EXPERTISE IN INTERPRETATION OF CT-ANGIO IS REQUIRED TO COMMENT ON THIS CASE.
53 yo woman after rigorous work experiences some chest pain and goes to ER. By then pain has subsided. She tells them she had a CT Angiogram 51/2 months prior that was completely normal and it is part of her electronic record. Indeed that report states "No significant plaque" in any coronary artery and Agatson Score of 0 in all coronary arteries. They order another. It is read by an "outside" Radiologist on his laptop at home and he finds "moderate atherosclerotic disease with worst lesions seen in the proximal LAD and mid LCX (50-69% decrease in luminal diameter and mild disease at the proximal RCA (less than 50% decrease in luminal diameter.)”. Agartson score was again 0 in all coronary arteries. Stating that "Your cardiac CT Angiogram indicated a progressive change from your prior CCTA”. they transfer her emergently to a Level III hospital for cardiac catheterization. This is done and the result of the procedure is "no evidence of significant disease" in any of the patient's coronary arteries. Unfortunately the patient suffers a major complication during the procedure. No case against anyone at the Level III hospital, so no need to comment on causation. Assuming you find that the outside Radiologist misread the CTA (I have been told the quality is poor and undiagnostic), I need you to so testify in mid June. Obviously expertise in reading CTAs is a requirement. Compensation for preparation and court appearance are a given.
Files:
No questions yet!
Do you believe there might have been medical error?
Firstly, without reviewing the images, It is critical to note that despite a coronary calcium score of zero you can still have significant Coronary artery disease. The prior report says “no significant plaque”. That simply means no lesions greater than 70%—-indeed that is what this second study reports although they stay there is called progression “ Again cardiac catheterization says no significant disease which again means nothing >70%. But there could still be lesions up to 69%. (That is not stated in the above paragraph) It is entirely irrelevant that the doctor read it on his “home laptop“ if his computer and screen were in fact appropriate for reading the study. Complications from cardiac catheterization are rare but I known risks for which the patient signed consent
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This patient has new chest pain and a new evaluation is warranted. Even if the CCTA overcalled a “lesion “ That is not causation if there is a complication for me later procedure.
What makes you a good expert for this case?
I deal with these cases all the time. While complications from cardiac catheterizations are rare, they do happen and while litigation can ensue, in this case there is no harm caused by The physician who read the CTTA— even the interventional cardiologist should not be held liable unless the complication was beyond the scope of what can be seen
How often do you encounter cases similar to this one in your practice?
I see “over reads “on CCTA Often. Usually, it is in the setting of calcified arteries which was not the case here
Do you believe there might have been medical error?
The coronary CT angiogram provides different information than the invasive coronary angiogram. In the CT , the wall of the vessel can be visualized and frequently coronary artery disease can be noticed. This may not be noticed in invasive coronary angiogram because the wall of the vessel is not noticed. It is likely that the radiologist has read it correctly and there might be disease present. Unless the CT angiogram is available, this cannot be confirmed. Nevertheless, there is no act of omission here but rather commission and that is perfectly reasonable to be read. The current cardiology guidelines do not recommend cardiac catheterization for such a patient unless they are suffering from significant symptoms. It is also possible that one radiologist may read a lesion different from another radiologist granted there was an artifact present. If the radiologist failed to acknowledge there was an artifact, then there could be a medical error. If the radiologist failed to utilize a high-quality imaging platform to read the study, there could be a medical error due to improper equipment. Otherwise, it is perfectly within the scope of practice to read the lesion different. This radiologist did not say that the lesion was severe (>70%) which should be investigated further with cardiac catheterization but rather said that it is moderate in severity which is currently recommended to be treated with medical therapy first rather than rushing to the cardiac catheterization lab.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
No. The medical error did not result in injury. The person making the decision to proceed with the heart catheterization made the judgment call and we many times do not proceed with cardiac catheterization in these patients. Therefore, the radiologist is unlikely to be held accountable for the medical error.
What makes you a good expert for this case?
I am currently appointed as co-director of cardiac imaging and have training in Cardiac CT and MRI. I work in an academic institution where we read several hundreds of CT scans every year and therefore, with the background knowledge of that and also of the interventional cardiology (doctors who put in stents and perform cardiac catheterization) and cardiology, I have a unique background to inform on this topic. I also have more than 100 peer reviewed papers published many of those are on cardiac CT scan which is the diagnostic study considered here.
How often do you encounter cases similar to this one in your practice?
We frequently encounter this in our practice. This is not an uncommon scenario.
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