Congestive heart failure (HF) remains one of the leading causes of morbidity, mortality, and hospitalization in adults in the United States. Advances in pharmacologic and device therapy for HF, and their associated reductions in morbidity and mortality, have led to increasing numbers of patients progressing to advanced stages of the disease. Of the approximately six million adults with HF, it has been estimated that 20% have ACC Stage D disease—the group of patients who should be considered for advanced heart failure therapies. Unfortunately, this potential pool far exceeds the roughly 3500 cardiac transplantations that are performed in the North America, and the 5700 performed worldwide, in each of the last several years. This chapter will discuss the indications for cardiac transplantation, risk stratification of patients with advanced disease, and the evaluation of the potential transplant candidate.