Despite our continued advances in the management of coronary artery disease, there have been no significant reductions in the morbidity or mortality related to end-stage heart failure. The syndrome of heart failure represents a common endpoint for several disease processes, however, at the molecular level there are certain biochemical similarities common to all failing myocardium. Targeting these derangements with gene therapy represents a promising option in the treatment of heart failure. In this review, we will discuss the common biochemical changes that occur in the failing heart, novel therapeutic targets, including the P-adrenergic receptor system and intracellular calcium regulation, and the vectors and transfer methodology responsible for delivering these transgenes to the myocardium.