Despite considerable improvements in the medical treatment of heart failure (HF), the gold standard for the treatment of these patients remains heart transplantation. Nevertheless, in consideration of the shortage of organ donors, this procedure can be offered only to a small percentage of patients who could benefit from a new heart. A number of innovative approaches are being investigated in terms of improved survival and quality of life in patients refractory to medical therapy and excluded from cardiac transplantation lists. These procedures include the optimization of medical therapy, coronary artery bypass surgery and valve surgery in high-risk patients, ventricular restoration techniques, and the implantation of ventricular assist devices as destination therapy. Future therapies for HF could include stem cell therapy, associated with standard revascularization techniques or with other procedures such as ventricular assist devices implantation or ventricular restoration techniques, allowing the potential differentiation of implanted stem cells in a resting and unloaded heart. The modern approach to surgical treatment of HF is multidisciplinary, given that the number of alternative available options to heart transplantation requires a close collaboration between both cardiologists and cardiac surgeons in treating patients with end-stage HF who are not candidates for transplant.