77 year old male with CAD and severe MR presented for elective surgical revascularization. Admitted to ICU s/p CABG x4 and MV Replacement on 11/11/24 with intraoperative course complicated by IVC tear requiring repair under deep circulatory arrest with a bovine pericardial patch and placement of intra-aortic balloon pump. In the ICU patient was under mechanical ventilation, in cardiogenic shock with multiple vasopressors and inotropic support with renal failure w/ continuous dialysis for fluid overload.
Patient condition continue deteriorating with severe metabolic acidosis worsening with open chest and open abdomen due to compartment syndrome of the abdomen. Due to his severe acidosis, IP made DNR by the family the day and passed on 11/15.
We do not have concern about pre-op handling. This would be a question about the surgical technique and the management of the tear itself.
*The operative note screenshots are attached.*
Thank you in advance, questions welcome.
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Do you believe there might have been medical error?
In appropriate placement of cannula, failure to recognize injury, delay in appropriate care, extended pump time resulted in multiple postop complications.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Error by surgeon in cannula placement and delayed recognition related in extended pump run and jumper complication that directly relate.
What makes you a good expert for this case?
17 yrs experience. In cardiac surgery at both academic and in private practice settings - including trainees.
How often do you encounter cases similar to this one in your practice?
<1% of cases would result in delayed recognition and delayed therapy.
Do you believe there might have been medical error?
Complications like a tear of the IVC can occur in the absence of malpractice. The operative report does not reveal any red flags. Once recognized, it appears that the surgeon and his colleagues went through the appropriate algorithm to address the issue, first trying to repair the hole while on bypass, then inserting a second cannula for drainage, the use of circulatory arrest, etc. One issue that does come up in such a case is whether the IVC was narrowed down by the repair, which could lead to malperfusion of the abdominal organs and distension. The patient's clinical course postoperatively can be explained by such an occurrence, and it would be critical to determine from the intraoperative TEE whether there was evidence of IVC narrowing. If there was narrowing, then the standard of care was breached.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
So, the question, as phrased is tricky. The causation element is satisfied since, it is likely, had the IVC injury not occurred, that the patient would have survived. However, it is unclear from the information provided whether the standard of care was met, as per my prior response. It will hinge on whether the IVC was narrowed by the repair.
What makes you a good expert for this case?
I haver performed thousands of CABGs and hundreds of valve surgeries, and have practiced in both the academic and private practice environments.
How often do you encounter cases similar to this one in your practice?
A tear of the IVC during CABG/Valve surgery is extremely rare. For most cardiac surgeons, this will occur fewer than 5 times in their career. I have removed cardiac tumors from the IVC, which require a similar sort of repair. Here is a youtube video I posted probably a decade ago on repairing the resulting hole under circulatory arrest: https://www.youtube.com/watch?v=rMv5ldKNK5I&t=3s
Do you believe there might have been medical error?
There are several aspects that are somewhat controversial here: 1) The described case was estimated to be at very high risk (morbidity/mortality of 15% ?). Was this estimate based on STS-PROM ? If so, was the case discussed in a multidisciplinary fashion and what alternatives were considered ? 2) Direct cannulation of the inferior vena cava (IVC) is somewhat troubling due to anatomic reasons such as it's very short length (prior to deeply dive into the right hemidiaphragm) and thin wall (hence, prone to injury). Aside from the specific (and individual) surgeon's routine, it is usually safer to cannulate the IVC from the lower aspect of the right atrium exactly for the anatomic reasons mentioned above, and for the possibility to repair the cannulation site easily at the end of cardiopulmonary bypass. A tear in the IVC caused by direct entry would be challenging to repair with the modality of cannulation performed in this case. 3) In addition, one has to wonder why umbilical tapes were not passed around each vena cava prior to go on bypass for the index operation ? This is routinely done in order to snare each vena cava, decrease venous return to the right atrium and improve venous drainage prior to opening either atrial cavity. 4) Was the second cross clamping necessary when decision was made to repair the IVC injury under circulatory arrest ? This appeared to add additional ischemic time to the myocardium. Myocardial protection could have been achieved by retrograde administration of cardioplegia with ventricular fibrillation cardiac arrest already provided by moderate hypothermia. This is routinely achieved in cases of Stanford type A acute aortic dissection, where cross clamp is not applied. 5) Snaring of the IVC to control bleeding from the tear, even if on cardiopulmonary bypass with the SVC cannula and while attempting to percutaneously (or directly, through a cut-down) cannulate the femoral vein/intrabdominal IVC) may have led to extreme liver engorgement/edema with risk of liver ischemia (hence resulting in the massively elevated INR and fibrinogen deficit). Although it doesn't transpire from the operative report, the time lag between IVC snaring/occlusion (even in presence of a Foley catheter) and femoral vein cannulation may have contributed to perioperative shock liver, metabolic acidosis, multiorgan failure, etc. 6) Last but not least, when considering the extensive amount of cardiopulmonary bypass time required for this case, the use of higher level of cardiopulmonary support (i.e. venoarterial ECMO) rather than IABP may have been a more favorable choice. This circumstance, however, may have been challenging if residual significant bleeding was still present.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Please, refer to comments made above.
What makes you a good expert for this case?
Attending cardiothoracic surgeon for the past 17 years, with legal/expert counsel role for the last 15.
How often do you encounter cases similar to this one in your practice?
Not often, as this appears to be an extraordinary combination of technical issues and high-risk type of case.
Do you believe there might have been medical error?
The pursestring in the IVC caught the frail tissues of a 77yo patient and tore the vessel, in addition to most likely negligent handling of the cannula itself that probably traumatized the IVC
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
traumatic and poor purse-string placement and cannulation technique led to injury to the IVC
What makes you a good expert for this case?
I perform cardiac cases routinely and I never experienced such a significant injury to the IVC that required patch repair and circulatory arrest.
How often do you encounter cases similar to this one in your practice?
very very rarely I encounter injuries of this magnitude
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