Patients with advanced heart failure refractory to optimal medical treatment have a high mortality and a poor quality of life with frequent hospital admissions. The lack of alternative treatment options has prompted the development of mechanical circulatory support (MCS) devices, first as bridge to heart transplant and subsequently as destination therapy as a valid alternative to transplant. Last generation MCS devices are mechanically reliable and their management has become increasingly less complex. Nowadays, medium-term survival does not significantly differ between MCS and heart transplant recipients. MCS management programs require a multidisciplinary team to optimize the pathway leading to rehabilitation and improved quality of life and decrease the frequent occurrence of complications. However, in the near future with the growing number of implants, the chances for clinical cardiologists to come across a MCS recipient will increase. The management of general or acute problems will no longer be limited to tertiary implanting centers. A key issue to improve patient outcomes is the provision of a smooth and careful transition from the hospital environment to home care. The aim of this review is to start this process by providing basic notions and general indications through several scenarios of MCS recipients presenting to the emergency room for acute clinical problems.