Although drug therapy of patients with chronic heart failure has improved significantly over the years, mortality still remains high. At present, heart transplantation is the gold standard therapy for patients with end stage heart disease. Due to the limited number of organs, a growing number of patients require the implantation of mechanical assist devices.Because of the excellent long-term survival after cardiac transplantation, current studies focus on long-term complications. The aim of these studies is the establishment of an immunosuppressive strategy that effectively prevents cardiac allograft vasculopathy in combination with a low incidence of negative side effects. Furthermore, quality of life is a major focus of current interest.Assist device implantation has changed from an experimental to a routine procedure in several centers. Still, many problems have to be solved. Especially because of recurrent infections the long-time use of assist devices is limited. For final judgment, results of current studies have to be awaited.