Of currently available methods for mechanical circulatory support, the Pierce-Donachy external pneumatic ventricular assist device has proved to be one of the most versatile and effective. Since 1981, 48 patients, aged 15 to 71 years (mean 43.0), with profound cardiogenic shock refractory to conventional therapy with drugs and intra-aortic balloon support, were supported with the Pierce-Donachy ventricular assist device. There were four patient groups. The largest group consisted of 30 patients with cardiogenic shock after cardiac operations. Nine required left ventricular support, six needed right ventricular support plus an intraaortic balloon pump, and 15 had biventricular support. Duration of support ranged from 3 hours to 22 days (mean 3.6 days). Eight of the first 11 patients died in the operating room of bleeding and/or biventricular failure. However, 16 patients, (53%) had improved cardiac function, 15 (50%) were weaned, and 11 (36%) were discharged. Of the last 19 patients, 47% survived. Frequent factors in nonsurvivors were myocardial infarction (75%) and renal failure (90%). Common complications in all patients were bleeding (52%) and infection (27%). The second group consisted of 11 patients with end-stage cardiomyopathy or acute myocardial infarction in whom the Pierce-Donachy ventricular assist device was used as a bridge to transplantation (left ventricular support, four patients; biventricular support, seven patients). Renal failure, infection, or coagulopathy that precluded transplantation developed in five patients. Five patients were supported for 8 hours to 75 days (mean 20.7 days) before undergoing successful transplantation, with one late death (six months) from rejection owing to noncompliance. One has subsequently undergone successful transplantation after 84 days of support. The third group consisted of four patients, aged 40 to 56 years (means 47.2), who had refractory cardiogenic shock after cardiac transplantation caused by pulmonary hypertension (two patients), hyperacute rejection (one patient), or graft failure (one patient). Despite biventricular support in all four (biventricular assist devices, two patients; right ventricular assist device plus intraaortic balloon pump, two patients), all died of infection and/or renal failure after 12 hours to 6 days (mean 3.4 days) of support. The final group consisted of three patients, aged 36 to 51 years (mean 45), with cardiogenic shock caused by acute myocardial infarction. One patient was supported with biventricular assist devices (3.5 days) and two patients were supported with a left ventricular assist device (8.5 and 15 days).(ABSTRACT TRUNCATED AT 400 WORDS)