Bariatric Surgery in HF Obesity surgery, or bariatric surgery, is recommended for class 2 obesity or above (BMI 35 kg/m2 ) and possibly in individuals with a BMI of 30 to 34.9 kg/m2 when associ- ated with comorbid conditions such as diabetes mellitus, sleep apnea, and systemic hypertension, but the safety and efficacy of bariatric surgery in patients with HF have not been ascertained. Bariatric surgery has been shown to improve cardiovascular risk factors, including sustain- able weight loss, reversal of diabetes mellitus, improve- ments in lipid profiles and inflammation, and a reduction in the frequency of apnea in those with OSA.228,247 In the Utah Obesity Study, a large retrospective cohort of 423 severely obese patients who underwent gastric bypass surgery compared with a control group of 733 severely obese subjects who did not have surgery, gastric bypass surgery was associated with a large reduction in BMI ; P<0.0001) and improved LV systolic function, as assessed by fractional midwall shortening, and improved diastolic function, as assessed by E/E ratio.230,232 Furthermore, in a long-term follow-up of the SOS study (Swedish Obesity Surgery), pa- tients in the surgery group compared with obese patients without surgery were more likely to have normal diastolic function and improved systolic function as defined by a slightly improved systolic myocardial velocity. 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. 