A 53 year old male in critical cardiogenic shock was taken to theatre for temporary mechanical circulatory support with CentriMag left and right ventricular assist devices.

A mistake occurred during the set-up of the CentriMag pumps. The motor cable of the LVAD was connected to the RVAD console and the motor cable of the RVAD was connected to the LVAD console.

The patient was established on BiVAD support.

There was imbalanced flow, with RVAD flow higher than LVAD flow. Attempts to increase LVAD flow had the opposite effect but the flow imbalance was well tolerated for two hours.

The patient then developed very low LVAD flow and a rising oxygen requirement. The left ventricle was not adequately unloaded on TOE. The initial working diagnosis was malposition of the aortic cannula and this was re-positioned. The actual cause of the problem was identified and corrected after three hours.