Heart transplantation (HT) remains the best treatment for selected patients with advanced heart failure (HF). Patients with New York Heart Association (NYHA) class IIIB and class IV HF are best discussed with the local HF/transplant center to optimize medical management and to consider high-risk non-transplant surgery where appropriate. Patients who require HT may have severe ventricular dysfunction. Exercise capacity is known to correlate with prognosis in advanced HF. Chronic HF is associated with a high left ventricular end-diastolic pressure (LVEDP), which in turn leads to pulmonary venous and pulmonary arterial hypertension. The best studied scoring system in the context of predicting the need for HT is the HF Survival Score (HFSS). Older patients run a higher risk of post-transplant malignancy and renal dysfunction as compared with younger recipients. Combined heart-liver transplantation has been increasingly performed, but data on patient and graft outcomes remain limited.