We present the case of a 24 year-old patient that developed massive hemolysis shortly after percutaneous left ventricular assist device, Impella 2.5, was placed. The hemolysis occurred without device alarm while the device was in the correct position. Further investigation of the device revealed fiber wrapped around the tip of the device, as a culprit. This case emphasizes on the special caution applied during device preparation to minimize the possible adverse events.
A 24 year-old woman with heart transplantation developed cardiogenic shock with multi-organ failure despite vasopressor and inotropic support. A percutaneous left ventricular assist device, Impella 2.5, was placed, set at performance 9, with 50,000 rpm and provided 2.5 L/min. Fifteen hours later, her hemoglobin decreased from 8.3 to 6.1 g/dL, along with the evidences of hemolysis including LDH of 2,139 unit/L, Haptoglobin of 22 mg/dl, Indirect Bilirubin of 11mg/dl and the presence of schistocyte on blood smear. Echocardiogram and chest radiography confirmed an adequate position ( Fig. 1 ) and there were no alarms from the device. The Impella was removed, resulting in resolution of hemolysis. On device examination, it was found to have high amount of hemolysis and there was a fiber wrapped around the tip of the device ( Fig. 2 ). We hypothesize that this contaminated fiber was probably from the sterile saline running the device before implantation. Once the fiber attached to the tip of the device and formed the clot, this clot and fiber itself rotating in high speed along with the device may enhance shear stress causing massive hemolysis, especially when the device was set to the maximal speeds in our patient. The excessive destruction of red blood cells results in anemia, while the increased level of plasma-free hemoglobin can cause renal dysfunction. Since the substantial hemolysis can occur , the special caution in device preparation in addition to serial hemoglobin with high suspicious of hemolysis is warranted.