The surgically implanted Impella device has become substantially more important in recent years and has been implanted increasingly more in Germany and worldwide. Initially designed for femoral or direct aortic implantation, the surgically implanted Impella device is nowadays nearly exclusively implanted using an axillary approach. The indications to surgically implant an Impella device range from cardiogenic shock through weaning from extracorporeal membrane oxygenation (ECMO) up to high-risk cardiac surgery interventions. The newly designed Impella 5.5 shows very promising results.