The number of people living with advanced heart disease is increasing rapidly as a result of improvements in cardiac treatments, better long-term survival from primary cardiac events, and the increase in the demographic of Americans over the age of 65. Successful living with advanced heart disease now often means patients must manage recurrent challenges to health and function from hospitalizations, exacerbations of illness, and cardiac procedures. Depression, anxiety and strain on intimate relationships are familiar problems for people with advanced heart disease that often go untreated. Though these problems have been studied in populations with acute coronary syndrome, there has been less attention focused on people in later stages of cardiac disease progression. Innovative psychological approaches are needed to address the emotional and behavioral challenges for patients coping with heart failure, implantable cardioverter defibrillators, ventricular assist devices, and heart transplant. This article describes common psychological difficulties for adults living with advanced heart disease and potential psychological targets for intervention.