A 55-year-old man with a history of mitral valve replacement (CarboMedics; Austin, TX) due to rheumatic disease was transferred to our ICU from an outside hospital with multiorgan failure. Five days earlier, he had begun to complain of dyspnea at rest along with a low-grade fever and was admitted to another institution with clinical and radiologic findings compatible with pulmonary edema. Despite the intensive medical treatment (ie, inotropes, diuretics, and broad-spectrum antibiotics), his condition deteriorated rapidly, and severe hypoxemic respiratory failure developed 2 days later, requiring mechanical ventilation. In addition, he became anuric and was started on renal replacement therapy, requiring high doses of inotropes and vasopressors in order to keep his systolic BP at barely > 75 mm Hg. Thus, he was transferred to our ICU in an extremely critical condition for further workup and treatment.