Introduction PTLD is one of the most devastating complications in solid organ transplant, with an overall incidence rate of more than 10%. This limits survival in every age group after any solid organ transplant, the highest being pediatric thoracic. In the general population, up to 50% of individuals 0-18 years of age are EBV seropositive compared with 90% in adults. This outlines a strong association that seroprevalence has with age, supporting EBV as primarily a concern in pediatrics. 
In transplant, the highest risk of developing EBV disease is by transplanting organs from EBV seropositive donors into seronegative recipients, likely because initial exposure occurs in the absence of preexisting host immunity and immunosuppression. This risk is not mitigated for patients who were seronegative at transplant receiving EBV negative donor organs.  
In transition from pediatric to adult transplant care, emphasis on independent living with a chronic health condition has inadvertently lessened the focus on the details, such as close EBV surveillance. This change and programmatic differences have led to gaps in awareness of the significant PTLD risk in the EBV seronegative transplant population.  
Methods We did a retrospective analysis of AYA patients transferred to our adult heart transplant program between 5/2016- 8/2022. We reviewed donor/recipient EBV serostatus at the time of transplant, recipient serostatus at transfer, and recipient EBV surveillance monitoring. In the pediatric program, surveillance included assessing titers annually for all EBV naïve patients and monitoring PCRs (Polymerase Chain Reaction) for any who seroconvert.  
Results Within the identified timeframe, we transitioned 12 patients, 2 being 18 years of age at time of transfer. Average age of transfer was 20, with a range of 18-23 yrs. While most were seropositive, 2/10 patients > 18 yrs. were seronegative at transfer. All followed the surveillance protocol prior to transfer. Of the 2 seronegative patients, neither had follow up surveillance after and 1 of the 2 developed EBV driven PTLD requiring chemotherapy and prolonged hospitalization. While an outline for transition of care was in place in 2016, a more in-depth process has evolved focusing on seamless transfer and consistent follow up.  
Conclusions While EBV monitoring is routine for pediatric (thoracic) programs, it is inconsistent across adult centers. Meanwhile, burden of disease remains highest in the EBV naïve pediatric recipient. Implementation of similar EBV surveillance across the continuum of care as well as highlighting serostatus within a patient summary may attenuate unchecked viral replication and detect seroconversion. This is important given the risk association of high viral load and of time between initial viral detection and development of PTLD. Both approaches allow risk stratification and could avoid significant morbidity and undue healthcare costs in an already fragile population.