Cardiac transplantation is the primary therapy for patients with end-stage heart failure, who remain symptomatic despite optimal medical therapy. For carefully selected patients, heart transplantation offers markedly improved survival and quality of life (Alraies & Eckman, 2014).

The most common indications for adult heart transplantation in the US for 2015 were cardiomyopathy (59.3%), coronary heart disease (35.0%) and congenital heart disease (3.2%) (Colvin et al., 2017).

Older patients are increasingly being considered for transplantation. In addition, there have been small increases in the number of patients requiring mechanical circulatory support (MCS) prior to transplantation, and those being evaluated for re-transplantation (Hunt & Haddad, 2008). Improvement in left ventricular assist devices has enabled their use as destination therapy for some patients with chronic heart failure, as well as a bridge to transplantation in others (Abraham & Smith, 2013).

Younger patients with complex congenital heart disease are also increasingly considered for transplantation. Worldwide the vast majority of transplant programmes carry out only a handful of paediatric heart transplants a year. In October 2017, the first international summit on controversies in paediatric end-stage heart failure and transplantation took place in Seattle. It is hoped that this is the first of many such conferences and the beginning of a collaborative process in this complex and controversial field (Chen et al. 2018).

Although an increasing number of heart transplants are taking place each year (Koomalsingh & Kobashigawa, 2018), acute rejection of heart transplants remains a problem with first-year rejection rates of 23% observed in the US in 2015 (Colvin et al., 2017). It is important to recognise that, although the available pool of heart donors should expand through better ex vivo preservation, more still needs to be done to optimise immunosuppression and patient outcomes (Koomalsingh & Kobashigawa, 2018).