Heart Transplant Recipients Research Articles

Hypothermic oxygenated perfusion of the donor heart in heart transplantation: the short-term outcome from a randomised, controlled, open-label, multicentre clinical trial

Static cold storage (SCS) remains the gold standard for preserving donor hearts before transplantation but is associated with ischaemia, anaerobic metabolism, and organ injuries, leading to patient morbidity and mortality. We aimed to evaluate whether continuous, hypothermic oxygenated machine perfusion (HOPE) of the donor heart is safe and superior compared with SCS. We performed a multinational, multicentre, randomised, controlled, open-label clinical trial with a superiority design at 15 transplant centres across eight European countries. Adult candidates for heart transplantation were eligible and randomly assigned in a 1:1 ratio. Donor inclusion criteria were age 18-70 years with no previous sternotomy and donation after brain death. In the treatment group, the preservation protocol involved the use of a portable machine perfusion system ensuring HOPE of the resting donor heart. The donor hearts in the control group underwent ischaemic SCS according to standard practices. The primary outcome was time to first event of a composite of either cardiac-related death, moderate or severe primary graft dysfunction (PGD) of the left ventricle, PGD of the right ventricle, acute cellular rejection at least grade 2R, or graft failure (with use of mechanical circulatory support or re-transplantation) within 30 days after transplantation. We included all patients who were randomly assigned, fulfilled inclusion and exclusion criteria, and received a transplant in the primary analysis and all patients who were randomly assigned and received a transplant in the safety analyses. This trial was registered with ClicalTrials.gov (NCT03991923) and is ongoing. A total of 229 patients were enrolled between Nov 25, 2020, and May 19, 2023. The primary analysis population included 204 patients who received a transplant. There were no patients who received a transplant lost to follow-up. All 100 donor hearts preserved with HOPE were transplantable after perfusion. The primary endpoint was registered in 19 (19%) of 101 patients in the HOPE group and 31 (30%) of 103 patients in the SCS group, corresponding to a risk reduction of 44% (hazard ratio 0·56; 95% CI 0·32-0·99; log-rank test p=0·059). PGD was the primary outcome event in 11 (11%) patients in the HOPE group and 29 (28%) in the SCS group (risk ratio 0·39; 95% CI 0·20-0·73). In the HOPE group, 63 (65%) patients had a reported serious adverse event (158 events) versus 87 (70%; 222 events) in the SCS group. Major adverse cardiac transplant events were reported in 18 (18%) and 33 (32%) patients in the HOPE and SCS group (risk ratio 0·56; 95% CI 0·34-0·92). Although there was not a significant difference in the primary endpoint, the 44% risk reduction associated with HOPE was suggested to be a clinically meaningful benefit. Post-transplant complications, measured as major adverse cardiac transplant events, were reduced. Analysis of secondary outcomes suggested that HOPE was beneficial in reducing primary graft dysfunction. HOPE in donor heart preservation addresses the existing challenges associated with graft preservation and the increasing complexity of donors and heart transplantation recipients. Future investigation will help to further elucidate the benefit of HOPE. XVIVO Perfusion.

Added prognostic value of visually estimated coronary artery calcium among heart transplant recipients

BackgroundCardiac hybrid positron emission tomography/computed tomography (PET/CT) has become a valid screening modality for cardiac allograft vasculopathy (CAV) following HT. Visually estimated coronary artery calcium (VECAC) can be quantified from CT images obtained as part of PET/CT and has been shown to be associated with adverse cardiovascular outcomes in coronary artery disease. We investigated the prognostic value of VECAC following heart transplantation (HT). MethodsA retrospective analysis of 430 consecutive adult HT patients who underwent 13N-ammonia cardiac PET/CT from 2016-2019 with follow-up through October 15, 2022, was performed. VECAC categories included: VECAC 0, VECAC 1-9, VECAC 10-99, and VECAC 100+. The association between VECAC categories and outcomes was assessed using univariable and multivariable proportional hazards regression. The primary outcome was death/retransplantation. ResultsThe cohort was 73% male, 33% had diabetes, 67% had estimated glomerular filtration rate<60 mL/min, median age was 61 years, and median time since HT was 7.5 years. VECAC alone was insufficiently sensitive to screen for CAV. During a median follow-up of 4.2 years ninety patients experienced death or retransplantation. Compared with those with VECAC 0, patients VECAC 10-99 (HR 2.25, 95% CI 1.23-4.14, p=0.009) and VECAC 100+ (HR 3.42, 95% CI 1.96-5.99, p<0.001) experienced an increased risk of death/retransplantation. The association was similar for cardiovascular death and cardiovascular hospitalization. After adjusting for other predictors of death/retransplantation, VECAC 10-99 (VECAC 10-99: aHR 1.95, 95% CI 1.03-3.71 p=0.04) and VECAC 100+ (VECAC 100+: aHR 2.33, 95% CI 1.17-4.63, p=0.02) remained independently associated with death/retransplantation. ConclusionsVECAC is an independent prognostic marker of death/retransplantation following HT and merits inclusion as a part of post-HT surveillance PET/CT.

Emerging Aspergillus lentulus infections in Taiwan: clinical and environmental surveillance.

This study aimed to investigate the prevalence and characteristics of Aspergillus lentulus clinical and environmental isolates in Taiwan. Aspergillus isolates obtained from patients at three hospitals and from 530 soil samples across Taiwan were screened. A. lentulus, confirmed by calmodulin sequencing, was subjected to antifungal susceptibility testing and cyp51A analyses. Soil samples yielding A. lentulus were analysed for residues of 25 azole fungicides. Nine A. lentulus isolates were identified, which included seven (1.2%, 7/601) isolates from three antifungal-naïve patients out of 601 Aspergillus section Fumigati clinical isolates and two (0.3%, 2/659) isolates out of 659 Aspergillus soil isolates. All isolates developed white colonies and failed to grow at 48°C. They were susceptible to anidulafungin but showed reduced susceptibility to amphotericin B (AmB), voriconazole and azole fungicides. One heart transplant recipient with proven invasive pulmonary aspergillosis (IPA) initially showed suboptimal response to voriconazole monotherapy but was cured with a combination of voriconazole-caspofungin, liposomal AmB (LAmB)-caspofungin, along with surgery, followed by voriconazole maintenance therapy. Among two critically ill patients with probable IPA, one survived with micafungin, while the other died of aspergillosis despite sequential isavuconazole and LAmB monotherapy. Clinical and environmental isolates sharing identical Cyp51A sequence are identified, matching the Cyp51A sequence of A. lentulus NIID0096. Flusilazole (0.0009 mg/kg) was detected in one soil sample. This study raises concerns about health threat posed by human pathogenic A. lentulus originating from natural environments and underscores the need for increased clinical and laboratory vigilance regarding A. lentulus infections.

LCP-Tacrolimus Extended-Release (Envarsus XR) Use in Adolescent and Young Adult Solid Organ Transplant Recipients.

Limited published experience describes once daily, extended-release tacrolimus (LCP-Tac) use in pediatric solid organ transplantation (SOT), particularly nonrenal SOT. LCP-Tac can simplify immunosuppression (IS) regimens, minimize immediate release-tacrolimus (IR-Tac)-associated adverse effects, and promote adherence. This study describes the successful use of LCP-Tac in adolescent and young adult (AYA) SOT populations. A single-center, retrospective chart review of AYA SOT recipients (age < 25 years) converted from IR-Tac to LCP-Tac. Graft survival, biopsy-proven acute rejection (BPAR), infection rates, estimated glomerular filtration rate (eGFR), and pill burden were assessed at five time points postconversion (1, 3, 6, 12, and 24 months). Intrapatient variability of tacrolimus, as assessed by coefficient of variability (CV%), was also analyzed. Twenty-nine AYA SOT recipients (19 heart, 6 kidney, and 4 liver) were converted to LCP-Tac, with a median age of 17.4 years at conversion. Conversion, mainly due to perceived or identified medication nonadherence, occurred at a median of 5.4 years posttransplant. No graft loss occurred within 24 months of conversion, and BPAR incidence rate was consistent with previous reports for these populations. Only one patient experienced CMV infection. Renal function remained stable postconversion. Successful conversion from IR-Tac to LCP-Tac was demonstrated in AYA heart, kidney, and liver transplant recipients. These AYA SOT recipients experienced reduced pill burden and improved tacrolimus trough concentration variability. However, the impact on medication adherence warrants further investigation. Future research should explore the targeted use of LCP-Tac to enhance IS tolerability and medication adherence in young SOT populations.

Beyond Survival: Empowering Women by Enhancing Reproductive Health Education for Heart Transplant Recipients.

Beyond Survival: Empowering Women by Enhancing Reproductive Health Education for Heart Transplant Recipients.

Donation After Circulatory Death Cardiac Recovery Technique: Single-Center Observational Outcomes

BackgroundRecovery of hearts from donation after circulatory death donors has been performed either with direct procurement and perfusion (DPP) using the TransMedics Organ Care System or with normothermic regional perfusion (NRP) with subsequent cold storage. It remains unclear which of these 2 strategies yields optimal posttransplant outcomes. MethodsAll heart transplant recipients from donors after circulatory death donors at the Vanderbilt University Medical Center (Nashville, TN) were reviewed (February 2020 to January 2023). Recipients were stratified into an NRP or DPP cohort. All DPP recoveries were performed using the TransMedics Organ Care System. The key outcome was severe primary graft dysfunction at 24 hours, defined by the need for postoperative extracorporeal membrane oxygenation. ResultsA total of 118 hearts were transplanted (NRP, 87; DPP, 31). Donors recovered using NRP were younger (25 years [interquartile range {IQR}, 21-31 years] vs 31 years [IQR, 24-37 years]; P = .008) and had shorter distance traveled (292 miles [158-516 miles] vs 449 miles [IQR, 248-635 miles]; P = .02). Recipient preoperative risk factors were similar between the groups. There was no difference in the incidence of severe primary graft dysfunction at 24 hours (NRP, 5.8%; and DPP, 12.9%; P = .24). However, ejection fraction at 7 days after transplantation was higher in the NRP group (65% [IQR, 60%-65%] vs 60% [IQR, 60%-68%]; P = .005). There was no difference in inotrope scores at 24 hours (P = 1.00) or 72 hours (P = .87) or in 30-day (NRP, 95% vs DPP, 97%; P = .75) and 1-year (NRP, 94% vs DPP, 86%; P = .19) survival. ConclusionsNRP and DPP strategies for recovery of cardiac allografts yield comparable early allograft outcomes. Future studies are needed to confirm these findings in larger prospective cohorts.

Outcome of cardiac implantable electronic devices in pediatric heart transplant recipients

Outcome of cardiac implantable electronic devices in pediatric heart transplant recipients

Contemporary Immunosuppression Management and 1-Year Outcomes in Dual Organ Heart Transplantation.

There have been limited reports on immunosuppression strategies and outcomes in dual organ heart transplant populations, primarily from before the 2018 United Network for Organ Sharing (UNOS) heart allocation policy change. Recent data suggested that outcomes with heart-lung and heart-liver transplants remained comparable in the new allocation era, yet heart-kidney recipients have worse 1-year survival. This single-center retrospective study evaluated adult heart-kidney, heart-liver, and heart-lung transplant recipients from September 2019 to May 2023. Immunosuppression regimen, infectious complications, and graft outcomes were collected for 12 months. A total of 36 patients (kidney n = 20, liver n = 9, and lung n = 7) were included in this study. Basiliximab was the most commonly employed induction strategy across the organ groups (12/20 in kidney, 4/9 in liver, and 7/7 in lung). All patients were on triple immunosuppression at 12 months posttransplant with prednisone wean achieved in one heart-liver recipient. Infection complications were frequently reported (95% kidney, 75% liver, 100% lung group). One patient went back to dialysis due to focal segmental glomerulosclerosis. One chronic lung allograft dysfunction was reported, but no other severe biopsy-proven rejection or retransplant was reported. The 1-year survival was 85% (17/20) in heart-kidney, 78% (7/9) in heart-liver, and 86% (6/7) in heart-lung recipients. This study summarized real-world immunosuppression strategies and outcomes in dual organ heart transplant recipients.

Postoperative pain management after thoracic transplantations.

Heart and lung transplantation evolution marked significant milestones. Pioneering efforts of Dr Christiaan Barnard with the first successful heart transplant in 1967, followed by advancements in heart-lung and single-lung transplants by Drs Bruce Reitz, Norman Shumway, and Joel Cooper laid the groundwork for contemporary organ transplantation, offering hope for patients with end-stage heart and pulmonary diseases. Pretransplant opioid use in heart transplant recipients is linked to higher mortality and opioid dependence posttransplant. Effective pain control is crucial to reduce opioid-related adverse effects and enhance recovery. However, research on specific pain management protocols for heart transplant recipients is limited. In lung transplantation effective pain management is crucial. Studies emphasize the benefits of multimodal strategies, including thoracic epidural analgesia and thoracic paravertebral blocks, to enhance recovery and reduce opioid use. Perioperative pain control challenges in lung transplantation are unique and necessitate careful consideration to prevent complications and improve outcomes. This review emphasizes the importance of tailored pain management in heart and lung transplant recipients. It advocates for extended follow-up and alternative analgesics to minimize opioid dependency and enhance quality of life. Further high-quality research is needed to optimize postoperative analgesia and improve patient outcomes.

Preparing the Heart for a New Baby: Management of Pregnancy in Heart Transplant Recipients.

Heart transplant (HT) recipients are more frequently reaching childbearing age given improvement in median survival and outcomes after HT. Although most pregnancies in HT recipients have favorable outcomes, poor fetal outcomes and maternal complications such as hypertensive disorders of pregnancy are more common in HT recipients than in the general population. In this review, we summarize the current evidence to guide the management of pregnancy in HT recipients. Preconception counseling, focused on risk stratification and optimal timing of conception, is the first important step to optimize pregnancy outcomes. During pregnancy and in the postpartum period, frequent monitoring of graft function and immunosuppressive levels is recommended. Calcineurin inhibitors and corticosteroids should be the mainstay of treatment for both prevention and treatment of graft rejection. Delivery planning should follow usual obstetric indications, preferably with vaginal delivery at term using regional anesthesia. A multidisciplinary care team should be involved in management through all stages of pregnancy to ensure success.

Safety and feasibility of adenosine stress cardiac MRI in heart transplant recipients.

Safety and feasibility of adenosine stress cardiac MRI in heart transplant recipients.

Management of Cardiometabolic Risk Factors in Heart Transplant Recipients: The Western Australian Experience

Management of Cardiometabolic Risk Factors in Heart Transplant Recipients: The Western Australian Experience

Characteristics of virus-specific immunological reactions following COVID-19 vaccination in heart transplant recipients

Heart transplant patients are at an increased risk of COVID-19 infection adverse outcomes because of underlying immunosuppression and concomitant comorbidities. To date, all large-scale randomized controlled trials for various COVID-19 vaccines have excluded solid organ transplant recipients. Therefore, the efficacy and safety of coronavirus infection prevention using COVID-19 vaccines in transplant heart patients has not been sufficiently studied. In this research, the evaluation of virus-specific immunological reactions after vaccination (double Vero Cell vaccination and Sputnik Light booster vaccination) in heart transplant patients has been carried out. In vaccinated heart transplant individuals who did not have a history of COVID-19, starting from 4–6 months after the 2nd dose of the vaccine, an increase in antibodies to S protein level of was observed, while maintaining statistically significant differences for 9–12 months after vaccination (regardless of whether with or without booster vaccination). However, the concentration of antibodies remained low, and 37% of patients detected no antibodies. In vaccinated heart transplant individuals following the previous COVID-19 infection, as compared to seronegative patients, post-vaccination immunity is accompanied by maintaining a high level of virus-specific IgG antibodies to the S protein of the SARS-CoV-2 virus in the dynamics of the post-vaccination period with a statistically significant increase of these antibodies by 9–12 months after booster vaccination. The specific cellular response (according to the assessment of CD3⁺154⁺ and CD3⁺IFNγ⁺ TNFα⁺ cells) to the S protein of the SARS-CoV-2 virus remained low throughout the entire follow-up period, was recorded in 5–40% of heart transplant patients and statistically significant changes in the number of spikereactive lymphocytes were observed in patients with a history of COVID-19 by 4–6 months after administration of the 2nd dose of the vaccine. This, together with the results of the assessment of the humoral response, indicates a more pronounced post-vaccination immunity in patients with a hybrid immunity. While developing a methodology for assessing the risk and benefit of a vaccination strategy for individual heart transplant patients, clinical efficacy, ongoing monitoring of rare serious adverse events, and data on vaccine immunogenicity should be taken into account.

Exploring the Preferences and Experiences of Heart and Lung Transplant Recipients of a Structured Dietetic Pre-Transplant Model of Care

Exploring the Preferences and Experiences of Heart and Lung Transplant Recipients of a Structured Dietetic Pre-Transplant Model of Care

Understanding the role of temporary epicardial pacemakers after heart transplantation in the cardiac intensive care unit

The International Society of Heart and Lung Transplantation (ISHLT) guidelines for the care of heart transplant recipients recommend the placement of temporary epicardial pacing wires at the time of surgery. However, there is little data regarding optimal postoperative pacing modality and its implication on ICU length of stay (LOS).We conducted a single-center retrospective cohort study of 187 patients who underwent heart transplantation from January 1, 2019 to February 28, 2023 and had postoperative epicardial pacemaker wires placed. The study's primary outcome was to observe the association between pacing modalities and prolonged ICU LOS (greater than 5 days). The secondary outcome was to observe the association between pacing modalities and prolonged hospital LOS (greater than 15 days), readmission within 30 days of discharge, days on inotropic and pressor support, death, high-grade rejection on biopsy, coronary artery vasculopathy at 1 year, primary graft dysfunction, mediastinitis, and development of a malignancy.22 patients (12%) had their pacing mode turned off at the time of arrival to the ICU, 36 patients (19%) had their pacing mode set to AAI, 101 patients (54%) had theirs set to DDD, and 28 (15%) had theirs set to VVI. No mode of epicardial pacing was associated with an increased ICU LOS, hospital LOS, increased readmission rates, increased short-term adverse effects (STAEs), increased long-term adverse effects (LTAEs), or increased duration of support with vasoactive medications.Our study demonstrated no significant association between the mode of temporary pacing and LOS or adverse effects after heart transplantation.

HLA Mismatches Identified by a Novel Algorithm Predict Risk of Antibody-mediated Rejection From De Novo Donor-specific Antibodies.

The development of de novo donor-specific antibodies (dnDSA) and antibody-mediated rejection (AMR) remains a barrier to long-term graft and patient survival. Most dnDSA are directed against mismatched donor HLA-DQ antigens. Here, we describe a novel algorithm, which we have termed categorical amino acid mismatched epitope, to evaluate HLA-DQ mismatches. In this algorithm, amino acid residues of HLA-DQ protein were categorized into 4 groups based on their chemical characteristics. The likelihood of categorically mismatched peptides presented by the recipient's HLA-DRB1 was expressed as a normalized value, %Rank score. Categorical HLA-DQ mismatches were analyzed in 386 heart transplant recipients who were mismatched with their donors at the HLA-DQB1 locus. We found that the presence of DQB1 mismatches with %Rank score ≤1 was associated with the development of dnDSA (P = 0.002). Furthermore, dnDSA increased the risk of AMR only in recipients who had DQ mismatches with %Rank score ≤1 (hazard ratio = 5.8), but the freedom from AMR was comparable between recipients with dnDSA and those without dnDSA if %Rank scores of DQ mismatching were >1. These results suggest that HLA-DQ mismatches evaluated by the categorical amino acid mismatched epitope algorithm can stratify the risk of development of dnDSA and AMR in heart transplant recipients.

Myocardial Work by Speckle-Tracking Echocardiography in Heart Transplant Recipients: Association Between Global Work Efficiency and Coronary Allograft Vasculopathy

Coronary allograft vasculopathy (CAV) is a leading cause of morbidity and mortality following heart transplantation. CAV is often diagnosed in later stages or during routine screening in asymptomatic subjects. Myocardial work (MW), calculated using left-ventricular global longitudinal strain (LV-GLS) and systemic blood pressure, may be associated with the presence of CAV and outperform conventional echocardiographic parameters. In this retrospective observational study, heart transplant recipients undergoing regular follow-up at our Institution between May 2022 and September 2023 were enrolled. All included patients underwent speckle tracking echocardiography, including MW indices. CAV was classified according to invasive coronary angiography or computed tomography performed within 12 months of index echocardiography. We collected all available clinical and echocardiographic parameters and evaluated potential association with CAV. CAV was detected in 29/93 (31%) patients (CAV+). Of the MW indices, mean global work efficiency (GWE) was 90±6%, and was significantly lower in CAV+ than CAV- subjects (86±7% vs 91±4%, p<0,001). GWE (OR 0.86; CI 0.77-0.94, p=0.002), E/e’ ratio (OR 1.27; CI 1.08-1.52, p=0.006) and LVEF (OR 0.90; CI 0.81-0.98, p=0.017) were independently associated with the presence of CAV. GWE (GWE vs LV-GLS, delta AUC 0.154, p=0.047) and the proposed model (GWE+E/e’ vs LV-GLS, delta AUC 0.198, p=0.004) were significantly superior in stratifying incremental risk for CAV compared to LV-GLS. In conclusion GWE was observed to be independently associated with the presence of CAV. MW could represent a novel non-invasive screening method for CAV in heart transplant recipients. Larger and prospective studies are needed to confirm this hypothesis.

Acute Kidney Injury Requiring Dialysis After Pediatric Heart Transplant.

Acute kidney injury (AKI) is a common complication of pediatric heart transplant, with a subset of patients developing severe AKI requiring dialysis (AKI-D). We aimed to identify the epidemiology, risk factors, and outcomes of postoperative AKI-D in pediatric heart transplant recipients. We retrospectively identified all pediatric first-time, single-organ heart transplants at our institution from 2014 to 2022. Postoperative AKI was defined as AKI within 2 weeks of transplant. Unadjusted and adjusted logistic regression were used to identify characteristics associated with AKI-D, and unadjusted time-to-event analyses were used to determine the association between AKI-D and survival free of kidney failure. Among 177 patients included, 116 (66%) developed postoperative AKI of any stage, including 13 (7%) who developed AKI-D with median time from transplant to dialysis initiation of 6 days (IQR 3-13). In adjusted models, increased cardiopulmonary bypass time (OR 1.19, 95% CI 1.04-1.37, per 15 min increase in bypass time) and higher weight at transplant were associated with higher odds of AKI-D, whereas patient demographics and pretransplant kidney function were not associated with AKI-D. AKI-D was associated with greater mortality during initial hospitalization (46% vs. 1%, p < 0.001) and a lower rate of survival free of kidney failure. The incidence of AKI-D after pediatric heart transplant was 7%, with extended cardiopulmonary bypass time associated with postoperative AKI-D even in adjusted models. Further research is needed to improve the prediction and management of AKI-D in this population.

Early Use of Aspirin for Coronary Allograft Prophylaxis in Heart Transplant Recipients.

Coronary allograft vasculopathy (CAV) remains a significant cause of morbidity and mortality after heart transplantation. The use of aspirin for CAV prophylaxis has recently garnered interest as a possible therapeutic adjunct in this setting. This 2-center retrospective cohort study included 372 patients who underwent heart transplantation between January 2009 and March 2018 and were stratified according to the commencement of aspirin during their index transplant admission. The primary outcome was the development of moderate or severe CAV (International Society for Heart and Lung Transplantation grade ≥2) at surveillance coronary angiography. Secondary endpoints included mortality at follow-up. There were no differences in age, sex, and cause of heart failure. In the early aspirin group, the preponderant risk factors included use of ventricular assist devices, pretransplant smoking, and mild or moderate rejection. Multivariable analyses to assess for independent predictors of CAV development and mortality demonstrated that aspirin was associated with reduced mortality (adjusted hazard ratio = 0.19; 95% confidence interval, 0.08-0.47, P < 0.01) and a trend toward a protective effect against the development of moderate or severe CAV (adjusted hazard ratio = 0.24; 95% confidence interval, 0.54-1.19; P = 0.08). In this retrospective risk-adjusted 2-center cohort study, early aspirin administration was associated with reduced risk of death and a trend toward a protective effect against CAV development. These findings warrant validation in prospective randomized trials.

Changes in waiting time, need for mechanical circulatory support and outcomes in paediatric heart transplant recipients.

Heart transplantation is a well-established treatment for end-stage heart failure in paediatric patients, demonstrating excellent long-term outcomes. This retrospective study analyses 35years of data on 244 paediatric recipients (<18years) at a single institution from 1986 to 2022. The analysis explores changes in diagnoses, survival, waiting times and mechanical circulatory support (MCS) over three decades (1991-2000, 2001-2010 and 2011-2020). Survival outcomes significantly improved over the study period, with 1-year survival rates increasing from 79.3% (1991-2000) to 92.3% (2011-2020, P=0.041). The median overall survival was 18.0years, and median conditional survival to 1year post-transplant was 20.9years. Survival differences were noted among age groups, with infants under 1year of age experiencing higher early mortality, and adolescents (aged 11-17years) facing increased long-term risks, possibly linked to adult donor characteristics. Waiting times for heart transplantation increased, especially for younger age groups (0-5 and 6-10years), reflecting the growing demand for donor organs. The use of MCS, including ventricular assist devices (VAD), surged, with 67% of recipients in the most recent decade receiving pre-transplant VAD support. Importantly, despite prolonged waiting times and increased VAD use, overall survival continued to be favourable. Early and long-term results after paediatric heart transplantation have been continuously improving over the past decades. Despite an increased demand for donor organs and the growing reliance on VAD as bridge to transplantation, post-transplantation survival is not compromised.