52-year-old female with a history of severe aortic stenosis with a TAVR and AAA repair in 2016. Cardiologist seeing her for ongoing shortness of breath and heaviness and chest with peripheral edema. Last heart cath was done in 2015 and last echo was 2021 with an EF of 50%.
Office visit in January of 2024 reports that PC was having increased fatigure. MD states she needs to exercise and lose weight. Cardiologist increased her Lasix from 20 to 40 mg daily and says he suspects that she “had poor diet over the holidays”. He orders a nuclear stress test and updated echo.
Follow up office visit in March reveals that her echo continues to show EF of 50%, but there's concern that the aortic valve gradient is quite high. Possible that she might need a redo of her aortic valve replacement. There's a note stating that the stress test was not done for unknown reasons. However, she is agreeable to a TEE to further evaluate the aortic valve disease and they rescheduled the stress test.
March 18th, TEE reveals severe stenosis, however no evidence of thrombus and a negative bubble study to the aortic valve. EF is now down to 40 to 45%. They would like for her to undergo a redo, but we need a heart cath first prior to surgery. The stress test is abandoned for the heart cath due to the inevitable TAVR redo procedure. They elect to discharge her, stating that they will schedule everything for “2 weeks out” to authorize the treatment plan through her insurance. However, the records show a very concerning EKG that was done in office with global ST depressions, which is new (and even mentioned in the cardiologist's note.) PC was still discharged home with fatigue and shortness of breath). OFFICE NOTES REDACTED AND ATTACHED AS SCREENSHOTS.
The next day, PC begins to have excruciating chest pain and is brought to the ER.
*Please note, we have the cath report, CTA results and a small amount of record from this admission, however we are missing a significant amount of information (labs, consults, etc). The full records have been ordered and should be available within 2-3 weeks. They obviously will be available in the expert package for official review.
PC is brought immediately to the cath lab and they find 90% blockage in mid LAD and first diag. (RESULT ATTACHED AS SCREENSHOT). No intervention, no Impella or balloon pump done because they would like to consult surgery to decide between the TAVR with intervention or open valve replacement/bypass? Heparin drip started. A CTA aorta was performed the next day and the results are part of the attached 2-part screenshot. This was approx 20-22 hours after the original heart cath.
Unfortunately, after the CTA, no final decision had been made and the PC was profoundly hypotensive and had AMS. Rapid response was called and treated with pressors, however did have full arrest. PC never recovered and after prolonged down time while working the code, PC died in the ICU.
Please note, the cardiologist from the office visit, the one who performed the heart cath and the lead on the treatment team for this PC is the same provider.
We are looking at 2 aspects: was it inappropriate to allow the PC to go home from cardiologist’s office based on the documentation, symptoms and abnormal EKG? Also, based on the limited information from the cath/CTA/timeline, was it appropriate to not intervene and/or plan for a faster treatment plan?
Please notify of any questions. Thank you in advance.
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Do you believe there might have been medical error?
In January, the patient's echocardiogram showed abnormal valve gradients that were already quite high. It’s unclear why there was a delay in evaluating the patient until March. By March, the records indicate that the patient had been experiencing chest pain for the past 7-10 days. The patient's EKG in the clinic also showed clear abnormalities, along with ongoing symptoms. While it’s possible the patient was not having active chest pain during the clinic visit, which could justify sending them home, if they were experiencing ongoing symptoms, they should have been admitted to the hospital. Delaying the procedure despite ongoing EKG changes and symptoms is not appropriate. The insurance covers an inpatient admission and, if necessary, a TAVR procedure, so lack of coverage should not have delayed hospitalization. In fact, the patient was admitted the very next day. While the angiogram showed coronary artery disease, it’s unclear whether the patient was having an active heart attack. If they were, it would make sense to address the coronary issues at that time. To clarify this, the coronary angiogram CDs or disks need to be reviewed. If the patient wasn’t having an active heart attack and was hemodynamically stable (with normal blood pressure and heart rates), it would have been reasonable to defer treatment until the cardiac surgery team could evaluate the patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There was a delay in this patient's management and treatment. The treatment depends on the symptoms of the patient. If there is documentation or evidence that the patient was symptomatic at the time of the first visit (January 2024) then there is a case since there is clear delay in treatment of this patient. For the second visit, 2 weeks is not considered a significant delay if the patient was not symptomatic during the visit. While, the notes mention that the patient had heart symptoms but it is written that they were before the visit. If there is any evidence/text messages where the patient has mentioned that he had chest pain the day of the visit, this can become a strong case since patient should have been admitted to the hospital. Patient was likely having chest pain during the visit because the EKG is abnormal and the patient was admitted the very next day however this is circumstantial evidence. Nonetheless, the second echocardiogram shows that the valve is very tight and narrowed. The valve stenosis measurements are extremely high, indicating that the heart is at risk of failing soon. There is already drop in ejection fraction which is another sign of this patient having a high risk of dying if the procedure is not carried out as soon as possible.
What makes you a good expert for this case?
I regularly perform TAVR procedures as well as coronary angiogram/coronary artery stents. I have been doing them since 2017.
How often do you encounter cases similar to this one in your practice?
This situation is not unusual when a patient first shows signs of severe disease who has not been following up with a heart doctor for a while. According to current guidelines, the valve should be monitored five years after surgery. Since the surgery was done in 2016, an echocardiogram should have been done in 2021, with the next one scheduled for 2026, depending on the severity of the valve disease at that time. However, if the 2021 echocardiogram revealed early signs of disease, another echocardiogram should have been done much sooner. Despite this, when valve dysfunction was first discovered in January 2024, I am surprised that the patient was not referred for treatment at that time and it is unclear why the procedure was delayed until March 2024, by which time the patient's valve condition had worsened.
Do you believe there might have been medical error?
With symptoms and this degree of aortic stenosis, urgent treatment was necessary- both medical and surgical
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The cause of death here is either closure of the aortic valve or further embolization into the coronaries. Seeing the cath films would help.
What makes you a good expert for this case?
Interventional cardiology, cardiac critical care and inpatient cardiology are my expertise and this case overlap with all of these.
How often do you encounter cases similar to this one in your practice?
I am the Director of Inpatient Cardiology Service and see similar patients in both the floor and the ICU setting. This is a rare complication but happens once every few months.
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