The 1-year survival rate after heart transplantation has improved since 1967 from ±30% to ±70%, and the 5-year survival rate is now ±50%. This improvement has brought renewed interest in this procedure, now done in about 20 centers in 8 countries, and increased confidence has widened the indication to patients who are less than terminally ill, to restore quality of life. This trend is illustrated by the Cape Town series, which can be divided into 2 parts: 10 patients treated by orthotopic heart transplantation (OHT), from 1967 to 1973, and 40 patients treated by heterotopic heart transplantation (HHT), from 1974 to 1981. The HHT group was younger (mean 37 ± 10 years versus 51 ± 9 years, p < 0.001), had been ill for a shorter length of time (mean 3.6 ± 0.7 years versus 6.6 ± 1.4 years, p < 0.091), and were in a lower New York Heart Association (NYHA) class (mean 3.45 ± 0.11 versus 3.9 ± 1.0, p < 0.006). The improved survival is linked to patient selection, progress in management, and switch to HHT, but not to progress in matching between donor and recipient. Since there is no means to predict tolerance of the donor heart, HHT limits the risks from unforseeable mismatch. The recipient's heart is a built-in assist device, maintaining life when the donor heart fails acutely at operation or during acute (3 cases) or chronic (2 cases) rejection. Had these patients undergone OHT they would have died. Comparing the 10 oldest HHT patients with the OHT series, no difference in pretransplant parameters was found. However, survival of HHT recipients was no longer during the critical post-HHT period: at 3 months, p < 0.011; at 6 months, p < 0.05. Larger series will separate the effects of progress in management from the intrinsic advantages of HHT. Retaining the recipient's heart is logical and has brought few complications. Survival rate of 40 HHT patients was 73% at 6, 65% at 12, and 51% at 36 months; 85% of survivors are in NYHA Class I. In patients in less than desperate condition, but who refuse to remain cripples, HHT eliminates the growing ethical problem of removing a recipient's heart that may still support the patient.