Purpose of Review <p> Heart failure in patients with congenital heart disease and particularly single ventricle physiology at all stages of palliation presents significant management challenges. Ventricular assist device (VAD) use in this population is increasing. This review summarizes the recent outcomes, physiologic considerations, and challenges of VAD therapy at each stage of single ventricle palliation.</p> Recent Findings <p> Survival after VAD implantation has been worse for patients with single ventricle physiology compared with biventricular physiology, though recent data suggest this disparity is narrowing. A variety of continuous and pulsatile flow devices are available for use, though many are not approved by the Food and Drug Administration for use in the pediatric population. Adverse effects are common with VADs at each stage of single ventricle palliation, regardless of device choice.</p> Summary <p> VAD therapy in patients with single ventricle heart disease requires an understanding of the complex cardiac physiology and device mechanics in order to optimize outcomes.</p>