The expanding role of cardiac transplantation as well as mechanical and antiarrhythmic bridging requires a critical reflection of the economic impact of these therapeutic modalities. Based on assumptions from the pertinent literature, cardiac transplantation requires costs of about 55,000 DM per year of life gained by the procedure. Even if a maximum social and professional reintegration percentage of about 60% is assumed, it does not seem possible to perform the procedure without additional costs to the health care system. The consequences of this are the following: 1) Cardiac transplantation should only be performed by centers experienced in all aspects of terminal heart failure care including a heart failure program, high-risk conventional surgery program, mechanical and antiarrhythmia bridging program, and qualified post transplant care program. 2) In order to evaluate potentially cost-saving therapeutic strategies in cardiac transplantation, multicenter trials have to be conducted which require a continuous scientific working group and research data organization based on the consensus of all participating transplant centers. 3) An improved professional reintegration program is necessary. 4) The ethical foundation for offering cardiac replacement to patients, namely, the responsibility for the individual person's well-being, has to be emphasized by physicians active in the field. 5) The society as a whole, not the group of physicians active in the field, has to debate and decide on how many resources should be spent in this field of health care. 6) Since potential cardiac transplant recipients are, to a large extent, recruited from patients suffering from coronary artery disease, it is essential to incorporate a primary preventive perspective into this high-technology field of medicine.