Acute heart failure represents a severe complication of several cardiac disorders. Coronary artery disease, acute bacterial endocarditis or acute decompensation of preexisting heart valve disease as well as endstage cardiomyopathies are the most frequent underlying causes. Because of the high mortality, surgical therapy should be always considered in addition to medical treatment. However, any therapeutical intervention must be based on an immediate diagnosis to evaluate type and severity of the disease. Surgical options comprise coronary revascularization, valve replacement or--reconstruction as well as a temporary support by means of mechanical assist devices.