The number of heart transplants performed each year is steadily increasing around the world. Anesthesia and perioperative management are different in these cases. For an optimal perioperative management and improved postoperative outcome, a full understanding of the physiology of the denervated heart, post-transplant morbidities, and immunosuppressant pharmacology is required. We hereby discuss the perioperative management of a patient who had undergone orthotopic heart transplant and presented to our setup for left ureteroscopy.