Current status of heart transplantation in Japan

Heart transplantation (HTx) in Japan has significantly progressed since the Organ Transplant Law was enacted in 1997. Despite improvements in surgical techniques, immunosuppressive therapy, and postoperative care, Japan still faces major challenges. These include a persistently low rate of organ donation, long waiting times, and high mortality among patients on the transplant waiting list, as about 25% of registered patients died before receiving a heart transplant, while only 39% successfully received one. HTx remains the definitive treatment for selected patients with end-stage heart failure who have already received maximally optimized guideline-directed medical therapy and, in many cases, mechanical circulatory support (MCS) such as left ventricular assist devices, offering superior long-term survival and quality of life compared with these advanced therapies. Data from the International Society for Heart and Lung Transplantation and Japanese studies consistently show that HTx recipients experience improved physical function, emotional well-being, and social reintegration. This review summarizes the current status of HTx in Japan, including its history, institutional framework, clinical outcomes, and allocation challenges. It also discusses next generation HTx such as new allocation systems, integrating HTx with MCS, expanding donor availability with donation after circulatory death with innovations in ex-vivo heart perfusion and the potential of xenotransplantation, and liquid biopsy. By addressing systemic limitations and adopting new technologies, Japan can improve access to HTx and outcomes for patients with advanced heart failure.