Patients with heart failure represent a significantly ill cohort, and the survival of the most advanced heart failure patients is dismal with medical management alone. This cohort of advanced heart-failure patients benefits from several surgical treatments. Although several techniques for surgical ventricular restoration in the setting of left ventricular aneurysms have been described, the broader application of these techniques to patients with ischemic cardiomyopathy has occurred during the last decade. This review focuses on left ventricular aneurysm (LVA) repair and surgical ventricular restoration, ventricular assist devices, and cardiac allograft transplantation for the treatment of advanced heart failure. Indications for these procedures are addressed, as well as intraoperative technical features and postoperative management strategies.