Perioperative management of patients with impaired left ventricular function

The development of acute perioperative left ventricular failure leading to haemodynamic catastrophe has several reasons. The management of left ventricular dysfunction requires a step-by-step therapeutic approach. Extensive haemodynamic monitoring is fundamental to distinguish between the need for positive inotropes, lowering pre- or afterload or increasing perfusion pressure by vasopressors. Catecholamines are still the cornerstone for treating acute left ventricular dysfunction. Whether synthetic, costly catecholamines offer any advantage over 'natural', low-priced catecholamines has not yet been definitely determined. Optimizing ventricular loading by vasoactive substances will help to improve overall myocardial performance. Knowledge of pre-existing cardiac disease and of haemodynamic principles are prerequisites for selecting an appropriate therapeutic regime. This appears to be more important for successfully treating acute perioperative myocardial failure than waiting for a new 'magic' substance.