There has been significant progress in heart failure treatment; its stages are defined as a management platform for cardiovascular specialists. Surgical ventricular restoration adds no outcome advantage in ischemic heart failure over coronary artery bypass surgery alone. Novel medical therapies may include cytokine blockade and the vasodilator, relaxin. Although diastolic failure is prevalent, its clinical significance is unclear. Cardiac resynchronization reduces mortality and hospitalization. Perioperative enoximone facilitates beta-blockade for prophylaxis against myocardial ischemia. Heart failure still determines outcome in pulmonary embolism and cardiac surgery. The practice of ventricular assist devices continues to progress. A profile system based on urgency of mechanical support will guide future outcome assessment. Clinical scoring systems will guide the management of right heart failure. Device flow determines the risk of cerebral hyperperfusion and neurologic dysfunction. Regardless of device type, renal dysfunction remains an important outcome determinant. Postoperative heparinization is increasingly challenged because of the risks of bleeding and heparin-induced thrombocytopenia. The practice of heart transplantation continues to mature. The bicaval rather than the biatrial technique improves short-term outcome. Oral sildenafil is effective for pulmonary hypertension and right ventricular support. Although immunosuppression with tacrolimus is beneficial, sirolimus is less nephrotoxic and preserves coronary vasomotor function. The induction of immunosuppression may be modified as it has a weak evidence base. Psychosocial factors also continue to influence clinical outcome significantly. The future of heart failure treatment is bright with signs of active growth and progress in this vibrant subspecialty.