Background Clinical outcome of heart transplantation in patients with heart failure and ascites has not been reported. Here, the clinical outcome of heart transplantation in patients with heart failure and ascites is evaluated. Methods and Results Between 1989 and 2005, 45 patients with heart failure and ascites underwent an orthotopic heart transplantation. Of the 45 patients, 33 were men (median age 44 years, range 10-63 years). Causes of heart failure included congenital heart disease in 4 patients (9%), dilated cardiomyopathy in 21 patients (47%), rheumatic heart disease in 7 patients (16%), coronary artery disease in 10 patients (22%), and others. Twenty of the 45 patients (44%) had undergone a previous cardiac operation. Hospital mortality occurred in 10 patients (22%) because of bleeding in 4, sepsis with multiple organ failure in 5 and non-diagnostic graft failure in 1 patient. Re-operation for postoperative bleeding occurred in 14 patients (31%). Independent risk factors for hospital death were low serum albumin (odds ratio 0.05; 95% confidence interval 0.003-0.591; p=0.018) and re-operation for bleeding (odds ratio 30.11; 95% confidence interval 2.38-380.26; p=0.009). Conclusions Heart transplantation in patients with heart failure and ascites was associated with high hospital mortality and morbidity. The co-existence of ascites and hypoalbuminemia implied poor prognosis. (Circ J 2007; 71: 1744 - 1748)