Heart transplantation is considered emergency surgery, and there is often little time for extensive evaluation in the immediate preoperative period. This chapter covers the preoperative considerations and reviews the intraoperative management of heart transplant patients. Patients with severe heart failure are often on many drugs, including diuretics, angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists. Many of these drugs interact with anesthesia and should be taken into account. Following pre-anaesthetic assessment, induction of anesthesia should be performed after placement of essential monitoring. Initial pharmacological support is required during the period of weaning from cardiopulmonary bypass (CPB), and this initial management is described with ongoing support and choice of agent. After CPB, the transesophageal echocardiography (TEE) should focus on the ventricular function. Finally, there should be a careful and thorough handover to the team taking over the patient's care following transfer to the intensive care unit.