The patient decompensated immediately after anesthetic induction for an elective atrial fibrillation ablation on 08/08/2024, with acute hypotension, severe biventricular failure on intra‑procedural TEE, metabolic acidosis, and cardiogenic shock; the ablation was aborted, the airway was secured, multiple pressors/inotropes were initiated, and urgent cath with Impella support was performed.
Alleged deviation: Proceeding to anesthetic induction for elective ablation in the setting of recent, documented worsening dyspnea (1–2 weeks) and a very elevated BNP (~2000 “4 weeks ago,” i.e., near the time of the procedure) without documented pre‑procedure optimization or up‑to‑date transthoracic LV function assessment, and with a plan to diurese “afterwards,” may fall below accepted pre‑procedure risk assessment/optimization practices for elective AF ablation and may have contributed to peri‑induction collapse.
Dr. S. documents persistent AF, shortness of breath for the past 1–2 weeks, plan for TEE followed by ablation, and that “if he needs to be admitted for diuresis afterwards, he understands and is willing” (08/08/2024, Dr. S.).
• Prior outside echo (04/25/2024) showed EF 50% with severely dilated left atrium 5.4 cm
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No questions yet!
Do you believe there might have been medical error?
1. Sounds like he was in decompensted chf prior to the procedure —worsening doe and needs diuresis prior to ablation..if ef was 50% 4 months prior sounds like there is a change and this should have been explored prior to and ELECTIVE procedure
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes giving anesthesia to a patient in ADHF is a contraindication unless surgery is urgent AND risk is properly explained to pt and family—this was elective however!
What makes you a good expert for this case?
I take care of these patients on a regular basis and always have to determine daily for multiple patients in office and hospital who is “clear” for a procedure/surgery
How often do you encounter cases similar to this one in your practice?
I’ve only had a cardiac arrest at induction a few times but only with patients at very high risk for procedure, e.g older patients with known cad and active chf and risk is always explained in detail to pt and family
Do you believe there might have been medical error?
With new symptoms of heart failure, it would be standard of care to evaluate the ejection fraction prior to general anesthesia.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Need more information as to the clinical course after the cardiovascular collapse including details of the cath and outcome.
What makes you a good expert for this case?
I routinely 1) evaluate and optimize patients prior to general anesthesia and clear them 2) manage cardiogenic shock and cardiac arrest as a complication of anesthesia/percutaneous cardiac procedures
How often do you encounter cases similar to this one in your practice?
Yes both in the preprocedural assessment and following the complication. Please note I do not perform atrial fibrillation ablations though do not find this experience necessarily relevant to this case.
Do you believe there might have been medical error?
From this initial look up, it appears that the patient was already in florid CHF. These patients need to be optimized and diuresed before any anesthesia induction. The vasodilation caused by the ablation will unfortunately overwhelm any limited reserve of the LV, and cause a sudden decline in hemodynamics. I will need to look at mote details, but the safe thing would have been aggressive diuresis, a net negativr balance and then reevaluate the decision to proceed. I am curious how anesthesia also agreed to intubate this patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The spiraling down LV failure was compounded by general anesthesia. When it is an elective case, you have time to evaluate and see if the patient is stable to be generally induced. In emergency, obviously nothing like that works. But it looks like they had time to go over the hemodynamics.
What makes you a good expert for this case?
I do a lot of structural cases with general anesthesia, most of which are already complicatsled with CHF.
How often do you encounter cases similar to this one in your practice?
Rarely, because florid CHF is caught always and treated with GDMT first. If we see the slightest inclination of decompensation, we stop and go back to square 1.
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