BACKGROUND:Left ventricular assist device (LVAD) therapy has revolutionized the treatment options for patients with advanced heart failure. Patient selection is essential for obtaining successful results. However, few data exist concerning the outcomes of patients evaluated for LVAD therapy but subsequently rejected or deferred. METHODS AND RESULTS:This is a retrospective review of all patients referred for LVAD therapy at our institution between January 2009 and December 2016. Baseline demographics and Interagency Registry for Mechanically Assisted Circulatory Support profiles were collected, and reasons for rejection or deferral for LVAD placement were investigated. A total of 669 patients were referred for LVAD therapy, and 228 patients (34%) were turned down. The yearly acceptance rate ranged between 57% and 75%. The average age of the turned-down cohort was 60.8 ± 12.5 years; 83% were men. Reasons for rejection included: patient being too sick (34%); psychosocial concerns (25%); patient declined (16%); decision was deferred for medical optimization (15%); or patient being too well (10%). The percentage of patients who were rejected due to psychosocial concerns has increased over time (P = 0.02), whereas the rate of deferral for medical optimization has remained stable (P = 0.10). One-year survival after initial LVAD consultation was 42% in those who were too sick, 64% in those with psychosocial concerns, 68% in patients who declined, 86% in those deferred for medical optimization; and 100% in those too well (P < 0.01). CONCLUSIONS:One-year survival is reduced among patients who were initially turned down for LVAD therapy, except for those in whom this decision was deferred for medical optimization or because the patient was too well. Psychosocial concerns have become a significant barrier to LVAD therapy.