A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the bicaval heart transplantation technique is superior to biatrial orthotopic heart transplantation (OHT). Altogether, 175 papers were found using the reported search, of which 20 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that many papers have documented the superiority of the bicaval technique over the biatrial technique for short-term outcomes. A meta-analysis of 41 papers on this topic found significant benefits for early atrial pressure, tricuspid valve regurgitation, return to sinus rhythm and even perioperative mortality. But for longer-term outcome, the largest series of 11,931 patients found no difference in survival between the two groups and the meta-analysis found no mortality differences at 1 or 3 years. The bicaval technique is also more demanding technically and has a slightly longer bypass and ischaemic time. The United Network for Organ Sharing (UNOS) database showed that in 2005 in the USA the bicaval technique has now become more popular than the biatrial technique (1083 procedures vs. 806).