In both studies, the LVEFs of the surgery and control groups were normal at baseline and similar at follow-up.231,248 Although severe HF or systolic dysfunction is considered a general contraindication to bariatric surgery,228,249 a few notable studies have investigated its safety and efficacy in obese patients with HF.232,243,244,250 In a retrospective study of 14 patients with HFrEF who underwent bariatric surgery (10 with laparoscopic Roux-en-Y gastric bypass) and had a Table 9. Recommendations for the Treatment of Obesity in Stages B and C HF: Patients With Cardiac Structural Abnormalities or Remodeling With or Without HF Symptoms Recommendations COR LOE Referenced Guideline References Purposeful weight loss via healthy dietary intervention and physical activity for the purposes of improving health-related QOL or managing comorbidities such as diabetes mellitus, hypertension, or sleep apnea may be reasonable in obese patients with HF. Sibutramine and ephedra weight loss preparations may contribute to the development of HF and should be avoided. COR indicates Class of Recommendation; HF, heart failure; LOE, Level of Evidence; and QOL, quality of life. Bozkurt et al decrease in mean BMI from 50.8 2.04 to 36.8 1.72 , significant improvement in LVEF from 23 2% to Similarly, in another retrospective report, 12 obese patients with HFrEF who underwent bariatric surgery had improvement in LVEF In both of these reports, patients also had improvements in NYHA functional class. Clearly, further prospective studies are needed to better define which patients can be safely re- ferred for bariatric surgery, the optimal surgical techniques, and the effects on long-term outcomes. 