Cardiac transplantation is best therapeutical option for end-stage heart disease. Previous reports on the influence of the AB0 system on cardiac transplant outcome indicate that blood group identical transplants have a better outcome than blood group compatible transplants. As the demand for donor organs largely exceeds the supply, it is our policy to use blood group compatible local donors for transplantation if no suitable AB0 identical recipient is available. The aim of this study was to determine outcome after blood group compatible transplants. Between 1984-2003 a total of 915 cardiac transplants have been performed at our center. Median follow-up was 127 months. Patients were analyzed according blood group matching (AB0 identical (I) vs. AB0 compatible(C)). Moreover subgroup analyses within the different groups were made to identify potential differences. Groups were analyzed for survival, graft rejection and graftvasculopathy (CAD). Kaplan-Meier analysis was used and log-rank test was performed to detect differences. A total of 81 transplants (8.9%) were blood group compatible. The majority (n=32) were 0A transplants (40%) followed by 0B (n=19; 23%), AAB (n=17; 21%), BAB (n=7; 9%) and 0AB (n=6; 7%). Overall survival comparison showed no significant difference in long-term survival (10-year) between the two groups (I: 52.2% vs. C: 42.1%; p: n.s.). Yet there was a clear trend towards lower survival within the C group. (10a survival: 0B: 73.3%, AAB:58.8%, BAB:32.1%, 0A:27.6%; p = 0.0568). In contrast, Freedom from acute rejection was significantly different between I and C groups (71.4% vs. 49.9%; p<0.0001). There was no difference in incidence of CAD (62.5% vs. 60.3%) as well as severe CAD (76.8% vs. 77.9%). In conclusion: The results of our analysis show that AB0 blood group compatible transplants have similar outcomes in behalf of survival and CAD as AB0 identical transplant. Yet rejection rates are significantly higher in AB0 compatible transplants. This finding needs further investigation.