BACKGROUND: Children with end-stage dilated cardiomyopathy (DCM) usually undergo heart transplantation or a short-term bridge with a ventricular assist device. Heartmate 3 (HM3) may represent an appealing longer-term option, though pediatric data are limited. We analyzed two clinical registries and hypothesized that adolescents with DCM treated with either HM3 or transplant would present similar survival. METHODS: The Pedimacs and Pediatric Heart Transplant Society registries were queried for DCM patients ages 10-18 years treated with HM3 or transplant, between 2017 and 2022. Mortality and adverse events were reported. RESULTS: Ninety HM3 and 306 transplant patients were reported within the respective registries. There was a higher proportion of Black patients in the HM3 cohort (40% vs. 30% in the transplant cohort, p = 0.03). Twelve- and 36-month survival rates were both 94.4% for HM3 patients and were 99.3% and 95.6% for transplant patients. In the HM3 group, there were 66 transplants (median time of 2.8 months), 3 late explants for recovery, and 3 early deaths. Conditional 1-year survival for HM3 and transplant was 100% and 96.3%, respectively, at 3 years. In the HM3 group, bleeding, stroke, and device malfunction rates were low at ≤ $$ \le $$  0.1 events per patient per year. CONCLUSIONS: Adolescents with DCM treated with either HM3 or transplant had excellent 3-year outcomes, though many HM3 pediatric patients are transplanted early after device placement. Safely supporting this group of patients for an extended duration with HM3 has implications for delaying/avoiding transplantation, longer-term patient survival, and donor organ availability.