The number of heart transplantation in Japan has gradually increased since the revised organ transplantation act became effective in July 2010. The long-term survival after heart transplantation is superior, compared to the survival in Europe and United States of America( USA). However, the number of patients on a waiting list is rapidly increasing due to an extreme donor shortage. Because of stagnating heart transplantation, there is a need for an optimal solution to an insufficient donor organ supply. We have experienced 125 adult heart transplantations with acceptable survival rate of over 90% at five years. On the other hand, an expected waiting period is lengthening to far longer than five years. Here, based on our experience, we describe the "real world" outcomes and mention the future aspect of the patients on the waiting list on ventricular assist device (VAD). Our suggestions are 1) to promote VAD weaning in patients with myocardial recovery, 2) to aggressively utilize marginal donors, and 3) to expand the indication to destination therapy.