Contemporary Heart Transplantation: Epidemiology, Selection, Surgical Practice, Immunobiology, Outcomes and Future Directions

Background: Heart transplantation is the reference standard for selected patients with 
advanced heart failure, but its use is constrained by donor scarcity, increasing recipient 
complexity, and the burden of long-term allograft surveillance and immunosuppression. 
Contemporary guidance from ISHLT, AHA and ESC has materially changed candidate 
evaluation, donor assessment, perioperative management and post-transplant monitoring. 
Methods: A structured narrative review was undertaken using major society guidelines, 
official registry reports and peer-reviewed literature prioritising primary studies, 
consensus documents and reviews published mainly between 2015 and July 2026, with 
older landmark studies retained where necessary for key concepts such as primary graft 
dysfunction and rejection classification.  
Results: Current evidence supports transplantation in highly selected patients with 
refractory stage D heart failure after multidisciplinary assessment of haemodynamics, 
end-organ function, frailty, psychosocial readiness and competing comorbidity. Donor 
selection has broadened through better size matching, coronary screening in older donors, 
and use of DCD recovery pathways. Bicaval orthotopic transplantation is generally 
preferred over biatrial implantation because of more favourable early and late outcomes, 
while heterotopic transplantation is now rare and reserved for exceptional anatomical or 
pulmonary vascular scenarios. Standard maintenance immunosuppression remains 
calcineurin inhibitor-based, usually tacrolimus with mycophenolate and corticosteroids, 
with selective use of induction therapy and mTOR-based renal-sparing or vasculopathy
targeted strategies. Endomyocardial biopsy remains the cornerstone of rejection 
diagnosis, increasingly complemented by gene-expression profiling and donor-derived 
cell-free DNA in selected patients. Contemporary survival is excellent at 1 year in North 
America and Western Europe, but late complications including cardiac allograft 
vasculopathy, chronic kidney disease, infection and malignancy continue to limit 
durability.  
Conclusions: The field is moving towards individualised donor-recipient matching, risk
adapted immunosuppression, expanded donor pools, and translational programmes in 
xenotransplantation and tolerance induction; however, equitable access, ethical 
governance, and prevention of late graft failure remain decisive priorities.