Objectives: Adherence to the medical regimen is widely considered to be critical in order to avert late rejection episodes, graft loss, patient death, and decrease medical costs following heart transplantation (HTx). In order to reduce medical nonadherence, pediatric recipients should be managed educationally and mortally as well as medically. In the present study, our management of 27 pediatric HTx recipients was reviewed retrospectively. Patients and method: 27 pediatric HTx recipients managed in Osaka University Hospital between 1992 and 2011 were investigated. As Japanese Organ Transplant Act had not accepted brain dead organ donation from children under 15 years of age until 2010, only 4 children underwent HTx in our hospital, whereas in Loma Linda University (N=11), Columbia University (N=7) and the other foreign hospitals (N=5). The mean age at HTx was 8.7 years. Sixteen were younger than 10 years Thirteen were male. Underlying disease was dilated cardiomyopathy in 15, restrictive cardiomyopathy in 9 and others in 3. All children who underwent oversea HTx returned to our hospital before going back to home. After stabilizing doses of medication, the recipients and their parents were educated again about HTx, medication and complications after HTx under Japanese specific environment. They came to outpatient clinic monthly even children who lived far from Osaka. Daily medication, body weight, body temperature and blood pressure, if possible were recorded by themselves or their relatives, which were shown to the doctors and patient coordinators at the clinic. If any ebvents, such as viral infection of classmates, diarrhea etc, happened, they sent E-mail or called to our staffs. If the patient proceeded to the next stage of education, medical staffs went their school and guided teachers and other staffs taking care of the patient. To manage adolescent patients, inter-patient or parent communication was important. We suggested them to attend the Transplant Games or the Kid's camp in summer. Elder patient might support younger ones mortally. Results: The mean follow up after HTx was 6.3 years (5 months to 20 years). All except one who died of renal failure 11 years after HTx, survived. Patient survival after 10 and 15 years after HTx were 100 and 86%, respectively. Four worked fully. Nineteen went to school with full academic load (senior high school in 1, junior high school in 6, elementally school in 10 and kindergarten in 2). NYHA class was 1 in all. Three experienced post lymphproliferative disorder but were cured. One was considered to undergo reHTx because of graft coronary atheroscrelosis. One was considered to undergo hemodialysis. Although 2 girls experienced medical nonadherence and cellular rejection at 10 and 15 years of their age, respectively, they recovered and took medication steadily after the above intervention. Conlusion: Although the number of patients was small, educational and mortal support as well as strict medical management may play a role in reducing medical nonadherence and improving their quality of life and prolonging their survival after HTx in children.