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institutional approach Home INR machines may be useful for families and are in some cases covered by insurance, typically after a specific period of time on anticoagulation therapy has been met Patients discharged to home may require ongoing physical and occupational therapies, which as noted previously are quite beneficial to rehabilitation prior to transplant.120 Transition to a prescribed exercise program should be considered for ongoing rehabilitation Patients may also elect to return to more vigorous activities as their physical conditioning improves, which is reasonable within limits of maintaining device safety and barring any imposed restrictions secondary to anticoagulation Integration into the school and/or daycare settings has been achieved and shown to be a feasible option Because the pediatric VAD patient is expected to be in the care of someone trained to respond appropriately to the device and patient, additional off-site teaching may be necessary with reintegration into the community.121 Educational competencies should be reassessed in the outpatient setting (device, driveline dressing changes) on a regular basis Patients are often accompanied by primary caregivers and those who do not routinely attend visits, but care for the patient should also be considered for periodic reeducation Early referral for psychosocial supports and intervention should be considered for caregivers and pediatric VAD patients Although VADs are a feasible means of supporting patients with end-stage heart failure until the time of transplantation, there is a potential for significant psychosocial impact on both patients and caregivers.122–124 Conclusion Long-term MCS for end-stage heart failure has become standard therapy at most pediatric heart transplant centers, with excellent outcomes in most patients However, more pediatric-specific devices are needed and there continues to be challenges with certain populations, including small infants and patients with complex CHD Many children are supported with adult devices and the use of these devices have ushered in the era of outpatient management for children on VADs There have been tremendous advancements in MCS for children over the past decade, and coming years hold great promise for further advancements Annotated References Blume ED, VanderPluym C, Lorts A, et al Second annual pediatric interagency registry for mechanical circulatory support (Pedimacs) report: Pre-implant characteristics and outcomes J Heart Lung Transplant 2018;37(1):38–45 This study is the most recent annual report from Pedimacs This multicenter registry of pediatric VADs demonstrated the current state of MCS and children and allows for in-depth analyses that would not be possible from single center studies Fraser CD Jr, Jaquiss RDB, Rosenthal DN, et al Prospective trial of a pediatric ventricular assist device N Engl J Med 2012;367(6):532–541 This is a seminal study in the field of pediatric MCS as it represents the first prospective study of a durable VAD in children The Berlin Heart Excor VAD was compared against a historical control group of patients that were supported on ECMO There was a significant improvement in survival noted in the children that received the Berlin Heart Excor VAD Morales DLS, Zafar F, Almond CS, et al Berlin Heart EXCOR use in patients with congenital ... Long-term MCS for end-stage heart failure has become standard therapy at most pediatric heart transplant centers, with excellent outcomes in most patients However, more pediatric- specific devices are needed and there continues to be... Fraser CD Jr, Jaquiss RDB, Rosenthal DN, et al Prospective trial of a pediatric ventricular assist device N Engl J Med 2012;367(6):532–541 This is a seminal study in the field of pediatric MCS as it represents the first prospective study... 2018;37(1):38–45 This study is the most recent annual report from Pedimacs This multicenter registry of pediatric VADs demonstrated the current state of MCS and children and allows for in-depth analyses