Serum albumin is an independent predictor of morbidity, including deep sternal wound infections, and mortality following cardiac surgery and left ventricular assist device (LVAD) implantation.1, 2 Preoperative hypoalbuminemia in patients being evaluated for LVAD implementation may be due to malnutrition and frailty, hepatic dysfunction due to both right and left heart failure, the cardiorenal syndrome, and systemic inflammation. Patients with hypoalbuminemia may potentially benefit from LVAD implantation since the combination of nutritional support and the reversal of heart failure may restore serum albumin to normal levels. On the other hand, the co-morbidities associated with hypoalbuminemia may increase perioperative morbidity and mortality and decrease long-term survival. Furthermore, patients with hypoalbuminemia undergoing LVAD implantation may not recover sufficiently to be considered candidates for heart transplantation. In view of the increasing costs associated with LVAD therapy,3 the known increased morbidity and mortality in patients with hypoalbuminemia, and the uncertainty of the option for heart transplantation, should patients with moderate and severe serum hypoalbuminemia undergo LVAD therapy? In this edition of the Journal, Critsinelis et al4 sought to determine short- and-long term survival in patients with low preoperative serum albumin levels who underwent continuous-flow LVAD implantation. In 526 patients who had undergone LVAD implantation at their center, 186 patients (35.4%) had moderate hypoalbuminemia (2.5-3.5 g/dL) and 18 (3.4%) had severe hypoalbuminemia (<2.5 g/dL). Patients with preoperative hypoalbuminemia were more likely to receive LVAD implementation for destination therapy, were more likely to have required preoperative circulatory support, had significantly lower preoperative hemoglobin levels and platelet counts, significantly higher white blood cell counts, and higher liver function enzyme levels. Hypoalbuminemia patients also had a higher incidence of postoperative morbidity, including infections and sepsis, gastrointestinal bleeding, neurological dysfunction, acute kidney injury, and an increased incidence of hospital readmissions. Preoperative hypoalbuminemia was also associated with significantly decreased early and long-term survival following LVAD implementation. However, hypoalbuminemia prior to LVAD implementation did not affect the success of bridge to transplantation and did not significantly affect survival after heart transplantation. Furthermore, there was no association between body mass index (BMI) and outcomes with LVAD implantation which suggests that the co-morbidities associated with hypoalbuminemia, and not preoperative BMI, are responsible for the increased morbidity and mortality associated with hypoalbuminemia. Patients with hypoalbuminemia, but with normal pre-albumin levels and a normal central venous pressure, had no difference in survival compared to patients with normal albumin levels. Should LVAD therapy be denied to patients with preoperative hypoalbuminemia? The answer lies in what co-morbidities responsible for preoperative hypoalbuminemia can be reversed following initiation of LVAD therapy. Reversing the sequelae of low cardiac output may improve appetite and absorption of nutrients, improve hepatic function, and reduce systemic inflammation. Critsinelis et al did not assess the effects of perioperative nutritional supplementation on perioperative morbidity and mortality in their patients. Furthermore, they limited their assessment to measuring only preoperative serum albumin levels. Hence, we do not know whether patients who had a significant increase in serum albumin levels post LVAD implantation had better short- and long-term survival. While deceased preoperative serum albumin levels are a marker for increased perioperative morbidity and decreased short- and long-term survival following LVAD implantation, the data from this study suggest that serum albumIn alone cannot be used to exclude patients for LVAD support who may be potential candidates for heart transplantation. These patients will require more aggressive perioperative nutritional supplementation and continued therapy for underlying co-morbidities in addition to LVAD support. Only then can we determine whether LVAD implementation can improve long- and short-time survival in patients with hypoalbuminemia.