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In Kazakhstan, geographical and cultural reasons do not favor the development of heart transplant activity. Thus, a surgical program for treatment of advanced, refractory heart failure was implemented, focusing the efforts on ventricular assist device (VAD) therapy. The program, supported and funded by the national healthcare system, is based on a single, highly specialized surgical Center for the operation, and on a regional infrastructure for outpatient follow-up. Regional VAD coordinators are educated by the National Center. They are in charge of regular patient check, anticoagulant and antiplatelet treatment prescription, and continuing patients' and caregivers' education, mainly regarding driveline exit site dressing and driveline stabilization. From November 2011 to November 2013, 95 patients received 100 devices, mainly for left ventricular support (LVAD): HeartMate II, n=70, HeartWare, n=25. Mean age was 49.5 years, and 87.37% of the patients were males. Most patients had INTERMACS profile 4 (55%), followed by 3 and 2 (17% each). Symptomatic and functional improvement are testified by changes from baseline to month 3 of NYHA functional class (from III-IV to I-II), results of the 6-min walk test (from 152 to 440 m), and NT-proBNP levels (from 6997 to 1126 pg/ml). Overall 1-year survival was 69%, with a trend for outcome improvement over time and a relationship with preoperative INTERMACS profile (1-year survival of 60% in patients with INTERMACS profile 1-2 vs 75% in those with INTERMACS profile 3-4). In summary, where and when a heart transplant program cannot be implemented, LVAD represents a realistic therapeutic alternative. The key points for a successful VAD program are a dedicated, highly specialized multidisciplinary team at the Cardiac Surgery Center, an infrastructure throughout the country for coordinated outpatient follow-up, adequate reimbursement for this activity, and support by the healthcare system.