Although surgical options exist, treatment for heart failure remains dominated by medical therapy. Even with optimal medical therapy, the mortality of heart failure continues to be high. Conventional wisdom in heart failure treatment leads many practitioners to believe that the patient is "too sick" for further operative procedures such as revascularization, valve repair or replacement and ventricular reconstruction. Improvements in intra and peri-operative care over the last 20 years have allowed for more complex procedures to be performed, and have improved the mortality rates of the more traditional surgeries. As the complexity of the operative procedure and morbidity of the patient has elevated so has the importance of a multidisciplinary approach in choosing treatment plans for patients. As the age of the population increases and acute management of ischemic heart disease improves, the prevalence of heart failure will likely increase. Improving access and changing treatment algorithms to include operative procedures can improve the treatment of heart failure patients.