One hundred forty-three patients underwent cardiac transplantation from 1980 to 1985; 122 received a heart, 19 received a heart-lung, and two received a heart-liver transplant. All patients received immunosuppression with prednisone and cyclosporine. General surgical complications have developed since transplantation in 40 patients (28%). Of these, 17 patients have required surgery: exploratory laparotomy (10 patients), inguinal or ventral herniorrhaphy (two patients), repair of false aneurysm of the femoral artery (two patients), repair of lymphocele of the groin (two patients), and incision and drainage of a perirectal abscess (one patient). Of the 10 patients who required laparotomy, three underwent sigmoid resection for a perforated sigmoid diverticulum (all survived), two underwent small bowel resection for perforation (both died), two had free intraperitoneal air with no site of perforation found (one died), one underwent a cholecystostomy and one a cholecystectomy for acute calculous cholecystitis (one died), and one underwent an elective pyloroplasty for gastric outlet obstruction secondary to vagus nerve injury during heart-lung transplantation and survived. All patients who underwent elective surgery survived. Six patients died without operation and at autopsy were found to have unrecognized general surgical complications including pancreatitis (three patients), cecal ulceration with sepsis (two patients), and jejunal perforation secondary to peritoneal dialysis (one patient). Eleven other patients had severe abdominal pain and five had gastrointestinal hemorrhage not requiring operation. Proper management of these patients includes early and aggressive diagnosis of conditions requiring operative intervention, strict attention to surgical technique, and careful titration of dose of immunosuppressive drugs. The 28% incidence of general surgical complications associated with heart and heart-lung transplantation emphasizes the role of the general surgeon in the management of these complex patients.