**Abstract**

The first heart transplantation (HTx) done by Dr. Wada in 1968 misled the general public not to allow to do brain-dead organ transplantation in Japan. It took almost 30 years to issue the Organ Transplantation Act to allow us to perform HTx in Japan. However, this Act required living written consent for brain death and organ donation. Therefore, children younger than 15 years could not donate their organs under brain-dead condition. After 6 years of struggle to revise this Act, the revised Act was issued in 2010 and brain-dead organ donation as well as HTx increased then. But the number in a year has been still extremely less than other developed countries in Japan. Then, we established a special donor management and assessment system to maximize donor organ availability as well as to improve post-transplant outcomes. During these periods, many types of mechanical circulatory supporting (MCS) have been introduced in Japan. Moreover, there have been many developments in immunosuppressive regimens and monitoring to improve outcomes after LVAD implantation and HTx. The chapter will summarize the past, current status, and future aspects of HTx as well as MCS in Japan.

**Keywords:** heart transplantation, mechanical circulatory support, donor assessment and management, immunosuppressive regimen, organ transplantation network system
