Since November 1974, heterotopic cardiac transplants have been performed at this unit in preference to orthotopic transplants. A number of reasons have led us to prefer this technique, namely donor malfunction in the immediate postoperative period and during rejection; right ventricular failure of the donor heart in the orthotopic position in patients with pulmonary hypertension; the ease of patient management; and the use of the donor heart as a temporary method of cardiac support. Disadvantages are the later recognition of rejection and the difficulty in performing transvenous endomyocardial biopsies. The results are satisfactory giving a 1, 2, and 3-year survival rate of 62%, 58%, and 50%, respectively.