Cardiopulmonary transplantation is an effective and evolving treatment for advanced cardiac, pulmonary and pulmonary vascular diseases. With the marking of the 50-year anniversary of the first heart and lung transplantation procedures, the completion of 70,000 adult lung transplants and over 130,000 adult heart transplants, the process of heart and lung transplant continues to mature. Clinicians are faced with increasing complexities that come about from advancing recipient age, broadening of donor and recipient criteria, increased use of preoperative and postoperative mechanical support, advancements in ex-vivo organ perfusion and advances in post-transplant care. The aforementioned complexities, combined with a highly dynamic intraoperative period present unique challenges for the anaesthesiologist, as a member of the heart and lung transplantation team.