However, all is not well with the current situation of LVADs. The patient has to undergo the psychological and physical trauma of another operation. For many patients with ischemic cardiomyopathy, the LVAD implantation is a second or even third operation (8). Perioperative bleeding is a significant complication. Furthermore, the bleeding may lead to increased preformed antibodies that makes transplantation extremely difficult in some patients (9). Perhaps the most common morbidity, however, is blood stream infection. In a recent report, over 60% of patients had blood stream infections during LVAD support (10). Furthermore, in the results from the Randomized Evaluation of Mechanical Assistance Therapy as an alternative in Congestive Heart failure (REMATCH) trial, permanent destination therapy using LVADs, 41% of the deaths in the LVAD recipients were related to infection (11). Although the risk of stroke and device failure have been reduced, they have not been eliminated. Also, the logistics of arranging outpatient care requires a well trained medical team who are available at all times. The coordination of hospital discharge includes extensive training of the patient, usually with a family member or close friend, arrangements for outpatient housing or maintenance of the patient at home, training of emergency paramedical personnel near the patient so that the patient can be emergently returned to the medical center if there is a problem and a team of LVAD coordinators who manage outpatient education as well as the outpatient clinic (12). Aside from the cost of the device itself (approximately $70,000 U.S. dollars), the implant surgery, intensive care unit and hospital stay and coordination of outpatient care may contribute to a very high bill. This is especially true if the patient is developing multiple organ failure and requires prolonged ventilatory support or dialysis. Therefore, for inotrope-dependent patients who are being carefully monitored in the hospital setting, who are active and exercise with supervision, who have no evidence of impending multiple organ failure, and who have no unusual reason so that their wait for a donor would be exceptionally long, most clinicians will continue with inotropes until transplantation and will not proceed with LVAD insertion unless one of those conditions changes.