ABSTRACT
During the last two decades, several advances have resulted in marked improvement in medium-term survival with excellent quality of life in pediatric heart transplant recipients. These were possible due to better donor and recipient selection, increased surgical experience in transplantation for complex congenital heart disease, development of effective rejection surveillance, and wider choice of immunosuppressive medications. Despite all of these advances, recipients suffer from the adverse effects of non-specific immunosuppression including infections, post-transplant lymphoproliferative disorders and other malignancies, renal dysfunction and other important end-organ toxicities. Furthermore, newer immunosuppressive regimens appear (so far) to have had relatively little impact on the incidence of allograft coronary vasculopathy (chronic rejection). Progress in our understanding of the immunologic mechanisms of rejection and graft acceptance should lead to more targeted immunosuppressive therapy and avoidance of non-specific immunosuppression. The ultimate goal is to induce a state of tolerance, wherein the recipient will accept the allograft indefinitely without the need for long-term immunosuppression and yet remain immunocompetent to other antigens. This quest is currently being realized in many animal models of solid organ transplantation and offers great hope for the future.