There are a number of surgical alternatives to repeat artery bypass grafting, which is the primary treatment for recurrent severe myocardial ischemia. In patients with endstage coronary artery disease unsuitable for repeat bypass procedures, orthotopic heart transplantation is now well established. However, the increasing donor shortage limits this option to relatively few patients, a fact well documented by longer waiting lists despite less stringent donor criteria. Hence, other surgical therapies, which may at this time be underused, should be explored. In addition to mechanical circulatory support by means of implantable blood pumps which are now available with wearable drivers and rechargeable batteries, mention should be made of surgical left ventricular volume reduction and reverse remodeling, transmyocardial laser revascularization (TMR), and dynamic cardiomyoplasty. The mechanisms that explain the beneficial effects of the three latter procedures are not fully understood. But it may be speculated for these procedures that Laplace and Starling laws play a major role in the sometimes spectacular recovery. It is probably due to the complexity of the procedures mentioned, the severe condition of the patients, the high risk of a proactive attitude under such circumstances, and the significant cost, that the number of these alternative procedures performed is still rather low despite the fact that the results are similar to those of transplantation. However, careful individual evaluation is of prime importance for better results. The presence or absence of symptoms is certainly a major issue for the decision-making process. If the left ventricular ejection fraction is preserved, transmyocardial laser revascularisation may relieve angina. Dynamic cardiomyoplasty may be appropriate if the left ventricular ejection fraction is low, provided the heart is not too big and that there is neither too much mitral regurgitation nor major arrhythmia. If the left ventricle is very big and major mitral regurgitation is present, volume reduction giving transventricular access to the mitral valve can be evaluated. A decision-making tree is proposed.