Three recent cases from one institution using the total artificial heart (TAH) before transplantation are reviewed. The first patient was implanted for 12 hours with the pneumatic Phoenix total artificial heart after failure of a donor heart 1 day after transplant. Following retransplantation the patient died from severe pulmonary edema, pulmonary hypertension, right ventricular failure, and Pseudomonas septicemia. The second patient was implanted with the Jarvik-7 total artificial heart for rapidly deteriorating idiopathic cardiomyopathy. Major complications during the 9 1/2-day implant consisted of severe pulmonary edema for the first 4 days and a multifocal cerebral embolic event on the seventh day after implantation from which he fully recovered. Major problems after transplant included disseminated toxoplasmosis and two mild episodes of rejection. The patient was discharged 68 days after surgery and remains well. The third patient was a 40-year-old woman with rapidly progressing acute influenza A viral myocarditis. Despite immunosuppressive and antiviral therapy, cardiogenic shock with multiple organ failure developed. The 70 ml Jarvik-7 was implanted for 4 1/2 days. Acute humoral rejection from autoantibodies and alloantibodies led to a cardiac arrest on the second day after transplantation. A second 70 ml Jarvik-7 implant was followed by severe multisystem and infectious complications. After prolonged intensive care support, the patient recovered and is now awaiting transplantation. Nearly 100% cytotoxic antibody reactivity caused by multiple antigenic stimuli is preventing ready access to donor hearts for this patient. We view the current role of the total artificial heart as a tool to preserve life until a suitable donor heart can be found, reverse the end-organ effects of progressive heart failure and low output, and restore transplant candidacy in selected patients with temporary reversible contraindications to transplantation.