Hospital mortality correlates with the number and level of inotropic support necessary to separate from CPB following adult open heart surgery. The application of a standard pharmacological formula together with hemodynamic criteria for VAD insertion after postcardiotomy cardiogenic shock results in earlier insertion, lower incidence of postoperative MOSF, and improved wean and discharge rates.

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with progressive symptoms of heart failure and was listed for heart transplantation. His condition deteriorated despite institution of inotropic drug support. An echocardiogram showed global biventricular dysfunction with no aortic stenosis or insufficiency. On June 20, 2000, a TCI VE HeartMate left ventricular assist system (LVAS) (Thoratec Corporation, Pleasanton, Calif) was implanted. The patient had an uneventful postoperative course and was discharged to his home on July 23, 2000. He was doing well with LVAS rates between 70 and 80 beats/min and flows ranging between 6 and 8 L/min. Two and one-half months after implantation, he began to have mild dyspnea with his usual activities. The LVAS rates and flows were inappropriately elevated at rest (80-100 beats/min, flows 8-9 L/min). An echocardiogram showed moderate LVAS inflow valve regurgitation and mild native aortic valve insufficiency. On October 3, 2000, an orthotopic heart transplantation was performed. The LVAS inflow valve had two small linear perforations in the leaflets and partial dehiscence of two commissures. The LVAS outflow valve was intact. The aortic valve was fused along the anterior aspect of the left noncoronary commissure (Figure 1). The posterior aspect of the commissure was open. A small thrombus was present along the right lunula of the left coronary cusp of the aortic valve. Examination of the ostium of the outflow graft insertion revealed it to be situated above the right coronary cusp with the angle of the graft directed toward the left coronary cusp. The ostia of the coronary arteries were patent. No

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