Today’s healthcare delivery system is challenged with an escalating number of heart failure patients who have exhausted medical therapy and overwhelmed the limits of organ transplantation. Scientific and technological advances over the last 20 years have now brought new surgical options to this vast patient population, ranging from ventricular restoration surgery to surgical gene therapy and beyond. This article reviews the myriad of surgical options that are available to these patients, their benefits and shortcomings, as well as potential future directions.