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age.48 Ischemic time (travel distance, complexity of surgery) and donor age should be taken into consideration for older pediatric candidates in deciding about accepting a potential donor heart Cold static storage has been the mainstay of organ preservation; however, alternate strategies are on the horizon, including continuous hypothermic or normothemic donor perfusion49,50 and donation after cardiac death.51 Although rarely a consideration in adults, in children the donor heart must be appropriately matched in size to the recipient Widely disparate ratios of weight between donor and recipient have been reported, with variable effects on outcome.52–55 Multivariable analysis of the ISHLT database has shown a ratio of less than 0.5 or more than 2.5 to be associated with an increased risk for mortality within the first year.2 However, donor-to-recipient weight ratio was not identified as a risk factor in a multivariable analysis of the PHTS registry.48 Surgical Techniques The basic techniques for implantation of a cardiac allograft have not changed significantly since their original description.56 In children, the size of the patient, the location of the heart, atrial arrangement, systemic venous anatomy, and pulmonary venous anatomy must all be taken into consideration when determining the surgical approach (Video 67.1) In some complex forms of congenital cardiac disease there may be a need to harvest portions of the pulmonary arteries, aorta, inferior vena cava, or the brachiocephalic vein to facilitate the anastomoses within the recipient These details should be planned during assessment prior to transplantation The surgical challenges pertaining to transplantation for patients with complexly malformed hearts have been summarized in the literature.57 There are two main types of atrial anastomoses, bicaval and biatrial The bicaval approach has been reported to be associated with fewer tachyarrhythmias, slightly better hemodynamics, less tricuspid regurgitation, a lower incidence of pacemaker support, and better exercise tolerance.58,59 The biatrial technique (usually reserved for smaller patients) has been associated with disturbances of conduction requiring the placement of pacemakers in up to onesixth, a higher risk of thromboembolism, poor atrial synchrony, and more atrioventricular valvar regurgitation due to distortion of the atrial anatomy The only randomized trial demonstrated that the bicaval technique resulted in better hemodynamics and survival.60 Management of the Recipient There are several important postoperative issues that must be anticipated and appropriately managed in the recipient The acutely denervated heart is frequently in slow sinus or junctional rhythm Ventricular dysfunction as a result of ischemia-reperfusion injury, compounded by brain death of the donor, can lead to acute decompensation of the transplanted heart, right ventricular failure being a specific concern The latter is exacerbated by elevated pulmonary vascular resistance In general, strategies of postoperative management include the following: (1) maintaining coronary arterial perfusion and systemic blood pressure by inotropic support; (2) pulmonary vasodilators to reduce the right ventricular afterload and pulmonary vascular resistance; (3) chronotropy with either pacing or isoproterenol; (4) optimization of preload to the ischemic and dilated right ventricle by limiting the circulating volume and central venous pressure, especially if there is systemic hypotension and/or low cardiac output unresponsive to fluid boluses; (5) ensuring an atrioventricular synchronous rhythm; (6) optimizing ventilator management to avoid hypercapnia and acidemia by optimizing peak early expiratory pressures and early extubation; and (7) providing early mechanical assistance to facilitate recovery of the transplanted heart if clinically warranted Specific Postoperative Complications Stenosis can develop at any of the anastomosis sites including the systemic venous anastomoses, the pulmonary arterial anastomoses, or the anastomosis of the reconstructed aorta These may be amenable to interventional treatment, usually requiring implantation of stents Less commonly, the size of the left atrial anastomosis may be a problem If it is hemodynamically significant and not recognized in the operating room at the time of the postoperative transesophageal echocardiogram, it will likely cause hemodynamic instability in the immediate period subsequent to transplantation and may require early reoperation Posttransplant Education The transplant team provides support and education to the family regarding recovery and possible posttransplant complications Signs and symptoms of rejection and infection must be reviewed and the transplant coordinator must arrange for necessary discharge education with transplant team members from the pharmacy, psychosocial, and dietary departments Other key teaching points for the family include medications and their side effects, healthy living, when and how the family should contact the transplant team, physical activity, regular dental exams, cancer screening, bone health, sexuality, pregnancy and birth control, and travel The family should be educated regarding routine posttransplant care as per each center's clinical practice