OBJECTIVE To describe the results of psychiatric evaluations and to describe psychiatric outcomes in patients in a heart transplantation program. DESIGN Descriptive study. SETTING Heart transplant unit at the Royal Victoria Hospital in Montreal from September 1984 to December 1995. PATIENTS A total of 706 candidates for heart transplantation, of whom 226 received a graft. INTERVENTIONS All candidates underwent a psychiatric evaluation consisting of a semi-structured interview with mental status examination and diagnosis of mental disorders. OUTCOME MEASURES Results of psychiatric evaluation and postoperative recovery and complications. RESULTS Twenty-eight candidates were found to be unsuitable for surgery because of psychiatric illness. The heart transplant recipients who had previously suffered from a psychiatric disorder fared worse than those who had not. The psychiatrist's recommendations for or against surgery depended on the patient's ability to cope with a number of stressors, including compliance with the medical regimen, the wait for a donor, the surgical procedure itself, adaptation to life with a new organ and the resolution of a distressing emotional state. Postoperative psychiatric complications ranged from organic mental syndromes to depression. CONCLUSIONS With the increase in the number of heart transplantations, the competition for organ donors is intensifying, and patient selection requires greater involvement of psychiatrists.