From August 1989 to January 1993, the authors performed laparoscopic biliary operations in 900 patients, 13 of whom had severe cardiac dysfunction. Nine patients were Goldman Class IV, and four patients were Goldman Class III. Three patients had recent myocardial infarction, five patients were known to have low left ventricular ejection fractions (10%, 21%, 25%, 26%, and 30%), one had severe myocardial ischemia, one had severe congestive heart failure, and one was in profound shock. Nine patients underwent successful laparoscopic cholecystectomy. Laparoscopic cholecystostomies were performed in three patients. One operation was converted to an open cholecystectomy. There was one death within 30 days of surgery. With appropriate hemodynamic monitoring and adequate perioperative support of cardiac function, laparoscopic cholecystectomy can be performed safely for acute cholecystitis in patients with severe cardiac disease. When compared with historical controls, laparoscopic cholecystectomy appears to be safer than open cholecystectomy.