Cardiac transplantation is an established therapy for end-stage heart failure. The number of heart transplant procedures performed worldwide has remained relatively unchanged in recent years. Although mortality rates on the waiting list have improved due to improved ventricular assist devices and rhythm correction techniques, it remains imperative to maximize use of all potential donor hearts. The recipient now presents with multiple complexities. The continued divergence between the rising number of transplant candidates added to the transplant waiting list and the number of suitable organ donors has increased pressure on clinicians to maximize the use of available thoracic organs for transplantation.