Infant Requires Heart Assist Device Following Delayed Clinical Evaluation

This case involves a female infant who suffered pneumonia at 16 months of age. She was taken to the pediatrician’s office and seen by a nurse practitioner, not the pediatrician. The infant had a chest x-ray which was read as enlarged cardiac size. Clinical correlation was recommended to exclude cardiac disease and the infant was scheduled for a followup one month later. Within the week, the infant was brought to the emergency room. She was found to have cardiac collapse secondary to cardiomyopathy. She was coded for 6 minutes and had a ventricular assist device placed.

Question(s) For Expert Witness

1. How often do you treat pediatric dilated cardiomyopathy?

2. What is the natural course for a 16-month-old diagnosed with idiopathic dilated cardiomyopathy before cardiac arrest (eg, medications, surveillance, symptoms, and when would they need a heart transplant)?

Expert Witness Response E-001712

As a practicing pediatric cardiologist and medical director of the inpatient cardiology unit at a tertiary pediatric referral and heart transplant center, I have seen and treated many patients with dilated cardiomyopathy. We serve as the primary referral center for our state for pediatric cardiology, and all patients with dilated cardiomyopathy that require acute cardiac care will come to our center. While cardiac arrest is a known complication of dilated cardiomyopathy, we are usually able to treat patients medically and/or transplant their heart before suffering a cardiac arrest. So, it is very likely that the cardiac arrest could have been prevented with earlier diagnosis, although it may not have prevented the need for eventual transplantation. It is also likely that the transplant could have been delayed, and possible that the transplant could have been avoided. The natural course for a dilated cardiomyopathy is variable, depending on the degree of cardiac dysfunction. Often, these patients can be treated with medications and close surveillance. Prolonged inpatient care is occasionally needed to optimize the medical therapy. When medical therapy is not adequate to maintain a stable cardiac output, then we consider a ventricular assist device and/or transplant.