Future improvements can be expected in cardiac transplantation in children. We continue to advance our understanding of the immune system, and to develop more specific immunosuppressive agents. Ultimately, the future for recipients may be improved by strategies such as induction therapy or donor-derived chimeric destined transfusions, designed to enhance the tolerance of the host to a human leukocyte antigen incompatible graft. Improvements in tolerance of the host would allow for reduction or elimination of many, if not all, of the immunosuppressive agents, and for longevity extending well into the adulthood. Survival, particularly for infants, has improved dramatically in the last decade. The most recent results from the registry of the International Society of Heart and Lung Transplantation/United Network for Organ Sharing show that recipients less than one year old at transplantation, who survive the first year, have greater than a 95% survival to four years (Fig. 1). As late outcomes continue to improve, transplantation will provide a better quality and duration of life for infants with hypoplastic left heart syndrome. It is possible, nonetheless, that some infants will require retransplantation, since the half life of a transplanted heart in children has been about 12 years. The alternative is conventional surgery with multiple palliative operations, and the need for later transplantation as end-stage cardiac function is reached. Efforts to increase potential donors and donor utilization can be supported by innovative schemes, such as ABO incompatible transplants. Additional efforts are made more urgent when the current data indicate excellent outcomes after transplantation, but a high mortality while waiting for transplantation.