Cardiac transplantation remains the primary therapeutic choice for most patients under 65 years of age with advanced heart failure who remain symptomatic despite maximal medical therapy. Cardiac transplantation should be reserved for those patients most likely to benefit in terms of both life expectancy and quality of life. The concept of survival benefit margin must be balanced with the principles of utility in the selection process. A critical component of outcomes research for advanced heart failure will be the generation of accurate data and analyses which predict long-term survival and quality of life with various therapeutic modalities. Patients with multiple comorbidities have inferior survival and might be considered for alternative therapies. We currently recommend the bicaval techniques as the transplant technique of choice except in small infants and children.