More than 30 years of experience in cardiac transplantation have resulted in cardiac transplantation being the primary therapeutic choice for patients under 65 years of age who have advanced heart failure and who remain symptomatic despite maximal medical therapy. The success and widespread use of cardiac transplantation is attributed to more liberal guidelines in recipient and donor selection, effective immunosuppressive therapy, close monitoring for rejection, and effective management of rejection. This article presents the current status of recipient and donor selection, surgical techniques, postoperative care, immunosuppression strategies, and rejection monitoring and management. Challenges associated with allocation of organs continue.