The objective of this focused review is to describe the rationale, methods, and potential clinical applications of dobutamine stress echocardiography (DSE) in heart transplant recipients. More than 500 studies in 150 heart transplant patients who underwent this procedure (1991-96) are reviewed. Relevant studies from the medical literature that have assessed the utility of DSE in the diagnosis of transplant coronary artery disease (TCAD) are discussed, the predictive ability of DSE for development of TCAD is determined, and the prognostic value of this test in the heart transplant population is evaluated. The protocol of DSE used in the laboratory for this study is presented and discussed with reference to other major studies that have determined the sensitivity, specificity, and positive and negative predictive accuracies. Since many noninvasive cardiac tests have not been consistently optimal to detect TCAD, a substantial number of patients undergo routine surveillance with coronary angiography to define the presence and magnitude of TCAD. Recent studies with DSE have shown it to be valuable in the noninvasive diagnosis of TCAD and to have an accuracy unmatched by other widely used imaging modalities. Other important evolving indications for DSE in heart transplant patients, such as prediction of prognosis and occurrence of cardiac events, are briefly discussed. Based on this study and the currently available literature, DSE appears to be a highly reproducible noninvasive test which can be serially employed in the routine surveillance of coronary artery disease in heart transplant patients.