In this lecture, Anne Dipchand discusses the challenges of complex paediatric recipients. Some key evolving areas include HLA antibodies, complex cardiac anatomy, and the impact of ventricular assist device technology on our practice and on waitlist mortality. The goal should be to identify infants who have “suboptimal” characteristics for staged surgical palliation so that they can be considered sooner for heart transplant, ideally prior to the accrual of additional risk factors for mortality after heart transplant. We hope you enjoy this lecture.