Heart transplantation is now firmly established as the most effective therapy for selected patients with end-stage heart disease who have exhausted all other treatment options. The excellent long-term survival and quality of life achieved by the large majority of heart transplant recipients has led to considerable broadening of the recipient eligibility criteria over the past 24 years of continuous transplant activity in Australia and New Zealand. Although these changes in recipient eligibility criteria have resulted in a marked increase in the potential pool of transplant recipients, heart transplantation remains a relatively rare procedure because of the scarcity of suitable cardiac donors. The primary aim of this review was to provide clinicians with guidelines that enable them to identify patients who are potential candidates for heart transplantation and those who are not. Appropriate timing of referral is also discussed. Apart from their role in the evaluation and management of patients referred for heart transplantation, cardiopulmonary transplant units provide a number of other important services. These include assistance in the diagnostic evaluation and management of patients with primary myocardial diseases and the investigation of novel alternative therapies for patients with end-stage heart disease.