Since its inception in 1977, the Cardiac Transplantation Service at Columbia-Presbyterian Medical Center has performed more than 900 heart transplant procedures, with a one-year survival rate of approximately 80%, and a 5-year survival rate of approximately 60%. Throughout our 20-year experience, the criteria for eligibility both donors and recipients has widened to include older and "reanimated" donors for selected recipients, as well as an extensive experience with recipients bridged to transplantation with mechanical assist devices. Of particular interest in recent years has been the need for additional therapy for the highly sensitized transplant candidate and ultimate transplant recipient, whose immunosuppressive regimen must be continuously monitored and modified to ensure graft survival. In light of the persistent donor organ crisis, continued efforts are being developed to more accurately characterize the transplant candidate waiting list in order to identify those patients who may be better served by either medical management or an alternative surgical procedure to transplantation, including high-risk coronary revascularization and mechanical or biological assistance. Current research interests at CPMC include left ventricular assist devices, xenotransplantation, and management of both transplant coronary artery disease and immunologic sensitization. Ongoing investigations in these and other areas of transplantation have been established to encourage continued growth both within the field and at CPMC through the 21st century.