Combined heart and kidney transplant is a rare but valuable treatment option for selected patients with end -stage cardiac and renal failure. We present the long -term outcome of a 27 -year -old man with pulmonary stenosis previously treated with valvuloplasty in 1998, who subsequently developed end-stage renal disease secondary to glomerulonephritis and progressive dilated cardiomyopathy with intolerance to hemodialysis. In 2006, he received a combined heart and kidney transplant using organs from a 52 -year -old deceased male donor. Cold ischemia time was 6.5 hours, HLA matching was 3 /6, induction immunosuppression consisted of anti -thymocyte globulin, and maintenance therapy included tacrolimus, mycophenolate mofetil, and prednisolone; tacrolimus was replaced with sirolimus at the end of the first posttransplant year to minimize nephrotoxicity and reduce the risk of cardiac allograft vasculopathy. The postoperative course was uneventful, with extubation on day 1, transfer to the ward on day 4, and discharge on day 14. During the 20 -year follow -up period, 19 endomyocardial biopsies were performed, with only 1 episode of cardiac rejection, which occurred in the second posttransplant year and was successfully controlled by intensification of mycophenolate mofetil therapy. No kidney allograft rejection occurred, and kidney graft biopsy was not required. At the most recent follow -up, approximately 20 years after transplant, left ventricular ejection fraction was 40%, tricuspid annular plane systolic excursion was 15 mm, serum creatinine was 1.2 mg /dL, and the urine protein/creatinine ratio was 0.35. This case demonstrates that combined heart and kidney transplant can provide durable long -term survival with preserved renal graft function and limited cardiac rejection risk in carefully selected patients.