Heart failure remains the leading cause of death in Western countries, affecting 4.9 million individuals and causing >300 000 deaths annually in the US alone. The disease is highly prevalent in the elderly population and often follows a course of progressive disability and deterioration. An estimated 15 000 patients with end-stage heart failure could benefit from heart transplant each year. Yet, as a result of a significant shortage of donor organs, only 2500 hearts are donated annually, and approximately one-third of patients awaiting heart transplant die each year. Mechanical circulatory support, primarily in the form of left ventricular assist devices (LVADs), has come to the forefront of treatment for severe congestive heart failure by providing a feasible alternative to patients who might otherwise die awaiting heart transplant. The arrival of LVADs has resulted in a dramatic shift in the management of heart failure, one that will undoubtedly affect and include a vast proportion of elderly patients. While LVADs represent a surgical approach to a disease that has traditionally been managed medically, the pharmacological application throughout the perioperative period remains of critical importance.