Thrombotic thrombocytopenic purpura (TTP) is an uncommon disorder characterized 
by a pentad of microangiopathic hemolytic anemia, thrombocytopenia, renal 
dysfunction, fever, and a fluctuating neurologic syndrome. Splenectomy is 
performed for patients who are refractory to plasma therapy and for relapsing 
TTP. We describe a case of a patient who died due to intramyocardial hemorrhage 
after undergoing laparoscopic splenectomy for TTP resistant to treatment with 
plasmapheresis. A 52-year-old woman was admitted with ecchymoses, low platelet 
count, weakness of left face and upper extremity, and a presumptive diagnosis of 
TTP. Vital signs were stable. White blood count was 7800/microL, hemoglobin 7.9 
g/dL, and platelet count of 13,000/microL. Her basic metabolic panel and liver 
function tests were normal. Further laboratory workup confirmed the diagnosis of 
TTP. The patient was initially treated with plasmapheresis and high dose steroid 
therapy but underwent an emergent laparoscopic splenectomy due to refractory 
TTP. At the end of the uneventful procedure, the patient suffered a cardiac 
arrest and died. Autopsy concluded that the death was from myocardial failure 
due to extensive myocardial hemorrhage secondary to TTP. There are several 
published case reports of sudden death due to cardiac involvement in TTP. 
However, intraoperative mortality is not reported. We conclude that TTP-related 
acute heart failure may represent an extremely important clinical risk in these 
patients who are undergoing surgery.