In heart failure, a common undcrl~'ing filctor is thc .modification of tile heart's shape from elliptical to sl)hcrical. This usually rcsuhs from stretched remote muscle after ischcmia, secondary dilatation after valve insuflicicncy, and intrinsic myocite defects fi'om nonischcmic cardiomyol)athy. The normal heart has a helical shal)e, with an elliptical filler orientation that proceeds toward the apex. Nornlal lil,er shortening is only 15%, l,ut this structurally ol,lique fiber conformation causes a 60% ejection fraction. In contrast, congestive heart failm'c patients undergo a structural change and develop a spherical shape through alfieal dilation. Tiffs causes a more transverse fiber orientation, so that 15% normal fiber shortening allows only 30% ejection fractiold, with fiwther reduction after intrinsically abnormal myocites. Current surgical aplwoaches to the spherical shape can suecessfidly restore tile elliptical formation in ischemie disease by tile surgical ventricular restoration with good results. 3-5 Recent intraoperative echoeardiographic tests in nonisehemic dilated cardiomyopathy have defined the weakest area by evaluating how regional left vcntricular segments arc ahered by disease. Tile consequence was site-selected treatments to exelude either tile lateral wall or the SCl~tunl. 67 This approach was stimulated through evolving recognition of the basic fiber orientation pattern and how it is ahercd by dilation. Tile novel concepts and anatomic dissections of Francisco Torrcnt-Guasp ~;,9 defined tile normal cardiac structure and were then used to explain vcntricular dynanfics in health and disease, lie anatolnically unscrolled tile left ventricle to show that the cardiac configuration contains two loops: a transverse lmsal loop to embrace or buttress a helical apical loop that contains two reciprocal spiral components called descending and ascending segments. These oldiquely oriented fibers are responsible for twisting to eject, and for suction for venous return, and this shape can be surgically restored. Tile underlying geometric change in congestive heart failure occurs when tile apical loop becomes spherical so that the naturally oblique fibers assume a more transverse orientation through dilation and then resemble the basal loop. Site selection becomes critical in idiopathic dilated cardiomyopathy when tile underlying disease is inhomogcneous. Restoration of the normal shallc of tile heart can be achieved by excluding tile SClltum with an intraeardiac patch inserted between the papillary muscle and subaortic septum to restore the conical shape. Anatomically, this procedure Septal Anterior Ventricular Exclusion, but we call it Pacopexy in recognition of tlle contributions of Francisco (Paco) Torrent-Guasp.