As increasing numbers of patients become eligible for heart transplantation, a large undersupply of suitable donor organs has developed. By matching recipient risk with donor risk, an effective expansion of the donor pool can occur while patient outcomes are maintained and organ wastage is minimized. As the safety of extended criteria is tested, the use of such organs can become more commonplace for certain recipients who might otherwise be excluded from transplantation. Future developments in organ preservation may allow for further use of marginal donor hearts.