▪ Abstract  Cardiac transplantation remains the gold standard of surgical therapies for advanced and end-stage heart failure. However, this very limited option trades one disease for another and can benefit only a small minority of patients. Heart failure is currently considered secondary to a structural increase in ventricular chamber volume or remodeling. Surgical therapies formerly contraindicated for the failing heart, as well as new therapies, can successfully affect ventricular remodeling and improve cardiac function. Surgical revascularization for patients with ejection fractions <20% is becoming common. Mitral valve repair is being explored, with surprisingly low operative mortality and encouraging intermediate results. Direct surgical approaches to restoring normal geometry and size to failing hearts, such as left ventricular reduction (Batista procedure), endoventricular patch plasty (Dor procedure), cardiomyoplasty, and prosthetic external constraints are under clinical investigation. Developments in mechanical assist therapy and a new generation of implantable intracorporeal assist devices are also discussed.