Pediatric heart transplantation has improved to the point that the initially restricted ages and indications have expanded considerably. The number of annual pediatric cardiac transplants has remained stable, but the number of centers performing transplants continues on a downward trend. Currently the half-life (50% still alive) for children who underwent transplantation in the early 1980s is 11.5 years, with a conditional half-life of more than 14 years. An era effect in improved survival is evident for the first time. There is an association between morbidity and the type of immunosuppression regimen employed. The early posttransplant period continues to be the highest risk time. Early rejection correlates with poor late outcome. Transplant coronary disease continues to be the most significant cause of late mortality. Detection of transplant coronary disease may be improved by adjunctive noninvasive imaging such as dobutamine stress echocardiography. There may be dramatic changes in clinical transplant protocols as a result of experience and new technology. This review focuses on key advances in knowledge reported in the past year.