**Abstract**

Left ventricular assist device (LVAD) therapy is an essential tool in the armamentarium for managing refractory heart failure. The traditional LVAD placement involves insertion of the inflow cannula (IC) at the left ventricle's true apex and attachment of the outflow graft (OG) to the ascending aorta (AA), which ensures alignment with physiological blood flow and minimizes complications. However, patient-specific anatomical variations and prior medical interventions necessitate considering alternative IC and OG placement techniques. This chapter reviews the standard and alternative IC and OG placement sites and emphasizes the importance of adapting LVAD component placement to individual patient needs, highlighting the potential of alternative techniques in improving outcomes. Despite the predominance of standard sites due to their proven efficacy, the heterogeneity of patient conditions underscores the need for flexible, patient-tailored approaches.

**Keywords:** LVAD, left ventricular assist device, inflow cannula, outflow graft, alternative sites
