The patient is a 61-year-old high-risk individual who presented to the hospital with lightheadedness and diarrhea for 3–4 days. She underwent a right ventricular endomyocardial biopsy to evaluate for infiltrative cardiomyopathy (amyloidosis). According to the procedure report, four biopsy bites were taken, two of which were large and cut in half.
The procedure was catastrophically complicated by right ventricular perforation, resulting in a large pericardial effusion leading to cardiac tamponade, cardiogenic shock, and cardiac arrest (asystole). This was noted at the end of the procedure when patient went hypotensive. She required approximately 9 minutes of CPR and emergent pericardiocentesis with drainage of 1,650 cc of blood, and received Kcentra. Her course was further complicated by an acute upper-extremity DVT.
Although she survived, she sustained significant injuries, including a subsequent right upper-extremity DVT and rib fractures. Prior to the procedure, she worked as a nurse’s aide. She is now unable to work, has lost her livelihood, and continues to experience exertional dyspnea and functional impairment.
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Do you believe there might have been medical error?
Need to see xray images and equipment used. Perforation is caused by biopsying the wrong wall of the heart which is likely what was done here.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Its clear that the perforation resulted in cardiac arrest from tamponade.
What makes you a good expert for this case?
I specialize in interventional heart failure and routinely perform endomyocardial biopsies including for amyloid (ie > 300 biopsies per year).
How often do you encounter cases similar to this one in your practice?
Catastrophic complication from biopsy is rare. But biopsy and evaluation for complication and management of complication is something I do often (ie weekly).
Do you believe there might have been medical error?
How to know whether there’s a medical error or not just based on the brief course of events as a perforation is a well-known complication of RV biopsy. In fact when we do them, we always perform an echocardiogram immediately post procedure to confirm no effusion. If that was not done, it could be considered a deviation of best practice, but if this was identified at the end of the procedure while still in the lab then maybe they did not get around to it. The management after that seemed appropriate based on the blurb. So at face value, this just looks like a horrible but known complication from a procedure
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Can cannot assess whether there was a medical error or not since this is unknown complication of this procedure. Would have to dive into the notes and the fluoroscopic imaging to determine if there was a deviation from best practice.
What makes you a good expert for this case?
I’ve been at practicing interventional cardiologist for 13 years. I have done a few expert witness reviews. And I have been involved with several RV biopsies.
How often do you encounter cases similar to this one in your practice?
I’ve never experienced this complication myself, but I have discussed with colleagues who have
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