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Echocardiography plays a major role in the diagnosis of a pericardial effusion with CT. Pericardiocentesis must be performed for tamponade with stress dose steroids and thyroxine supplementation.Learning Objectives: Acute myocarditis is an inflammatory process of the myocardium that can lead to heart failure and can be rapidly progressive and fatal. Mechanical circulatory support may be a life-saving measure allowing a bridge to recovery or transplantation. Centrifugal pumps have been designed for reliability and smaller size for use in a broader population than 1st generation pulsatile devices. We report a case of a 16yo who presented in marginally compensated heart failure. Her initial echo showed severe biventricular dysfunction (EF of 14%). Despite aggressive medical management, there was no change in ventricular function and she worsened and was intubated. Myocardial biopsies revealed lymphocytic inflammation with negative viral PCR. Her condition deteriorated with end organ dysfunction. She was cannulated onto V-A ECMO via right IJ and right carotid artery with additional venous cannula in the femoral vein and dilation of the PFO was performed. With minimal improvement in her heart function and inability to wean from ECMO, she underwent centrifugal VAD placement (HeartWare, Inc, Miramar, FL, USA) on hospital D#28. An attempt with LVAD support alone was trialed but not successful due to severe RV dysfunction. Intrapericardial BiVAD support was then instituted with HeartWare devices. The LVAD was implanted into the LV apex with the outflow graft anastomosed to the ascending aorta and the RVAD was placed on the diaphragmatic surface of the RV with the outflow graft anastomosed to the pulmonary artery. After early mediastinal hemorrhage, post-op recovery was uncomplicated. On BiVAD D#7, she was extubated and began aggressive rehabilitation. Anticoagulation was targeted to an INR of 2.5-3.5. Aspirin was used as an antiplatelet agent. On BiVAD D#42 she was ambulating well and was discharged home for continued rehab. She had no organ dysfunction and normal nutrition when she underwent orthotopic heart transplantation 74 days after BiVAD implant. While the need for biventricular support is rare in pediatric patients, it can be used successfully as a bridge to transplantation.

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