Background:  The current pandemic has necessitated a change in the delivery of health care. Increasingly, virtual strategies have been employed. Tele-rehabilitation (TR) allows access to care required to optimize recovery while maintaining social distancing. It has been used in small pediatric studies and in adult cardiac populations with success, however there is no reported experience with its use in providing cardiac rehabilitation in the pediatric population.  
Methods: Describe the rehabilitation journey including transition to TR of a pediatric patient with heart failure through ventricular assist device (VAD) and transplant (Tx) recovery.  
Results: A 16-year-old male with a congenitally corrected transposition of the great arteries presented with progressive heart failure necessitating VAD placement and was successfully bridged to a heart transplant after 13 weeks of support. He was supported with physiotherapy-led TR during the pre and post Tx period as outlined in Table 1. Complications post-VAD necessitating targeted rehabilitation included peripheral nerve injury resulting in right foot drop, exacerbation of thoracic outlet syndrome, and general weakness deconditioning. Challenges to TR experienced included the need to develop a strategy to monitor status during exercise in the context of potential cardiovascular instability, availability of equipment within the home, and technological limitations including inconsistent wireless access. Opportunities observed included more physiotherapist-led sessions than historically, maximizing family involvement in the rehabilitation process, family convenience by sessions conducted virtually, ability to observe the patient real-time in the home setting, and enhancement of the therapeutic relationship.  Strategies employed included use of items within the home (light weights, stairs, yoga mat), and use of body weight exercises and on-line videos with music for aerobic and strength training. Use of rating of perceived exertion scale ensured adequate intensity for training effect and caregiver participation during sessions was needed to monitor and provide feedback to therapist and hands-on support to patient. No adverse events occurred during TR sessions. Select outcomes are listed in Table 2. Post-Tx he had a short length of stay and at final visit 4 months post-Tx had improved strength to near normal. His 6 minute walk distance improved though he continued show some evidence of reduced muscular endurance.
Conclusion: This first experience with TR in a pediatric cardiac patient demonstrated feasibility and safety and may maximize opportunities for rehabilitation and minimize the travel burden on the family. Outcome for this patient suggests that improvement in status during VAD support may lead to better early Tx outcomes. Further study is warranted.