Heart failure is a clinical syndrome of decreased cardiac output that results in functional limitation, significant morbidity and death (Stein et al. J Heart Lung Transplant 35(1):92–8, 2016). Symptoms can improve with medical management and/or spontaneous recovery, but in the absence of this, heart transplantation remains the ultimate treatment option. Ventricular assist devices (VADs) are mechanical pumps designed to support a failing heart which requires more than medical management, offloading volume and supplementing cardiac output. This preserves end-organ function and may help the heart to recover from damage since the abatement of cardiac work and oxygen consumption provides the shocked myocardial fibres with the necessary energies to repair and optimise their performance. VADs are often needed in children with heart failure as a bridge to transplant and are necessary due to the limited availability of paediatric organ donors. VAD may also bridge the patient to recovery or ‘to decision’ if the prognosis is unclear.