The impact of left ventricular ejection fraction (LVEF) on outcome in patients with heart failure (HF) undergoing noncardiac surgery has not been extensively evaluated. In this study, 174 patients (mean age, 75+/-12 years, 47% male, mean LVEF (47%+/-18%) underwent intermediate- or high-risk noncardiac surgery. Patients were stratified by LVEF, and adverse perioperative complications were identified and compared. Adverse perioperative events occurred in 53 patients (30.5%), including 14 (8.1%) deaths within 30 days, 26 (14.9%) myocardial infarctions, and 44 (25.3%) HF exacerbations. Among the factors associated with adverse perioperative outcomes in the first 30 days were advanced age (>80 years), diabetes, and a severely decreased LVEF (<30%). Long-term mortality was high, and Cox proportional hazards analysis demonstrated that LVEF was an independent risk factor for long-term mortality.