In addition to my consulting work and writing the Health Business Blog, I’m chairman of the board of Advanced Practice Strategies (APS), a medical risk management firm that provides litigation support for malpractice defense and an eLearning curriculum focused on enhancing patient safety.
To learn more contact: Timothy Croke, Director of Demonstrative Evidence Group. firstname.lastname@example.org or 617-357-0553 ext. 6664.
Here’s the Advanced Practice Strategies case of the month.
Aortic Valve Replacement with Post Operative Complications
The patient presented with severe aortic stenosis due to a bicuspid aortic valve. The defendant recommended replacing the aortic valve with a 17-millimeter St. Jude mechanical valve. The operation itself proved uneventful; however, as the patient’s chest was being closed, she suffered sudden cardiac arrest. The defendant immediately reopened the incision to perform coronary artery bypass grafts to the right coronary artery, the proximal left anterior descending artery (LAD), and the distal artery (LAD). After placing the grafts, the defendant put the patient on an Abiomed biventricular assist device to help support heart function. Unfortunately, the procedure was not successful; the plaintiff developed multi-organ failure and died shortly thereafter.
The plaintiff claimed that the defendant chose the incorrect replacement valve and performed the procedure improperly. Further, the plaintiff claimed, the ostia (the coronary arteries’ openings from the aorta), were compromised, preventing adequate blood flow to the heart, resulting in the patient’s cardiac arrest. According to this argument, a 17-millimeter valve should not have been used because its opening did not allow sufficient blood flow. The plaintiff’s position was that had a larger valve been used her cardiac function would have been better and her outcome different.
The defense claimed the autopsy clearly indicated that the St. Jude 17-millimeter valve had been placed correctly at the aortic annulus (the ring of tissue supporting the valve) and did not obstruct coronary artery blood flow. Furthermore, when the plaintiff went into arrest, the defendant physician responded appropriately by reopening the patient’s incision immediately and performing the coronary artery bypass grafts. Despite the grafts and a new aortic valve, however, the plaintiff’s cardiac function remained compromised, leading to her death. The defense contended that, while the patient’s outcome was unfortunate, the procedure to replace her valve had been done correctly and that the size of the valve did not matter, since the outflow diameter for both the 17-millimeter and the 19-millimeter valve is the same; the two valves differ only in the size of the cuff needed to attach the valve to the aortic annulus.
Collaborating with the defendant and her attorney, APS created visual aids to help illustrate these defense positions.
The first diagram demonstrated the normal circulation of blood through the heart and the role of the aortic valve.
Further, working with the defendant, APS created a board illustrating that, as revealed by the autopsy, the patient’s valve had been correctly placed and contrasting this correct placement with the appearance of and complications following improper placement. This board definitively demonstrated that a valve correctly placed at the aortic annulus is a comfortable distance from the coronary arteries’ ostia and in no way obstructs blood flow. Clarifying this point enabled the jury to see that — given the proof provided by the autopsy that the valve had been correctly placed — the plaintiff’s claims were unfounded.
Another key issue for the defendant was the differences and similarities between the 17-millimeter valve used in the surgery and the 19-millimeter valve that the plaintiff claimed should have been used. Specifically, the defendant wanted to show that a larger valve would not have made any difference to the patient’s outcome because the actual valve openings (through which the blood flows) for both are exactly the same diameter; only their outer sewing cuffs differ in size.
Another illustration showed the location of the coronary artery bypass grafts placed after the plaintiff’s cardiac arrest
This series of illustrations helped the defense to convey the following key points to the jury successfully:
- The defendant’s decision to use a 17-millimeter St. Jude valve for the aortic valve replacement was completely appropriate.
- The autopsy confirmed that the valve was the correct size and in the correct location, with no evidence that the coronary arteries’ ostia were kinked or blocked.
- Although the outcome in this case was unfortunate, the defendant’s actions were appropriate and within the standard of care.
The jury found in favor of the defense.
“I thought your illustrations were excellent and helped clarify our explanations for the jury.”