A 73-year-old male with a history of severe mitral regurgitation, diabetes, hypertension, and obesity underwent mitral valve surgery on February 22, initially attempted as a repair but converted to bioprosthetic replacement after intraoperative difficulties.
The surgery was prolonged, with a cross-clamp time of 236 minutes and bypass time of 277 minutes, well above typical ranges, largely due to the reported failed repair attempt that resulted in re-clamping. The operative note also documents the surgeon left a synthetic neochord loop “free-floating” in the left ventricle, a concern for us. Upon transfer from the operating table, the patient suffered a cardiac arrest, theorized as an air embolism, and was ultimately resuscitated.
However, he then developed severe biventricular failure, with particularly severe right ventricular dysfunction, requiring initiation of VA ECMO within 24 hours. Despite temporary stabilization, the patient endured a cascade of complications including limb ischemia secondary to vasopressor use, ultimately resulting in a right below-knee amputation, left transmetatarsal amputation, multiple finger amputations, a cerebellar infarct, subarachnoid hemorrhage, severe malnutrition, dialysis-dependent renal failure, and prolonged mechanical ventilation with tracheostomy.
While the placement of the prosthetic mitral valve was ultimately achieved and confirmed on imaging, we wish to analyze not only the technical proficiency of the procedure, but the decision to persist with an extended repair in the face of moderate residual mitral regurgitation and the electively retained neochord loop possibly causing the IP his catastrophic residual complications. IP was hospitalized for approx. 2.5 months post-op.
A redacted OP note has been attached. Additional information is available upon request.
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Do you believe there might have been medical error?
If there were so many complications, it's evident that there was a medical error. Nevertheless, it happens that a mitral repair fails and the valve needs to be replaced. I believe the surgeon did the right thing to go back and replace the valve once he recognized his second repair was not optimal. The free floating chords in the ventricle should not have cause any issue, unless the pledgets were not removed and embolized. The long bypass and crossclamp times are typical of complex cases especially when the mitral valve needs to be re-repaired or replaced. As far as there is good myocardial protection, the heart should resume its normal function at the end. But apparently the surgeon had issues with drainage since the very beginning, and that lead to poor myocardial protection, reason why the heart function was not normal at the end. Not appropriate de-airing at the end of the case might have caused air embolism, especially upon transportation (air can move and be trapped in the right coronary artery and cause an arrest). The air in the ventricle should have been recognized by the echocardiographer.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
several issues since the beginning of the case caused a cascade of events that lead to poor outcome. There were: poor drainage failed repair of the mitral valve inappropriate de-airing
What makes you a good expert for this case?
I perfom open heart cases on a daily basis in a busy NY Institution
How often do you encounter cases similar to this one in your practice?
Cases with so many issues are infrequent to encounter. But it happens,
Do you believe there might have been medical error?
Mitral valve repair is a very complex procedure requiring high expertise and years of experience. Anatomic and echocardiographic assessment performed perioperatively are paramount. Type of repair has to conform with the present valve pathology. Decision for valve replacement has to be taken timely in order to minimize cardiopulmonary bypass and cross clamp timing. Lastly, decision for mechanical support following surgery has to be made timely in order to decrease the risk of severe postoperative complications.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Possibly an error in judgement on type of repair performed, as well as perioperative management.
What makes you a good expert for this case?
I have been an expert reviewer for 15 years.
How often do you encounter cases similar to this one in your practice?
Very often. I have reviewed prior cases of mitral valve procedures leading to major morbidity and mortality. Most of them stemmed from suboptimal operative experience or judgement.
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