During the past 20 years, the number of older patients undergoing heart transplantation has steadily increased as a result of expanding indications for this procedure. At UCLA, 1,046 adult heart transplant procedures were performed from 1984-2004. Actuarial one-, 3-, 5-year survival rates for all recipients are 83%, 76%, and 72%, respectively. Our patients were grouped into 2 eras: those transplanted between 1984-1993 and those between 1994-2004. The current era, incorporating those patients transplanted between 1994-2004, may be defined by the introduction of pravastatin in 1994, which we have reported to benefit heart transplant patients. There were 403 adult heart transplant recipients in the pre-1994 era and 643 adult recipients in the current era. Additionally, patients were then grouped by age into those aged 18-61 years and those older than age 61 years. In the current era, there was less rejection and cardiac allograft vasculopathy (CAV) with improved survival and comparable survival in younger versus older patients. Although cellular rejection has decreased over the 1990's decade, we have reported that the incidence of noncellular or humoral rejection in our cardiac transplant recipients has remained unchanged despite improved immunosuppressive therapies. Thus, there appears to be a need for newer immunosuppressive agents to treat humoral rejection effectively. CAV is one of the major factors limiting long-term survival in heart transplant patients. Early CAV can be detected by intravascular ultrasound (IVUS), which is a new technology that detects intimal thickening in the donor coronary arteries. We demonstrated in the multicenter IVUS validation study that the progression of IVUS-defined intimal thickening > or = 0.5 mm in the first year after heart transplantation appears to be a reliable surrogate marker for subsequent mortality, nonfatal major adverse cardiac events, and the development of angiographic CAV through 5 years follow-up. The limitation on the number of transplants performed has been the number of donor organs available. We began the alternate list at our program in 1992, which is designed to match those patients excluded for regular heart transplant listing (mostly older patients) to marginal donor hearts which are unused. We have demonstrated that the alternate list patients who have undergone heart transplant have satisfactory outcomes. This has allowed expansion of the donor pool and offered heart transplantation to those patients who would not routinely have an opportunity for this life extending procedure.