A paradoxic hypotensive response to resuscitative treatment may be the first clue to dynamic left ventricular outflow tract obstruction (DLVOTO) in critically ill patients. If unrecognized, routine interventions aimed at improving cardiac performance may actually result in hypotension and low cardiac output, thus putting patients at risk for adverse event. It is imperative, therefore, that the pathophysiologic processes involved in DLVOTO be fully understood in order to initiate safe and appropriate therapy in critically ill patients. Our presentation and discussion focus on a hypotensive critically ill patient with unrecognized DLVOTO until further evaluation with transesophageal echocardiogram (TEE). We recommend that early TEE be performed on critically ill patients with unexplained hypotension that is poorly responsive to conventional resuscitative measures.