BACKGROUND. Gated single photon emission computed tomography (SPECT) provides information on myocardial perfusion and left ventricular ejection fraction (LVEF), which correlates with risk of cardiac events in patients with known or suspected coronary artery disease (CAD). We hypothesize that decreased LVEF at time of renal transplant evaluation is an independent risk factor for cardiac death and nonfatal events after transplant. METHODS AND RESULTS. A total of 653 recipients of renal allografts between 1998 and 2005 had stress SPECT imaging before transplantation. One hundred and nineteen (18%) patients had left ventricular (LV) systolic dysfunction (LVEF ≤45%). The patients with LV dysfunction differed from the patients with normal LVEF having a higher proportion of males, smokers, left ventricular hypertrophy, previous left heart catheterization, and higher exposure to dialysis. During a mean follow-up of 3.01±1.86 years postrenal transplant, 66 patients died and 67 additional patients experienced at least one nonfatal cardiac-related complication. Patients with LV systolic dysfunction were at considerably higher risk for cardiac complications (hazard ratio [HR] 1.8, P=0.01) and all-cause mortality (HR 2.0, P=0.01) after transplantation. By multivariate analysis, LV systolic dysfunction was associated with a 5-fold increase in the cardiac mortality risk, a 2-fold increase in all-cause mortality risk, and a 70% increase in posttransplant cardiac complications. CONCLUSIONS. Systolic dysfunction is associated with increased risk for overall and cardiac-related death and nonfatal events after renal transplantation, an association independent of ischemic disease. © 2007 Lippincott Williams & Wilkins, Inc.