Postischemic derangement of myocardial metabolism that is further aggravated by the systemic neuroendocrine response to surgical trauma may explain reversible myocardial dysfunction after cardiac surgical procedures. Since 1991, all patients with signs of cardiac failure after operation for ischemic heart disease (45/515 patients) were treated according to our metabolic strategy. Sixteen patients in whom we previously would have considered use of an intraaortic balloon pump were treated by prolonged unloading of the heart with cardiopulmonary bypass, by glutamate infusion, and by high-dose glucose-insulin-potassium. Rapid improvement in hemodynamic performance was seen in the first hour and almost full recovery within 6 hours in the surviving patients (12/16). None of the 3 patients requiring mechanical assist survived. Our early clinical experience suggests that metabolic support with glutamate and high-dose glucose-insulin-potassium is a safe treatment with a high success rate in reversible cardiac failure.