Case Archive
 
Cardiology (Interventional)
Ref. # 360501

A 62-year-old man was admitted with a diagnosis of unstable angina. He underwent a cardiac catheterization at a major medical center. Findings included total occlusion of the right coronary artery with left to right collateral filling of the distal vessel. Two days later the cardiologist opened the occluded right coronary artery with balloon angioplasty and implanted six stents in the artery. The stents were inserted over a SciMed Platinum Plus wire. At the end of the procedure the wire was found to be fractured and irremovable. Open-heart surgery was required to remove the wire and one-and-a-half stents. A two-vessel coronary artery bypass operation was also performed. Intra-op a fresh myocardial infarction was identified involving the right ventricle and inferior wall of the left ventricle. These areas are supplied by the right coronary artery. Following the surgery the patient experienced cardiac arrest with ventricular fibrillation. After resuscitation he was hypotensive and required pressor support. He developed multiple organ failure and died several weeks later. A medQuest interventional cardiologist reported the video of the stent implantation procedure showed improper and negligent use of the wire, causing it to fracture. The distal portion of the wire was improperly fixed and not free to rotate in response to rotation of the proximal portion of the wire, rendering it prone to fracture. Additionally, lab records were incomplete, the video contained an inaccurate chronology of the procedure, and the angiography log was missing. The guide wire would not have fractured absent the negligence of the physician user. If the wire had not fractured the open-heart surgery would not have been required, the patient would not have suffered multiple organ failure and he would have survived.




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