There was a scarcity of research on health-related quality of life (HRQOL) in older persons considering advanced heart failure surgical treatments. For a study, researchers compared HRQOL among 3 groups of older (60–80 years) patients with heart failure before heart transplantation (HT) or long-term mechanical circulatory support (MCS) and identified factors associated with HRQOL using data from the SUSTAIN (Sustaining Quality of Life of the Aged: Heart Transplant or Mechanical Support) study: (1) HT candidates with MCS, (2) HT candidates without MCS, and (3) candidates ineligible for HT and scheduled for long-term MCS. Patients from 13 US sites completed self-reported HRQOL measures (EuroQol-5 Dimension Questionnaire, Kansas City Cardiomyopathy Questionnaire–12), depressive symptoms (Personal Health Questionnaire–8), anxiety (State-Trait Anxiety Inventory–state form), cognitive status (Montreal Cognitive Assessment), and performance-based measures (6-minute walk test and 5-m gait speed). ANOVA, 2 tests, Fisher’s exact tests, and linear regression were used in the analysis. There were 393 patients in the research; most of them were white men who were married. HT candidates with MCS (n=118) and HT candidates without MCS (n=121) were considerably older, had more comorbidities, and had a higher New York Heart Association class than long-term MCS candidates (n=154). Long-term MCS patients reported lower HRQOL than HT patients with and without MCS (EQ-5D visual analog scale scores of somewhere between 46±23 against somewhere between 68±18 versus somewhere between 54±23 [P<0.001] and Kansas City Cardiomyopathy Questionnaire–12 overall summary scores of somewhere between 35±21 versus somewhere between 60±21 versus somewhere between 49±22 [P<0.001]). In multivariable analyses, there was a lower 6-minute walk distance, higher New York Heart Association class, depressive symptoms, and not being an HT candidate with MCS were all related to worse overall HRQOL. The data showed significant variations in overall and domain-specific HRQOL of elderly heart failure patients before HT or long-term MCS. Understanding the disparities in HRQOL might have aided in the selection of more appropriate and individualized advanced heart failure treatments.