We report the case of a 30-month-old boy affected by severe cardiac failure in dilated cardiomyopathy requiring heart transplantation (HT), who was referred to our Emergency Department with a lightly symptomatic acute cardiac rejec-tion, suspected by point of care clinical ultrasound, performed by the Pediatrician. Despite the improvement in medical therapy and the development in mechanical circulatory support, HT still remains the best therapeutic option to im-prove survival and quality of life in patients with advanced heart failure. Rejection remains an important reason for death after pediatric HT and it can be unrecognized until more severe, because of a specific signs at presentation. Point of care ultrasound (POCUS) enhances the clinician’s ability to early recognize many pathologic patterns allowing a timely and targeted treatment, as we describe in this case report report.