Elevated pulmonary vascular resistance (PVR) continues to pose challenges in heart transplantation, but does the common belief that implanting a larger organ when the PVR is high actually affect outcomes? The purpose of this study is to assess post-transplantation outcomes in recipients with increased PVR in relation to donor organ size. The United Network for Organ Sharing (UNOS) database was used to identify patients ages 0-18 years at time of listing who underwent transplantation between 2010 and 2019 and for whom cardiac catheterization and donor-recipient weight data was available. Patients were divided by listing PVR into <3, 3-6, and >6 Wood units. Donor-Recipient weight ratio was categorized as undersized (≤0.80), mid-size (0.81-1.2), and oversized (>1.2). Subgroup analysis was done with an additional supersized group (>2.0). 1491 patients met study criteria. Median age [years (IQR)] 10 (3-15) and 45% female. 4% of heart transplantation cases used undersized, 45% used mid-size, and 51% used oversized organs. More patients with PVR>6 were transplanted with an oversized organ compared to patients with PVR<3 [59% (148/252) vs 48% (430/894), p=0.003). There was no difference in survival between the organ size groups regardless of PVR; this includes patients with PVR>6 at listing who were transplanted with an oversized organ versus those transplanted with an undersized (p=0.359) or mid-sized (p=0.956) organ. In subgroup analysis, even in patients transplanted with a supersized organ, there was no survival difference noted regardless of PVR. Despite a persistent practice pattern to transplant high PVR patients with oversized organs, there remains no difference in post-transplantation survival between these patients and those transplanted with smaller organs. Therefore, transplants in patients with high PVR should not be delayed by waiting for larger organs.