Because of the lack of donor hearts, thousands of patients annually die with end-stage heart failure. Surgical alternatives to transplantation include partial left ventricular resection, dynamic cardiomyoplasty, and left ventricular assist devices. Partial left ventricular resection is an innovative procedure in which the heart is surgically reduced in size and cardiac function is dramatically improved immediately after surgery. Long-term follow-up is required to determine the success of this procedure. Dynamic cardiomyoplasty has been in use for 12 years. In properly selected patients, it results in significant amelioration of symptoms and improvement in quality of life. Improved survival and objective physiologic improvement have not been documented. A randomized trial is now in progress to evaluate survival with surgical therapy versus survival with medical therapy. Left ventricular assist devices have been shown to be extremely effective as a short- and long-term "bridge" to heart transplantation in mortally ill patients. They are not approved for long-term support as an alternative to transplantation in the United States, but a randomized trial is now underway to compare the efficacy of these devices with the efficacy of medical therapy in New York Heart Association functional class IV patients.