One hundred sixty-eight children underwent heart transplantation from January 1989 to December 1992 at Loma Linda University Medical Center. Maintenance immunosuppression consisted of cyclosporine and azathioprine. Perioperatively, 19 patients required peritoneal dialysis, with a 42% hospital mortality rate. During a follow-up period ranging from 3 months to 4 years, major surgical procedures were performed on 72 patients (43%). Cardiovascular and thoracic interventions included balloon angioplasty of aortic coarctation (10 patients, 2 of whom later required surgical repair), permanent pacemaker placement (n = 4), extracorporeal membrane oxygenation (n = 4), right pulmonary artery banding (n = 1), retransplantation (n = 2), repair of pulmonary venous obstruction (three patients, one of whom underwent two more reoperations), thrombectomy of the abdominal aorta (n = 1), delayed sternotomy closure (n = 10), plication of the diaphragm (n = 5), tracheostomy (n = 2), and repair of lung herniation (n = 1). The overall procedural mortality rate for this group was 12.3%. There was one death associated with operations performed for conditions unrelated to the cardiac disease: hernia repair (n = 3), gastrointestinal procedures (n = 6), percutaneous gastrostomy (n = 5), and miscellaneous (n = 15). Risk factors affecting patient survival were the need for dialysis and the number (two or more) of pretransplant or posttransplant surgical procedures. Children with transplanted hearts can tolerate surgical intervention for treatment of complications or other untreated problems at an acceptable risk.