Long-term pediatric heart transplantation

Pediatric heart transplantation remains the definitive therapy for selected children with end-stage heart failure. Short-term outcomes over the last decades have shown excellent survival; however, long-term outcomes remain a challenge. Cardiac allograft vasculopathy is the leading cause of late graft failure and mortality beyond the first year post-transplant. Chronic rejection, renal dysfunction related to lifelong immunosuppression, and post-transplant lymphoproliferative disorders are major contributors to late morbidity. Adolescents face an increased risk of graft loss, largely driven by nonadherence, which is most frequent during the transition to adult care. Growth, neurodevelopment, and quality of life are generally favorable, especially in children who undergo transplantation at younger ages. Re-transplantation is an option when graft dysfunction, but it is associated with inferior outcomes compared with primary transplant. This article explores detailed chronic post-transplant complications, including rejection, cardiac allograft vasculopathy (CAV), graft failure, infection, renal dysfunction, and malignancy, which influence long-term results. We highlight that a multidisciplinary approach with a special focus on the transition from pediatric to adult care, individualized immunosuppression, adherence support, cardiac rehabilitation, and early detection of graft vasculopathy is essential to further optimize long-term outcomes.