The operative procedure of cardiac transplantation, whether orthotopic or heterotopic, must be performed with meticulous attention to technical detail and hemostasis. The price for technical misadventures and bleeding complications is high in terms of patient morbidity and mortality. Few cardiac surgical procedures are more straightforward than a heart transplant performed in a young individual who has not undergone previous cardiac surgery. Few greater technical challenges exist, however, than the patient in a state of precarious hemodynamic balance undergoing heart transplantation in the wake of one, two, or more previous cardiac surgical procedures. The principles outlined herein will serve as a foundation for the safe performance of cardiac transplantation regardless of the situation.