The increasing number of patients with heart failure has been a major driving force behind the development of ventricular assist devices. Heart transplantation (HT) offers the heart failure patient the opportunity to live free from mechanical assistance. Unfortunately, the number of hearts available for transplantation is relatively small and as such the number of operations performed in the United States in any particular year is in the thousands. Since most of these operations are concentrated in a few heart transplant centers, the average cardiac anesthesiologist is not likely to be involved in their care. As with the VAD patients, anesthetic management is focused on maintaining hemodynamic stability in spite of greatly impaired systolic and diastolic function up until CPB can be initiated. Following placement of arterial and central venous access, anesthesia induction is undertaken using a variety of techniques (eg, high-dose narcotic) depending upon patient's comorbidities and individual preference of the anesthesiologist. Inotropes and vasoconstrictors are employed to maintain blood pressure until CPB can be initiated. Should sternotomy not be readily accomplished, femoral-femoral bypass should be considered if the patient's hemodynamics deteriorate and access to the heart and great vessels is delayed. Sterile techniques as with all cardiac surgery patients must be scrupulous. Pulmonary arterial catheters are usually not floated, as the native heart will be excised, however if desired, a PA catheter can be placed in a sterile sheath for advancement into the grafted heart to assist in separation from cardiopulmonary bypass. Close communication between the anesthesia team, the surgical team, and the organ harvest team is critical to coordinate timely delivery of the heart to be transplanted in order to minimize the ischemic time prior to implantation.