Background <p>Low family socio-economic status is a known factor that can contribute to increased mortality for patients with cardiovascular disease. However, in developing countries, the prognostic impact of socio-economic level on pediatric HTx is unclear.</p> Methods <p>We conducted a retrospective cohort analysis of children younger than 18 years who underwent heart transplantation (HTx) at our center from October 1, 2005, to May 31, 2023. To assess the impact of socio-economic status, we followed up with the discharged children until September 30, 2023, monitoring for all-cause mortality and unplanned readmission events. To evaluate the relationship between socio-economic status and prognosis, we assigned a composite score based on an assessment of household income, parental education level, and occupation. The Cox proportional hazards model and the Kaplan-Meier method were utilized for this analysis.</p> Results <p>64 children (median age at operation 14 years, IQR 13–15) were enrolled and one case died in hospital due to primary graft dysfunction, 63 (98.4%) children had a median follow-up of 60 months (IQR 5.9-113.9). During the follow-up period, 10 (15.9%) children died, and 20 (31.7%) children had 25 unplanned readmissions. Children had higher all-cause mortality and more unplanned readmissions in families with low socio-economic status (<i>n</i> = 33) than middle (<i>n</i> = 10) or high (<i>n</i> = 20) family socio-economic status. Hazard ratios were 5.99,(95%CI:2.28–10.64, <i>P</i> = 0.003) for all-cause mortality for low versus high family socio-economic status, and 2.53 (95%CI:1.04–9.43, <i>P</i> = 0.029) for middle versus high family socio-economic status.</p> Conclusions <p>Lower family socio-economic status is associated with a worse prognosis than high family socio-economic status. Measures to alleviate economic disparities are needed to improve the prognosis of pediatric HTx.</p>