the clinician in choosing the optimal speed to adequately unload the left ventricle. Advances in 3-dimensional echocardiography enhance the understanding of chamber geometry for both types of LVADs. Novel outflow graft imaging techniques have been developed to better characterize aortic insufficiency, which may be underestimated with current standard methods.