Between 1987 and 2008, 45 patients have undergone cardiac transplantation in Hawai'i. This article summarizes the authors' experiences with cardiac transplantation over this 21-year period. The cumulative 1-, 3- and 5-year survival rates after transplantation have been 73.8%, 70.0%, and 63.2%, respectively. The corresponding survival rates have improved over the last eight years and are now 90.0%, 87.5%, and 83.3%, respectively. Despite clinical improvements, low patient volumes make the maintenance of a state-based program in Hawai'i difficult. Problems with financing and referral biases will need to be addressed if a local program is to continue.