Heart transplantation remains the best option for long term survival in pediatric patients suffering from end stage cardiomyopathy. Data from the Pediatric Heart Transplant Study indicates an expected 10. year survival of 70% following cardiac transplantation among pediatric patients with cardiomyopathy. Despite this successful therapy, mortality prior to cardiac transplantation remains substantial. Over the past decade, mechanical circulatory support has improved survival in patients who deteriorate prior to cardiac transplantation. In a recent analysis, nearly 10% of pediatric heart transplant patients are supported by ventricular assist devices prior to transplant. However, the availability of mechanical devices for small children and infants remains severely limited. A paracorporeal pump for infants and children is currently in clinical trials, and an NHLBI initiative has focused on the development of durable implantable pumps for small pediatric patients. © 2010.