While biventricular assist device (BiVAD) support has historically been used in children with advanced heart failure, contemporary management favors left ventricular assist device (LVAD) only support. We aimed to compare outcomes between LVAD and BiVAD support and to evaluate temporal trends in device strategy.

This retrospective, single centre, observational study included all consecutive patients who underwent Berlin Heart EXCOR implantation from 2004 to 2025. Patients were stratified into LVAD and BiVAD groups. Primary outcome was survival to transplant or explantation. Secondary outcomes included stroke and duration of support.

A total of 76 patients received either LVAD (n = 53, 70%) or BiVAD (23, 30%). For the entire cohort, the median age at implantation was 21 months (IQR 7.2–116.8), median weight was 10.6 kg (IQR 7.0–26.9), and median time on support was 55 days (21.0–138.0). Diagnosis was dilated cardiomyopathy in 67 (88.2%), congenital heart disease in nine (11.8%). There was no significant difference between LVAD and BiVAD in preoperative diagnosis, weight or right ventricular (RV) function. BiVAD represented 90% of VAD support in the early era versus 6% in the most recent era ( Fig. 1 ). Overall, 56 patients (73.6%) underwent heart transplantation, 13 patients (17.1%) underwent device explantation, six (7.8%) died on support, with one still on support at analysis. Survival to transplant or recovery was similar between groups (LVAD: 92.3% vs. BiVAD: 91.6%). Patients on LVAD support were more likely to undergo device explantation (23% vs. 0%) and had fewer strokes compared to those on BIVAD support (0.16%/day on support vs. 0.33%, p < 0.05).

BiVAD predominated early, whereas LVAD is now preferred. Survival was similar in an LVAD only strategy, even with pre-implant RV dysfunction. Differences in stroke rates may reflect evolving anticoagulation management over time rather than configuration alone.