Despite tremendous advances in the medical management of congestive heart failure the gold standard for the treatment of end stage congestive heart failure remains cardiac transplantation. The acknowledged critical limitation of sufficient suitable organ donors has resulted in the refinement and development of novel surgical alternatives for the treatment of congestive heart failure. These approaches include the extension of current conventional cardiac operations such as mitral valve repair to the failing ventricle, surgically reconstructing the size and shape of the failing left ventricle in order to optimize geometry and render it a more efficient pump, and partial or complete replacement of the ventricle with a mechanical device. The continued evolution of such therapies is likely to one day have a significant epidemiologic impact on patients suffering from end stage heart failure.