There has been a paradigm change in LVADs, from the old (HeartMate XVE) pulsatile flow to the new (HeartMate II) devices (Wilson et al. J Am Coll Cardiol. 2009;54:1647-59). The low pulsatile characteristics of blood flow of these advanced circulatory pumps have created a complex weave of hemocompatibility. (Mehra MR Eur Heart J. 2017) An alteration in hemocompatibility and a change in clinical management results in an interwoven clinical cascade: during hemolysis the risk for stroke rises; therapy for pump thrombosis impacts stroke rates; gastrointestinal bleeding forces anticoagulant changes; strokes force a change in anticoagulant therapy and BP; BP changes impact pump flow.