The use of paracorporeal mechanical biventricular support devices either as a bridge to transplantation or while awaiting recovery of the failing heart has been well described in the literature. The majority of these reports detail conditions specific to the adult population. We describe use of the Thoratec ventricular assist device (Thoratec Corp, Pleasanton, CA) in the smallest known cardiomyopathy patient to date to be successfully supported with an emergent biventricular device before subsequent cardiac transplantation. The operative technique, pump settings, and modifications utilized to optimize peripheral perfusion are detailed. © 2005 by The Society of Thoracic Surgeons.