*Purpose: The utilization of endomyocardial biopsy (EMB) in the post-transplant surveillance of pediatric heart transplant (pHT) recipients can be challenging for a myriad of reasons; however, EMB remains the gold standard in practice. Recently, the utilization of non-invasive biomarkers, such as donor derived cell free DNA (dd-cfDNA) (AlloSure, CareDx, Brisbane) have been used to identify organ injury in pediatrics to help alleviate these challenges. Our objective was to assess the performance and understand how AlloSure compared to data published in adult HT recipients.

*Methods: 614 samples from 338 unique patients were collected from June 2018 – November 2021. All patients were less than 15 years old and were managed across 61 transplant programs around the country. These samples were analyzed to determine the dd-cfDNA median and distribution in pHT recipients.

*Results: The median age at time of transplant was 6.24 years old [IQR 0.4 – 14.96]. The median dd-cfDNA of the stable patients was 0.12% [IQR 0.12 – 0.31]. Unstable patients seem to have a much wider range of elevated results the reasons for which are multifactorial. The population density kernel distribution mirrored a strongly negatively skewed distribution as previously reported in adults HT recipients.

*Conclusions: The distribution of dd-cfDNA in this cohort of pediatric patients less than 15 years old demonstrates that the overall distribution of AlloSure in pediatrics is similar to what has been previously published in adult heart recipients, with the stable pHT recipient having very low levels of dd-cfDNA.

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