Standards and new developments of thoracic organ transplantation are reviewed with particular focus on current treatment strategies, alternatives to transplantation, and xenotransplantation. The current indications for heart, single and bilateral sequential lung, and heart-lung transplantation as well as the technical aspects of each procedure are presented. Criteria for transplant recipients and absolute and relative contraindications are pointed out. Criteria for donor selection are also reviewed. The results of single, double-sequential, and heart-lung transplantation over the past 10 years as reported by the International Society for Heart and Lung Transplantation Database are stated. In addition, the experience of the lung and heart-lung transplantation program at the Hannover Medical School is reviewed, including the current immunosuppression regimens. This experience includes 1075 heart,heart-lung, and lung transplantations since 1983. The 1- and 5-year actuarial survival rates for heart transplant recipients are 81% and 70%, for heart-lung recipients 76% and 61%, and for single and double lung transplant recipients 77% and 59%, respectively. During the past decade there has been continuous improvement in the results of heart, lung, and heart-lung transplantation. Alternatives to thoracic organ transplantation, living-related lobar transplantation, new antirejection agents, and xenograft transplantation are areas for continuing and future investigation.