Cardiac transplantation has played a pivotal role in the therapeutic algorithm for anatomically uncorrectable congenital heart disease, particularly the failing single ventricle. The historical evolution from Kantrowitz to Bailey and beyond challenges the application of this scarce resource to complex cardiac malformations in the presence of physiologic and circulatory failure. While selection of cardiac transplantation as primary therapy for hypoplastic-left heart syndrome is currently rare, the failing single ventricle in various stages of the Fontan pathway is increasingly considered for this therapy. The results of transplantation in this complex situation have progressively improved and now approached the late outcomes for other conditions. Mechanical circulatory support for the failing single ventricle has recently carried infants and children to successful transplant. The development of miniaturized continuous flow pumps offers the hope of major new avenues of successful circulatory support for single ventricle patients. © 2012, World Society for Pediatric and Congential Heart Surgery. All rights reserved.