Bleeding is the most common postoperative complication after implantation of left ventricular assist devices, necessitating reoperation in up to 60% of recipients. The implications of massive blood transfusions are great and include infection, pulmonary insufficiency, increased costs, right heart failure, allosensitization, and viral transmission, some of which can prove fatal or preclude transplantation. Preoperative evaluation and preparation are essential, intraoperative hemostasis is imperative, and "shotgun" product replacement should be avoided. Adherence to protocols emphasizing "hemostatic readiness" could reduce the incidence of bleeding complications that pervade left ventricular assist device therapy and potentially improve current successes in bridging to transplantation.