Heart transplantation has been established as therapy in patients with terminal heart failure who remain severely symptomatic (NYHA III-IV) despite optimal drug therapy and surgical interventions other than transplantation. In addition to symptoms, various objective criteria are used to determine the patients most suitable for transplantation. Of these, peak oxygen consumption below 12-14 ml/kg/min, no irreversibly elevated pulmonary resistance, and no major concomitant disease are most important. However, conventional therapy of advanced heart failure has considerably improved over the last decade. Thus, heart transplantation may be avoided or at least postponed in many patients. Nevertheless, continuous treatment at a heart failure/heart transplantation clinic in collaboration with the general practitioner is essential in these patients. This may allow to closely monitor these severely ill patients and to select the optimal point of time for transplantation. Prognosis after heart transplantation is relatively good with a 10-year survival of 63%. However, graft coronary artery disease and lymphomas are still unresolved problems which limit the success of heart transplantation. Competent clinical monitoring, aggressive therapy of conventional risk factors and good co-operation of patients and doctors are the basis for a successful outcome.