Over the past six decades, heart transplantation has evolved from an experimental procedure into a cornerstone therapy for patients with advanced heart failure. This progress has been driven by significant advancements in immunosuppressive therapy, surgical techniques, mechanical circulatory support, and organ preservation technologies, including the use of ex vivo perfusion systems and donation after circulatory death. These developments, while improving outcomes, have also introduced greater complexity to the perioperative management of heart transplant recipients. Anesthesiologists play a critical role in this process, requiring meticulous preoperative assessment, optimization of medical comorbidities, and strategic planning. Intraoperative care demands a nuanced understanding of the challenges posed by unstable hemodynamics, mechanical support devices, bleeding risks, and the logistics of graft transport and perfusion. Postoperative complications, particularly primary graft dysfunction, remain significant and often life-threatening. This chapter equips anesthesiologists with the essential knowledge to manage these complexities effectively and adapt to ongoing innovations in the dynamic field of heart transplantation.