Traumatic experiences are not unusual in pediatric heart transplant (HT) recipients before and after transplantation. Post-traumat ic stress symptoms (PTSS) present at the time of transplant evaluation and developing after ward occur with an unknown frequency. We sought to determine the burden of these symp toms in heart transplant patients. We reviewed 51 consecutive HTs between 2003-2007, including 40 primary transplants and 11 re transplants. Symptoms were present in 17 of the 51 patients (34%) at the time of orthotopic heart transplantation evaluation. None met the criteria for full post traumatic stress disor der. Transplant complications were examined. Nineteen subjects of the total sample had rejection in the first year following transplant. Rejection rates in the first year was 41% for those with PTSS (7 of 17 patients) and 36% for those without (12 of 33 patients) (P=n.s). Of those patients presenting for a second heart transplant, 55% had PTSS at the time of trans plant evaluation and/or the peritransplant peri od; whereas, (28%) undergoing a primary transplant had PTSS. In addition to symptoms resulting from the disease process leading to HT and other prior experiences, the HT itself seems to present a large psychiatric burden on patients. All patients need to be followed before and after HT for signs and symptoms related to PTSS. Future studies should be undertaken to determine if preventative detec tion and treatment of patients with these PTSS symptoms early can lead to better outcomes.