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Background: Young severely obese patients with advanced heart failure may not be suitable candidates for cardiac transplantation because of surgical morbidity and availability of adequately sized donor hearts., Methods and Results: We report 2 patients with severe systolic dysfunction and Class IV heart failure despite maximal medical therapy who were considered for cardiac transplantation. Because of their severe obesity, transplantation was not considered an optimal therapy, and both were referred for bariatric surgery. The individuals had nonischemic cardiomyopathy. Both underwent laparoscopic vertical gastrectomy, minimizing surgical risk while providing definitive reduction in gastric volume. They experienced substantial weight loss and resolution of dyspnea. Inotrope infusion was discontinued in 1 dobutamine-dependent individual. They achieved weight reduction of 46 to 52 kg after the surgery. End-systolic volume index improved from 64 to 49 mL/m(2) and from 66 to 39 mL/m(2). Left ventricular ejection fraction improved from 20% to 45% and from 25% to 39%. They remain symptom-free and are no longer listed for transplant at 2 years' follow-up., Conclusions: Bariatric surgery may lead to improvement in left ventricular systolic dysfunction in young morbidly obese individuals with nonischemic cardiomyopathy. Potential explanations for the improvement in left ventricular function include reduced direct toxic effects of adiposity on cardiomyocytes and improved hemodynamics after weight loss. The potential for bariatric surgery to provide an alternative to heart transplantation in extreme obesity merits further study.