As with any emergency anesthetic, efforts are initially directed at the ABCs of airway, breathing, and circulation. The awake patient with active ischemia and tight left main disease can be quite challenging. Should myocardial oxygen consumption outpace supply, this patient population can develop profound ventricular dysfunction. ECG signs of ischemia develop and PA pressures rise. Systemic and pulmonary artery pressures equilibrate. TEE can demonstrate striking dysfunction and acute mitral insufficiency. Restoration of the balance between supply and demand will improve systemic pressures, lower PA pressures, and improve LV contractility. By using the ECG, PA catheter, and TEE in combination the anesthesiologist can detect and restore, if possible, hemodynamic stability. Some patients will present in cardiogenic shock on IABP or percutaneous VAD support. In these instances, the anesthesiologist attempts to maintain viability until the initiation of CPB. Complete hemodynamic collapse secondary to ventricular dysfunction and or fibrillatory cardiac arrest can occur at any moment and as such the surgeon and anesthesiologist should be prepared for the immediate institution of CPB.