Background ABO‐incompatible heart transplantation (HTx) has become a standard procedure for children below 2 years of age due to an immunologically immature immune system and associated low isohemagglutinin titers. Methods We report a case of an ABO‐incompatible HTx (recipient blood group O, donor blood group A) at the age of 5 years and 11 months with a fully matured immune system and previously high isohemagglutinin titers that diminished as a result of human leucocyte antigen (HLA) desensitization therapy with rituximab and immunoglobulins. Results The anti‐A titer at the time of HTx was 1:16 with post‐transplant isoagglutinin titers never exceeding 1:4 without any signs of rejection with now 3 years of post‐HTx follow‐up. Conclusions ABO isohemagglutinin titers should be routinely assessed in children undergoing desensitization therapy since ABOi transplantation can be considered in selected cases to expand the donor pool with the option of crossing the ABO barrier to find a better‐matched allograft.

Background VAD support for early graft failure after HTx is a rare event in pediatrics. Methods We retrospectively describe our single‐center experience with post‐HTx VAD support in a cohort of patients transplanted between 01/05 and 12/20. Results Nine patients underwent VAD insertion in the early post‐HTx period [median age 6.1 years (Range 0.3–20.3), median weight 17.6 kg (Range 3.5–65.0), and congenital heart disease (67%)]. Of the nine patients with early graft failure, almost half (44%) were implanted after 2015 and all of these patients had a pre‐HTx plan for possible post‐transplant VAD insertion. Time to VAD implant was a median of 0 day (Range 0–11). Total time on VAD support was a median of 12 days (Range 3.0–478.0). Two‐thirds (n = 6; 67%) of the patients were weaned from support, retransplanted (11%) and two patients died (22%). In all of the patients where post‐HTx VAD was anticipated there was 100% survival. Conclusions In this small patient series, post‐HTx VAD was a useful measure in selected patients especially with pre‐HTx planning. However, more shared experiences to verify these findings are needed.