Ventricular assist device malfunction: sometimes it is a zebra

Humans and machines fail. It is a matter of fact. Preventing, recognizing, and troubleshooting problems with the many intricate systems used by perfusionists are key skills within the profession. Preventive measures are used in an attempt to fend off errors before they occur. Skills are taught during the educational process to enable clinicians to recover from, and mitigate the effects of, critical events when they do occur. Diagnostic procedures have been developed to step through the troubleshooting process for device and procedural failures. The most common cause of an event is at the top of the list along with its solution. Sometimes, however, the most common issue is not the cause of the problem. Sometimes the problem cannot be diagnosed within the clinical setting. This case is a report of such a situation.