Currently, heart transplantation is the gold standard of treatment for patients with end-stage heart failure. With the number of donor organs steadily decreasing, new surgical strategies have evolved. Selected patients with ischaemic cardiomyopathy or mitral valve insufficiency may be suitable candidates for conventional surgical procedures. New developments regarding assist devices such as LVAD and TAH increase our chances of employing these systems as a definite treatment option (destination therapy). New innovative concepts like external ventricular reshaping (Myosplints, CorCap) or left ventricular reconstruction are currently undergoing clinical evaluation. The clinical results of cardiac resynchronisation therapy offer a new treatment option for patients with LBB. The value of different treatment options and their role in modern surgical heart failure management is discussed.