These pathologies include valvular heart disease, left heart failure with preserved or reduced ejection fraction, primary or secondary pulmonary hypertension (PH), preexisting or postcardiotomy right ventricular dysfunction (RVD), and postcardiotomy low cardiac output syndrome (LCOS). 1-12 Contemporary cardiac surgery patients are sicker than historical cohorts due to advancements in cardiovascular care. 10-15 As such, it is not unusual for anesthesiologists to encounter patients with coexisting left heart failure, PH, RVD, and LCOS during cardiac surgery. In isolation, left heart failure, LCOS, PH, and RVD require specific considerations during treatment. Management strategies for left heart failure and LCOS include inotropic support, reduction of left ventricular (LV) wall tension (lower systemic vascular resistance and lower LV filling pressures), and provision of optimal LV perfusion pressures. 7-9,13,16 PH treatment is more complex and depends on the etiology; inhaled selective pulmonary vasodilators are useful for primary PH treatment, whereas secondary PH from left heart disease may require correction of mitral or aortic valvular disease or treatment of left heart failure to unload the pulmonary vasculature. 5,6 Treatment of RVD requires a reduction in RV wall tension (reduction in pulmonary vascular resistance and RV filling pressures), maintenance of RV perfusion pressures, and inotropic support. Intraoperative management challenges arise when left heart failure, LCOS, PH, and RVD exist simultaneously after separation from CPB. Although the ideal pharmacologic agent to treat these conditions is elusive, inodilating agents such as milrinone, dobutamine, and levosimendan have pharmacodynamic properties that may help treat coexisting left heart failure, LCOS, PH, and RVD. 7-9,13-16 Milrinone is an inodilator that has shown promise for the management of isolated or concurrent left heart failure, LCOS, PH, and RVD post-CPB. 7-9,13 Both intravenous
