Heart transplant (HT) has been considered as a therapy for pediatric end-stage heart failure (HF) for more than four decades. Children with HF represent a very heterogeneous population, affected by different congenital or acquired heart diseases. Progresses in cardiac surgery and medical therapies, leading to improved prognosis, require periodic re-assessment of indications to HT. Systemic diseases, inherited inborn errors of metabolism, genetic syndromes or associated extra-cardiac malformations can contraindicate HT. In these conditions a tailored evaluation is needed. Pediatric heart disease, which more often may be an indication to HT, as well as prognostic parameters in pediatric HF are discussed.