Purpose Pediatric heart-lung transplant (HLT) is known to have poor survival. We sought to define if there has been any improvement in pediatric HLT outcomes over time and if there is a cohort that portends better or worse survival. Methods Pediatric ( proportional hazard model was used to identify risk factors for post-transplant survival. Results There has been a 30% drop in pediatric HLT in Era 2. ECMO at transplant has increased from 4% in Era 1 to 12% in Era 2. Similarly, PRA>10% (11.6% to 25.9%, p=0.01), and congenital heart disease (CHD) without Eisenmenger Syndrome (ES) (14% to 25.9%, p=0.03) have increased, whereas, CHD with ES has significantly decreased in Era 2 (23.1% to 9.4%, p=0.01). Two-year post-transplant survival has not changed between eras (p=0.99); however, two-year conditional survival has significantly increased (p=0.01) as shown in Figure 1. Patients on ECMO at transplant have a 7.9 times increased risk of mortality post-transplant (CI: 2.2-29.3, p=0.002). Infant (HR: 2.9, CI: 1.5-5.9, p=0.002) and 2-11 year old (HR: 1.7, CI: 1.0-2.7, p=0.037) patients also have an elevated risk of mortality post-transplant compared to adolescents. Only 13% (2/15) of ECMO patients survived beyond two years post-transplant with a median survival of 64 days, but in the current era, a patient not on ECMO has a median survival of nearly 3 years. Conclusion Although the number of pediatric HLT has decreased significantly, the long-term outcomes continue to improve post-HLT. With a median post-transplant survival of 2 months for a patient on ECMO, we should be prudent about HLT since it adds little survival benefit. However, in a well selected cohort, HLT can add significant survival benefit.