The increasing awareness of pediatric heart failure in the setting of limited cardiac donor organ availability has led to substantial growth in pediatric ventricular assist devices. Despite major advancements witnessed over the last decade in the field, however, many challenges persist, particularly in addressing device-size mismatch and anatomical complexities in the pediatric population. This chapter reviews recent breakthroughs in real-world applications of mechanical circulatory support, including catheter-based techniques and targeted solutions for single-ventricle circulation. Further discussion is added to highlight newer devices on the horizon, particularly total artificial heart systems, that hold promise for addressing the current unmet needs in the management of pediatric heart failure.