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The gap between the number of potential recipients of a cardiac graft and the availability of donor hearts is still growing. A proper selection of heart transplant candidates is mandatory to ensure that patients in critical need, who are likely to benefit from this procedure, are identified. The work-up of a patient with terminal chronic heart failure includes a comprehensive cardiac and systemic evaluation. Critical in the decision is the exclusion of irreversible pulmonary hypertension. Furthermore, underlying diseases that could compromise short- and long-term prognosis after transplantation should be carefully assessed. The mortality on the waiting list and the growing pool of patients with chronic heart failure that is excluded from transplantation has stimulated the search for alternative treatment modalities. Besides a pharmacologic approach, the last few years have witnessed a tremendous evolution in so-called mechanical devices, designed to improve both morbidity and mortality of these patients. Although several of these devices have only just entered the clinical phase, internal cardioverter defibrillators, left ventricular assist devices and biventricular pacemakers can no longer be viewed as experimental tools.