Heart transplantation has evolved as the "gold standard" therapy, with median survival exceeding 10 years, for patients with endstage heart failure (HF). Advancements in the fields of immunosuppression, infection prophylaxis, and surgical techniques have transformed heart transplantation from what was once considered an experimental intervention into a routine treatment. The number of heart transplants reported to the International Society of Heart and Lung Transplantation registry worldwide has been 3,500-4,000 annually, but has not been increased over the past 2 decades because of donor shortage despite the growing number of patients with HF. This imbalance between the supply of donor hearts and the demand of patients with endstage HF has led to increased use of mechanical circulatory support as destination therapy, because the supply of mechanical devices is virtually unlimited. Although mechanical circulatory support technology is improving, heart transplantation remains the preferred treatment for many patients because of major complications, such as stroke, bleeding and infection, and because of limited quality of life related to the driveline and the need for battery change. Therefore, significant efforts have been made to maximize the number of heart transplants and to ensure good outcomes.