Heart failure (HF) is an emerging epidemic affecting 15 million people in the USA and Europe. HF-related mortality was unchanged between 1995 and 2009, despite a decrease in the incidence of cardiovascular disease. Conventional explanations include an aging population and improved treatment of acute myocardial infarction and HF. An adverse relationship between structure and function is the central theme in patients with systolic dysfunction. The normal elliptical ventricular shape becomes spherical in ischemic, valvular, and nonischemic dilated cardiomyopathy. Therapeutic decisions should be made on the basis of ventricular volume rather than ejection fraction. When left ventricular end-systolic volume index exceeds 60 ml/m², medical therapy, CABG surgery, and mitral repair have limited benefit. This form-function relationship can be corrected by surgical ventricular restoration (SVR), which returns the ventricle to a normal volume and shape. Consistent early and late benefits in the treatment of ischemic dilated cardiomyopathy with SVR have been reported in >5,000 patients from various international centers. The prospective, randomized STICH trial did not confirm these findings and the reasons for this discrepancy are examined in detail. Future surgical options for SVR in nonischemic and valvular dilated cardiomyopathy, and its integration with left ventricular assist devices and cell therapy, are described.