Pediatric ventricular assist devices (VADs) have become a critical therapeutic option for children with end stage heart failure, which number dramatically raised in last two decades. Unlike adults, pediatric population presents unique challenges due to their varying sizes, the underlying congenital heart disease, the scarcity of pediatric heart donors. VADs can be employed as a bridge to recovery, a bridge to transplant or, in some cases, a destination therapy. In last decade, EXCOR Berlin heart seemed to be the only long-term resource for smaller children, due to the lack of smaller sized devices; however, recent technological advances led to the development of miniaturized devices tailored for pediatric uses, increasing the quality of life and the outcome of a consistent part of pediatric population. Complications, such as thromboembolism, infection, and bleeding, remain significant concerns; however, the most recent shared protocols for anticoagulation significantly improved the patients’ outcome. Ongoing research aims to optimize devices’ biocompatibility, reduce adverse events, and expand the range of eligible patients. A multidisciplinary approach in dedicated centers is still critical, and careful patient selection and the timing and choice of assistance are essential for successful outcomes. Pediatric VADs management represents a still evolving research field with promising implications for pediatric cardiology and surgery.