Options for managing heart failure patients with cardiogenic shock refractory to inotropic and intra-aortic balloon pump (IABP) therapy are limited. Ventricular assist devices (VADs) can bridge these patients to heart transplantation. However, controversy exists over whether extracorporeal membrane oxygenation (ECMO) before VAD placement is beneficial. We report our use of biventricular assist devices (BiVADs) as a direct bridge to transplant. Since July 1999, 19 Thoratec BiVADs were implanted for heart failure unresponsive to medical therapy. Patient ages ranged from 20 to 67 years. Causes of heart failure included idiopathic 32%, ischemic 26%, postcardiotomy 21%, and other 21%. All patients were in cardiogenic shock, and three were receiving cardiopulmonary resuscitation (CPR) before implant. Preimplant conditions included IABP 89%, mechanical ventilation 68%, three or more inotropes 84%, hyperbilirubinemia 59%, acute renal failure 63%, and hemodialysis 16%. Fifty-nine percent of patients bridged successfully to transplantation, with 90% posttransplant survival. Duration of BiVAD support ranged from 0 to 91 days, with two patients currently on support awaiting transplantation. Complications included bleeding requiring reoperation 26%, stroke 11%, infection (any positive culture) 68%, and cannula site infection 5%. The Thoratec BiVAD can successfully be used as a direct bridge to transplantation in heart failure patients with cardiogenic shock.