Case Archive
Cardio-Thoracic Surgery
Ref. # 17087

An Ohio man was admitted to a major medical center for mitral valve repair. The cardiac surgeon elected to do a minimally invasive procedure, a mini thoracotomy. Post-op the patient experienced a sudden drop in blood pressure which was unresponsive to volume administration. An exploratory laparotomy performed by the general surgeon revealed laceration of the liver in two places, the dome and the free margin, which apparently occurred during insertion of a chest tube. There is no documentation of the nature or extent of the liver injury. For five days post-op the patient did well but then suffered multiple organ failure, septic shock and renal failure. Treatment during his 43-day hospital stay included dialysis. The liver remained problematic and the mitral valve regurgitation returned to 2+. A medQuest cardio-thoracic surgeon reported the laceration of the liver during the course of establishing chest drainage in open-heart surgery fell well below the standard of care. There was a negligent failure once the injury was discovered to turn the patient's care over to an appropriate trauma or hepatic surgeon. Furthermore the absence of records during this critical juncture constituted negligence. The hepatic injury caused the patient's subsequent complications. His outcome would been vastly improved had his liver not been "skewered."

Cardio-Thoracic Surgery
Ref. # 80028

A 29 year old Michigan man suffered blunt chest trauma with an aortic tear due to a motor vehicle accident. Intra-op the patient experienced decreased perfusion with documented distal pressures of predominantly 40. The patient emerged from surgery paraplegic. A medQuest cardio-thoracic surgeon reported the attending surgeon negligently employed a 7 mm Gott shunt, which was too small. At the time, existing literature supported use of a 9 mm Gott shunt. The patient's paraplegia was preventable.

Cardio-Thoracic Surgery
Ref. # 52728

A 51 year old Pennsylvania man underwent triple coronary artery bypass surgery sue to 100% occlusion of the left anterior descending artery. The initial post-op course was uncomplicated: the patient was extubated and then transferred to the step-down unit. Two days later the patient's cardiac monitor was disconnected and later that morning he was found by the nursing staff on the floor of his room in cardiogenic shock. CPR was initiated and the patient was taken to the OR for an emergency reexploration. No clot was found in the pulmonary artery. The patient suffered global myocardial dysfunction. An EEG was concurrent with hypoxic brain injury. A medQuest cardio-thoracic surgeon reported gross negligence in sending the patient to an unmonitored bed so soon after surgery. The lack of cardiac monitoring led to delay in effective resuscitative efforts and was responsible for the hypoxic brain injury.

Cardio-Thoracic Surgery
Ref. # 12697

A Pennsylvania woman underwent a heart catheterization, which led to a diagnosis of a dilated left atrium with moderate pulmonary hypertension caused by moderately severe rheumatic mitral valve stenosis. Three weeks later the patient underwent a mitral valve replacement. The attending surgeons attempted to cut the partially fused valve but then instead performed a replacement with a prosthesis, a 23 mm Omniscience valve. The patient's condition did not improve. She made several ER visits and in-patient stays due to chest pain, shortness of breath, and worsening congestive heart failure. Mitral valve and aortic valve regurgitation were identified at various times. Five years into this period, the patient developed a vaginal bleed due to Coumadin therapy, requiring a hysterectomy and bilateral oophorectomy. Two years later, a periodic work-up and stress test suggested defective mitral valve prosthesis. The patient returned to one of the initial physicians for a catheterization, which showed that the valve was normal. The patient was referred to another surgeon with recommendation for a heart-lung transplant. Unsatisfied with the patient's test results, this surgeon performed another catheterization, which confirmed a significant pressure difference across the valve. A mitral valve re-replacement was performed, with a 29 mm St. Jude. Post-op testing showed excellent flow through the annulus. After aggressive respiratory therapy, the woman returned to active health. A medQuest cardio-thoracic surgeon reported that a 23 Omniscience valve is much too small for an adult female. The reasons for its implantation were never documented. The fact that the subsequent surgeons were able to implant a 29 St. Jude attests to the size of the patient's mitral annulus. Through their negligence, the initial surgeons caused most if not all of the woman's complications, which were avoidable.

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