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device, 11% had died, and 3% had recovered, for an overall positive outcome of 89% The authors found that the HVAD system in the pediatric population was associated with low mortality in the majority of patients supported for 1 year This is comparable to adult data, although temporary right VAD support and pump exchange remain risk factors for poor outcomes in the pediatric population Although very encouraging, the dataset did not allow an analysis of the morbidities, which will need to be studied Prior to 2012, only one pediatric VAD program had an intracorporeal CF device Now, 5 years later, every program uses intracorporeal CF devices routinely With recent improvements, CF VADs are now placed more often that EXCORs in pediatrics, according to most recent Pedimacs report.44 This shift toward CF VADs in pediatrics follows the previous trend in adults Future Devices The National Heart, Lung, and Blood Institute started the Pediatric Circulatory Support Program for development of novel MCS devices for infants and children in 2004 Careful selection led to more than $20 million of support granted to five contractors: PediaFlow pediatric VAD (University of Pittsburgh), PediPump (Cleveland Clinic), pediatric cardiopulmonary assist system (Ension, Inc.), Pediatric Jarvik 2000 (Jarvik Heart, Inc.), and pediatric VAD (Pennsylvania State University).45 This was followed with funding for the Pumps for Kids, Infants, and Neonates (PumpKIN) preclinical program in 2010 to further develop four MCS devices Four contracts totaling $23.6 million were allotted for continuation of three of the Pediatric Circulatory Support Program devices (pediatric cardiopulmonary assist system, Jarvik 2000, and PediaFlow), as well as the pediatric pump-lung (PediPL) (Levitronix, LLC) Of the initial devices funded, only the Jarvik 2015 is still undergoing testing It is an intracorporeal, axial CF VAD no larger than an AA battery, designed to support pediatric patients between 8 and 20 kg After a series of changes to the original device, most recently to decrease hemolysis,46 the device has passed animals studies,47 and a randomized trial that began in 2017 is enrolling 88 patients to be compared 1 : 1 versus the EXCOR Other companies are looking to develop new types of MCS for children as well VADovations is a private company that is currently testing intracorporeal CF devices in animals, focusing specifically on hemocompatibility, including preserving von Willebrand factor function to reduce nonsurgical bleeding and reducing platelet activation to limit thromboembolic events These promising animal studies have the potential for use as a right VAD in adults and acute rightsided support for the Fontan circulation Being only 8 mm in diameter and 50 mm long (size of AA battery), the device can easily sit inline with a blood conduit Although these and other systems are years from widespread use in children, it reflects the increased interest and funding going toward developing long-term solutions for pediatric heart failure and CHD Special Populations Bivad Versus LVAD Support As seen in the adult VAD experience, the number of BiVADs always decreases as decision-making matures, which correlates with an increase in survival and decrease in morbidity This is documented by multiple institutional series and by examination of the Pedimacs or INTERMACS registries Stiller and Hetzer have written regarding their use of the Berlin Heart EXCOR VAD at the Berlin Heart Institute Despite essentially similar patient populations over time, they have decreased the number of BiVADs, which has contributed to improved outcomes Improved survival of LVADs over BiVADs was also demonstrated in the pediatric field by the early North American experience with the EXCOR (88% vs 64% 6-month survival).32 A follow-up study of this cohort specifically attempted to identify those patient groups who would benefit from BiVAD support over LVAD support but unfortunately were unable to identify any patient cohort.48 However, this should not be taken to mean that there are no patients who benefit from BiVAD support because the lack of identifying a cohort was surely secondary to patient numbers Most experts agree there are patients who benefit from BiVAD support over LVAD support, likely those with primary unremitting arrhythmia burden, certain severe biventricular restrictive disease, or certain congenital patients with biventricular failure Not only can improved decision making decrease the need for right VAD support, but perioperative techniques have also led to decreased need for BiVAD support Right ventricular stress can be reduced by limiting circulating volume, reducing myocardial edema and cytokine overload with ultrafiltration, limiting bleeding and thus postoperative transfusions, and supporting the right heart aggressively in the immediate postimplant period (e.g., inhaled nitric oxide, milrinone, and/or epinephrine) Managing septal shift and minimizing tricuspid insufficiency via transesophageal echocardiography when separating from cardiopulmonary bypass and closing the sternum is important The increasing use of intracorporeal CF devices in the pediatric population underlines how the maturation of the field has progressed from 40% of patients receiving BiVAD support to less than 20% presently Ultimately, a small portion of patients (likely