73 year old year with severe MR admitted for MVR and CABG redo evaluation. Past medical hx is remarkable for CAD with two recent MIs, DM, HTN, s/p CABG on 12/2001. 6 weeks ago pt presented to outside hospital with CP and found to have STEMI complicated with cardiogenic shock, respiratory failure and CHF and noted to have severe MR. She underwent placement of IABP on admission. One day PTA, LHC showed 80% stenosis of LIMA-LAD graft with placement of Taxus stent, codominant RCA with 100% occlusion, mild stenosis of the LCx, and left main trunk stenosis. 3+ MR and EF of 30%. Patient discharged. LAte april patient presented to ED again c/o SOB and chest pressure for one week. Troponins noted to be at 0.59, BNP of 3630, and treated with Nitro, heparin, aspirin. She was admitted for MI and diuresed with lasix. Creatinine doubled from 1.2 to 2.1. Echo: EF 30-35%, with 3+ MR and annular calcification, Trace AI and aortic sclerosis with mean gradient of 7mmhg. One week post admission patient found unresponsive, bradycardic and hypotensive, requiring atropine but no CPR. Patient developed respiratory failure as a result and transferred to ICU. Also had IABP placed again and remained on it as attempts to weaning led to decreased urine output. At that time, patient also noted to have thrombocytopenia with platelets of 69 down from 302 on admission but prior to IABP placement. Heparin was d/c'd and switched to Argatroban. HIT panel sent but no results available. Pt also c/o RUQ pain, LFTs showed AST: 757, ALT 985, Alk. 77. HIDA scan was suspicious for CBD obstruction and acute cholecystitis. RUQ u/s + for gallstones, no GB wall thickening. Repeat LFTs on 5/7 showed AST:69 and ALT: 508. Patient evaluated by CTS for possible redo-CABG/MVR but unable to due to inability to wean off IABP. On arrival to our hospital, pt weaned off AIBP, Swan placed and CI noted to be 1.8 with PAPs 60/30, wedge= PAD and decreased UOP despite lasix gtt. Also c/p CP and put back on IABP. Patient placed on NTP and NTG for afterload reduction with no improvement in PA pressures. Patient now lethargic, creatinine increasing to 1.6. Also on Bivalirudin given ? of HIT. Patient currently satting at 94% on 4L EKG shows trifascicular block Current Na= 130 Current platelets= 103 PMHx: s/p MI x2, HTN, questionable hx of CRI 2/2 to nephrosclerosis, PVD and DJD. No tobacco or ETOH use. Patient evaluated by CTS and scheduled for OR for next day for MVR and redo-CABG. Anesthesia called to preop patient. What would be your plan for this patient?