Introduction: Non-alcoholic fatty liver disease (NAFLD) is increasing due to current obesity epidemic. NAFLD patients are also at higher risk for cardiac events. Gastric bypass surgery (GBP) is increasingly utilized as a treatment for morbid obesity and is shown to improve liver fibrosis in NAFLD patients. The aim our study is to assess the impact of GBP on development of cirrhosis, occurrence of cardiac events, and overall survival among NAFLD patients. Methods: This is a single-center retrospective study on NAFLD patients (2007-2011) with diagnosis based on histology with changes of steatohepatitis or imaging with findings of steatosis, excluding other liver diseases. All patients had documented alcohol use of <10 g/d. Medical charts were reviewed for a) demographics, comorbidities, history of GBP, and b) follow-up from first clinic encounter for diagnosis of cirrhosis or of cardiac event (arrhythmia, congestive heart failure, angina, myocardial infarction, stroke, or peripheral arterial disease), transplantation, and survival. Results: Of 230 NAFLD patients, 29 with GBP differed from the remaining 201 for age (54±11 vs. 48±8 years, p=0.002), females (83% vs. 61%, p=0.024), and BMI (35±8 vs. 40±9 kg/m2, p=0.002). Compared to patients without GBP, those with GBP had fewer cardiac events (3.5% vs. 15%, p=0.090) and cirrhosis (24% vs. 57%, p=0.001). None of GBP patients needed liver transplantation (LT) compared to 20 (10%) patients without GBP who underwent LT, p=0.070. Overall survival tended to be better among GBP patients (96.5% vs. 90%, p=0.230) with significantly better LT-free survival (96.5% vs. 80%, p=0.035). Controlling for age, sex, cirrhosis, diabetes, BMI, use of beta blockers, and use of statins, the risk of cardiac events and the LT-free mortality were reduced with GPB, although not statistically significant due to small sample size: HR 0.29, 95% CI 0.04-2.34, p=0.25 and HR 0.58, 95% CI 0.05-4.56, p=0.52, respectively. LT-free mortality was 43-fold higher in presence of cirrhosis: 43 (5.3-353) and was reduced by 76% (0.24; 0.07-0.81) with use of statin and by 60% in females (0.4; 0.17-0.92). Conclusion: GBP improves the natural history of NAFLD with reduced risk of end organ damage, cardiac or liver-related complications, and mortality. Given the protective effect of statins on LT-free mortality, physicians may be encouraged to continue use of these drugs in NAFLD patients when indicated for treatment of dyslipidemia or cardiac disease. Further larger studies are suggested to examine the impact of GBP on hard end points, including LT-free mortality. Studies are urgently needed to identify patients at risk for cirrhosis in NAFLD, as a basis for using GBP as a potential personalized treatment option to improve their survival.