may prove to be a safer anticoagulation strategy.436,437 FIG 16.15 A child with a Berlin Ventricular Assist Device The child is extubated, deintensified, and fully ambulatory Newer generation continuous flow assist devices designed for adults are increasingly being used in children These include the Heartmate II (Thoratec) and Heart Ware HVAD (Heart Ware).438,439 The HVAD device in particular, an implantable pump, has been used in patients with body surface areas as low as 0.6 m2.439 Both of these devices have been used to support patients with biventricular as well as single ventricle physiology.440,441 Unlike the other devices described above, with the total artificial heart (SynCardia), the patient's native ventricles are removed and replaced with intracorporeal pneumatic pumping chambers In addition to the original 70-mL device, a smaller, 50-mL device has recently begun clinical studies and has increased the potential for use in the pediatric population The total artificial heart may be suitable for support of previously transplanted patients with end-stage complications such as advanced coronary disease or rejection as immunosuppressive medications can be minimized.442,443 The total artificial heart may also be uniquely suited for support of the failing Fontan circulation.444 Complex, extensive, and lengthy reconstruction can be accomplished combined with implantation of a total artificial heart to allow for rehabilitation and a potentially more straightforward heart transplant with fewer anatomic challenges Conclusions The beginning of cardiac surgery can be traced to the ligation of the persistently patent arterial duct, performed by Robert Gross in 1938, and reported in 1939 Cardiac surgery began, therefore, with the treatment of congenital cardiac disease In the last 80 years, we have seen tremendous progress Correction or palliation of congenitally malformed hearts is now routinely performed in infants and neonates, with the expectation of survival in most instances Our goal in this chapter has been to review issues common to all congenital cardiac operations including incisions, materials used, conduct of CPB, and the options for extracorporeal support We have sought to provide a balanced overview of the current state of the art, including the mean and first standard deviation of thought The topic of surgical techniques is vast, and obviously beyond the scope of a single chapter We believe we have provided a background, context, and a reasonable starting point for more thorough investigation