Net Prolongation of Life with Ventricular Assist Device Support in Teenagers: Are We There Yet?

Heart transplantation prolongs survival in children with end-stage heart disease, yet a single donor heart does not provide a normal lifespan. Contemporary graft survival for teenagers is approximately 15 years, the shortest of any pediatric age group, and re-transplantation remains uncommon. For most patients, the first allograft is the only allograft. Recent adult data demonstrating survival with durable mechanical circulatory support comparable to transplantation raise an important question for adolescents: could intentionally extending ventricular assist device (VAD) support through the teenage years, with transplantation deferred to adulthood, increase total life-years? This perspective examines that hypothesis for adolescents with dilated cardiomyopathy. We review the heightened risks of rejection, graft loss, and treatment nonadherence during adolescence; contemporary outcomes with dischargeable durable VADs in children; the potential for myocardial recovery during extended support; and organ allocation policies that may unintentionally discourage a prolonged-support strategy. We also examine patient and family perspectives and discuss unresolved questions regarding stroke risk, allosensitization, long-term quality of life, and optimal timing of transplantation. No prospective data currently support intentional long-term VAD support as a bridge to transplantation in teenagers, and this concept should be viewed as a hypothesis rather than a practice recommendation. However, for carefully selected adolescents who are clinically stable on durable VAD support, delayed transplantation may be a reasonable topic for shared decision-making discussions while acknowledging the substantial uncertainties that remain. As durable device technology continues to improve, evaluating whether prolonged VAD support can achieve net prolongation of life in teenagers warrants prospective investigation.