The case is described of the first 'domino-donor' operation performed, in May 1987, in the United States. A 28-year-old man with cystic fibrosis and end-stage lung disease received the heart and lungs of an anonymous donor and donated his heart to another man with ischemic cardiomyopathy. The operative procedures involved were similar to previously described techniques, with some modifications to boost the technical ease of each operation. In order to procure and transplant the multiple organs over a significant distance, the technique of cardiopulmonary bypass and profound hypothermia was employed. Similar domino-donor operations that have been performed since are surveyed, and key considerations in determining when to undertake this procedure are discussed.