Jayden Melvin Espaillat is a 6 m.o. male with infantile hemangiomas on his right retro auricle and right parotid. He is being seen in clinic today for 1 month follow-up after initiation of propanolol 3mg/kg/day divided into TID. Due to cardiac history he was admitted on 4/10/24 for initiation of propanolol therapy. Hemangiomas was initially noticed in 2/2024 he was treated multiple times for parotitis prior to being diagnosed with hemangiomas. He has a PMH of severe hypoplasia of the transverse arch with coarctation of the aorta status post repair on 10/25/2023. During his repair he experienced right diaphragmatic paralysis requiring hemi diaphragmatic plication. He experienced intra-abdominal bleeding, mediastinal bleeding, and pulmonary hemorrhage.
Interval History:
Mother reports that he has been doing well since discharge. He has had 0 hospitalizations and 0 emergency room visits. Mother denies fatigue or increased tiredness. Reports he typically tolerates 4-5oz of high calorie formula every 3-4 hours. He also has started to consume for solid foods. He is currently teething. Denies abdominal pain. Reports intermittent emesis after medication administration with night time feed.
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Do you believe there might have been medical error?
This was a complex case of congenital hypoplasia of the transverse aortic arch and descending aorta (coarctation) that was complicated by mediastinal tamponade and LEFT (not right) hemidiaphragmatic paralysis. The tamponade was secondary to significant ascites transversing the peritoneum and filling the mediastinum. The physiology of this is unclear to me. It does not appear, however, that the tamponade was secondary to bleeding. The left hemidiaphragmatic paralysis was likely secondary to phrenic nerve injury, unfortunately a known complication when operating on the aortic arch, particularly when the anatomy is barely sizeable on a 3 day old child. Each complication was detected promptly and addressed properly, in my opinion. The hemangiomas reported at the beginning of the case, appear unrelated to the case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Please, refer to my comments in the previous section. I don't believe there is any causation.
What makes you a good expert for this case?
Attending cardiothoracic surgeon for 17 years with legal/expert consultant activity for the past 15.
How often do you encounter cases similar to this one in your practice?
I mostly manage adult cardiac surgery patient. In several circumstances, however, they carry congenital structural defects that are addressed in the adult age.
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