Purpose of reviewToday, heart transplant offers a 1-year survival of 91% to select patients with end-stage heart failure. Since the implementation of heart allocation system change in Oct 2018, transplantation needs have to be met in critically ill candidates with high waitlist mortality. This brings forth the contemporary challenges of use of more patients bridged from mechanical circulatory support, use of marginal hearts, older donor age, allosensitization, donation after circulatory death, and hepatitis C-positive donors.Recent findingsAdvances in rejection surveillance and diagnosis, immunosuppression, and prophylaxis have no doubt increase the median survival post-heart transplant. However, long-term complications of malignancy, infections, and coronary allograft vasculopathy continue to threaten longevity. Evolving therapeutics in autoimmune diseases and cancer immunotherapy has generated much needed interest and research in antibody-mediated rejection pathways targeting B cells, plasma cells, cytokines, pathologic antibodies, and complement mechanisms.SummaryRecent innovations in diagnosis of rejection via peripheral gene expression profiling, improved surveillance of complications, and novel immunosuppression medications hold tremendous promise in the contemporary landscape of heart transplantation.