Background Hypothermic circulatory arrest (HCA) has been used as an adjunct to cardiopulmonary bypass for decades, both electively and emergently, to facilitate a bloodless operative field while maintaining cerebral protection. The aim of this study is to determine the impact of HCA during heart transplantation on posttransplant outcomes. Methods All adult patients undergoing orthotopic heart transplantation at our institution between 2000 and 2012 were retrospectively reviewed. Patients were stratified based on need for HCA during surgery; patients who required HCA (HCA group, n = 25), and patients who did not (no-HCA group, n = 903). The primary outcomes of interest were 30-day and 1-year mortality and postoperative complication rate. Results Indications for HCA included control of significant hemorrhage (n = 9), need for distal aortic procedures (n = 9), or as an aid in difficult mediastinal dissection (n = 7). Mean duration of HCA was 22 ± 18 minutes at a mean temperature of 24.5° ± 5.5°C. Significantly more patients in the HCA group underwent transplant for congenital heart disease (16.0% HCA versus 2.8% no-HCA, p = 0.006), and patients in the HCA group had undergone more prior sternotomies (HCA 1 [interquartile range: 1 to 2] versus no-HCA 1 [interquartile range: 0 to 1], p < 0.001]. There was no statistical difference in 30-day mortality (8.0% HCA versus 4.2% no-HCA, p = 0.29) or 1-year mortality (8.0% HCA versus 12.3% no-HCA, p = 0.76). The HCA group had higher rates of reoperation for mediastinal bleeding and postoperative respiratory failure. Conclusions The need for HCA during heart transplantation is rare but, when required, it is frequently a life-saving adjunct to cardiopulmonary bypass. However, patients who require HCA have higher rates of postoperative complications. Risk factors for needing HCA during transplantation include congenital heart disease and more than one prior sternotomies.