OBJECTIVES: Heart transplantation is the gold standard therapy for pediatric end-stage heart failure. Ventricular assist devices (VADs) have improved waitlist survival, but their effect on post-transplant outcomes remains uncertain. This study aimed to evaluate the impact of pre-transplant VAD support on outcomes in pediatric heart transplant recipients. METHODS: We performed a systematic review and a meta-analysis using three different databases to compare outcomes in pediatric heart transplant recipients with and without pre-transplant VAD support. The primary outcome was long-term survival. Secondary outcomes were postoperative stroke, hospital length of stay (LOS), and post-transplantation rejection. RESULTS: A total of 3247 studies were identified, of which five were included in the analysis. There was no significant difference in long-term survival among patients who survived to transplantation between the groups (HR 0.963; 95% CI 0.84 to 1.10; p = 0.582). However, the postoperative stroke rate was significantly higher in the VAD group (OR 2.17; 95% CI 1.63 to 2.89; p < 0.0001), while no significant differences were observed in hospital LOS (SMD -0.09; 95% CI -0.33 to 0.14; p = 0.4375) or post-transplant rejection (OR 1.18; 95% CI 1.00 to 1.39; p = 0.0505). CONCLUSIONS: Pre-transplant VAD support was associated with non-inferior survival despite greater baseline severity among patients who survived to transplantation, enabling access to transplantation, but at the cost of higher VAD-related complications, particularly stroke, with no differences in hospital LOS or rejection.