Cardiothoracic Surgery Procedure Results in Pulmonary Embolism and Neurological Damage

This case involves a 15-year-old female patient who presented to her PCP for an unrelated complaint. The PCP auscultated a heart murmur and referred the patient to a pediatric cardiologist. A TTE diagnosed a coarctation of the aorta. Days later, a CTA was performed to better visualize the aortic arch. The cardiothoracic surgeon interpreted the study as showing a lesion at the arch between the innominate and L carotid and recommended a more complex surgery to repair the lesion instead of a simple repair of the coarctation. A month later, the patient underwent surgery involving a median sternotomy under deep cardiac arrest instead of simple left throacotamy for simple coartation repair. In the post-operative period the patient suffered pulmonary embolism which migrated to her brain. She is now left with marked dystonia and other neurologic deficits. It was not until 6-months post-op that the CTA was interpreted by a pediatric radiologist, confirming 60% coarctation of the aorta with no abnormality of the aortic arch. This case takes place in the state of Utah.

Question(s) For Expert Witness

1. How often do you perform repairs of coartation of the aorta?

2. Have you ever had a patient develop the complications that this patient suffered post-operatively?

3. What diagnostic procedures should be performed prior to taking the patient to the OR?

4. Have you ever served as an expert witness on a similar case?

Expert Witness Response E-006213

I frequently perform aortic arch repair. Between thoracotomy, full arch reconstruction and counting arches which are components of more complex defects than compared to this case, I perform about 30 repairs per year on children. Prior to taking the patient to the operating room, there are many standards of care that could have been upheld in this case. Most patients begin with a TTE. I routinely obtain axial imaging and use an MRI to avoid radiation. A CTA is also adequate and perhaps has a better resolution. I have served as an expert witness on a somewhat similar case in which an adult had a traumatic rupture of the aortic isthmus, in whom there was a question of developing an obstruction due to surgical technique.