**6. Conclusion**

Pediatric heart failure is a complex clinical syndrome associated with high morbidity and mortality. While VAD therapy has emerged as an important tool in the management of severe or refractory heart failure, it is not uncommon to encounter arrhythmias in such patients, including during and after VAD therapy, due to the underlying pathology. To date, data on arrhythmias and arrhythmia management in the context of VADs in pediatric patients are lacking. While we have a baseline understanding of etiologies of arrhythmia substrates in patients with congenital heart disease and cardiomyopathy, the changes that occur with VAD implant are less well understood. Additionally, in pediatrics, there is evidence that new ventricular arrhythmias can present after VAD removal [11]. At this time, there is a scientific statement from the AHA that offers suggestions and recommendation for the adult population and can be a useful resource [25]. However, pediatric patients are unique and must be treated in a case-by-case basis. Maintaining sinus rhythm is clearly advantageous in the biventricular heart and can help avoid right heart failure [60]. However, in this era where fewer than 50% of pediatric patients are discharged with a VAD, one must ask how aggressively to treat these arrhythmias, especially when it comes to implanting an ICD [61]. With adult data suggesting no benefit to ICD implantation, there must be careful consideration before implanting one in a pediatric patient, especially if the patient will remain hospitalized. If an ICD is already in place, a multidisciplinary approach with the heart failure team, patient, and patient's family is necessary to determine what, if any, therapies should remain turned on when a VAD is implanted. Despite this, it is likely in the patient's best interest to avoid sustained arrhythmias and attempt to maintain appropriate heart rates to optimize VAD function, especially in single ventricle patients [41]. As technologies emerge and survival improves, the need for data to help direct management is greater than ever; however collaborative efforts will be absolutely necessary to gain the necessary knowledge.
