Preoperative evaluation of heart transplant patients should focus on cardiac functional status and any symptoms or signs of heart failure. All such patients should be evaluated with ECG and TTE prior to surgery. Invasive monitors should be placed if/when warranted by clinical status and surgical procedure.The transplanted heart cannot respond to indirect acting agents such as ephedrine. In addition, it cannot respond to peripheral stimuli that might induce hemodynamic changes such as carotid massage, laryngoscopy, or Valsalva maneuvers. Beta effects (versus alpha effects) of epinephrine and norepinephrine are exaggerated in heart transplant recipients. Isoproterenol is the mainstay of chronotropic therapy; dobutamine can be beneficial as well. Epinephrine and norepinephrine should be reserved for refractory cardiogenic shock. General anesthesia is preferred (over regional anesthetics) because the denervated heart does not reflexively compensate for hemodynamic changes induced by use of regional anesthetics. Of note, EKG interpretation may show two P waves (one from the native atrium and one from the implanted atrium). The native (non-conducting) P waves should not be confused with complete heart block.