Adults with congenital heart disease (ACHD) represent a growing, albeit still small, proportion of heart transplant (HT) recipients (1, 2). These patients frequently present with complex anatomy and physiology, and atypical manifestations of cardiac failure. Despite being younger than other HT candidates, they have higher risk for adverse outcomes early after HT. This relates to prior thoracic operations, longer allograft ischemic time, a high prevalence of sensitization, less frequent use of pre-transplant mechanical circulatory support (1), and underappreciated end-organ dysfunction.