Inclusion criteria:

1. Advanced heart failure with plan to treat with LVAD
2. Over 18 years of age
3. Patients must be able to read and understand English
4. Patient must sign the informed consent form

Exclusion criteria:

1. History of ischemic stroke
2. History of intracerebral hemorrhage
3. Known >70% stenosis of the internal carotid artery
4. Known >70% stenosis of the middle cerebral artery
5. Skull defect or skull surgery that will preclude monitoring
6. Unable or unwilling to remain in bed for 30 minutes (to tolerate TCD monitoring)
7. Unable or unwilling to return for 3-month study visit
8. INTERMACS profile 1 (critically ill patients requiring temporary assist devices such as ECMO, Impella, aortic balloon pump)