From September 1988 until March 1990, 22 orthotopic heart transplantations (HTX) were performed in 20 patients (18 male and 2 female). Median age was 56.5 years (23-66). The indication for HTX was an end-stage ischemic disease in 7 pts. a dilated cardiomyopathy in 13 pts, and a retransplantation in 2 pts. The mean waiting time was 58 days. Immunosuppressive therapy included OKT3, prednisone and azathioprine. Cyclosporine was introduced at day 10. Donor hearts were obtained from our institution in 5 cases, from other hospitals in Belgium in 9 cases, and from other European countries in 8 cases. The mean ischemic time was 129 +/- 28 min. No patient died in the operating room. During the first postoperative month, weekly endomyocardial biopsies were performed to detect early rejection. Five patients died in the early postoperative period, mainly from rejection. After a mean hospital stay of 23 days, 15 patients (75%) were discharged. During the late follow-up, 3 patients died: 1 from chronic mediasdinitis, 1 from hypoglycemia, and 1 from cardiac arrest following non-compliance with the medical treatment. In conclusion, early acute rejection after HTX still remains a major cause of death.