The Very Low Head turbine (VLHT) is an axial flow turbine developed for heads below 4.5 m and flow rates up to 30 m3/s. In this work, the state of the art, the technological advancements and the scientific gaps were discussed and generalized, with a special focus on design, ecological behavior, costs, performance at different flows, heads and rotational speeds. The flow field and the hydraulic behavior under different configurations (e.g. in presence of cavitation and with an upstream obstacle) were described, with the aim of deriving engineering suggestions. Results of ecological tests were generalized (fish survival rate is more than 90%) by using the blade strike model, proposing an expeditious method for a preliminary appraisal of the ecological impact on downstream migrating fish. Despite the hundreds of installations worldwide, especially in existing barriers, some scientific gaps need to be better addressed yet, e.g., the influence of the number of blades and axis inclination on the efficiency, the influence of flow, head and rotational speed on the flow field and a quantification of the head losses through the trash rack above the runner.