A 70-year-old patient with idiopathic dilated cardiomyopathy underwent implantation of a HeartMate III left ventricular assist device (LVAD) at INTERMACS IV. Postoperatively, right ventricular (RV) failure was managed with vasopressors, inotropes, inhaled nitric oxide, and sildenafil. On day 12, the patient became profoundly hypotensive with a pulmonary artery pulsatility index of 1.3 (reference 1.85), indicating impaired RV function.

LVAD interrogation showed an abrupt rise in pulsatility index (PI) and reduced pump flow (Panel A). Transoesophageal echocardiogram (mid-oesophageal five-chamber view focused on the left heart) revealed near-total collapse of the left atrium without pericardial fluid compression (Panel B). Colour Doppler showed turbulent flow between the left atrium and left ventricle (LV) with a peak gradient of 43 mmHg during systole (Panels C and D). The LV cavity was small with kissing walls, while the RV was severely dilated. The diagnosis was left-sided suction and intracavitary obstruction due to left preload deficiency, triggered by fluid overload in a failing RV. Reducing LVAD speed improved systemic pressure and reopened the left-side system (Panel E).