52yo F with previous TAVR, has failed valve and becomes symptomatic. Possible delays with abnormal EKG in office and heart cath, dies following day. (Case #422)

• Medical Probability: 10 / 10
• Medical Error Summary: With symptoms and this degree of aortic stenosis, urgent treatment was necessary- both medical and surgical
• Causation Probability: 9 / 10
• Causation Summary: The cause of death here is either closure of the aortic valve or further embolization into the coronaries. Seeing the cath films would help.
• Expert Summary: Interventional cardiology, cardiac critical care and inpatient cardiology are my expertise and this case overlap with all of these.
• Similar Summary: I am the Director of Inpatient Cardiology Service and see similar patients in both the floor and the ICU setting. This is a rare complication but happens once every few months.

Preoperative clearance prior to elective hysterectomy. (Case #429)

• Medical Probability: 9 / 10
• Medical Error Summary: Given the patients blood pressure is 279/114 on insertion of the arterial line- which must be immediately preoperative- it would be against standard of care to send such a patient to the operating roo...
• Causation Probability: 10 / 10
• Causation Summary: There is no question whatsoever that the neurologic injury is a direct result of the blood pressure.
• Expert Summary: I practice both inpatient and outpatient cardiology, including in a critical care setting where I frequently manage blood pressure requiring vasoactive drips such as was done in this case. I also rou...
• Similar Summary: I routinely evaluate preoperatively for surgery and routinely manage severe hyper or hypo tension. This though is a very rare case mostly because of the description of being unable to take additional...

Patient did well after surgery. 3 days later CT showed massive aspiration. Plastic found in left bronchi. Died two weeks later of hypoxic respiratory failure. (Case #458)

• Medical Probability: 7 / 10
• Medical Error Summary: The plastic debris in the airway could only have been introduced by health care provider.
• Causation Probability: 8 / 10
• Causation Summary: This led to a cascade of events including reintubation, malnutrition, etc
• Expert Summary: I routinely practice in the ICU as a cardiac critical care specialist
• Similar Summary: this is a common case to an icu

Procedural complication resulting in cardiac arrest from a cardiac perforation (Case #490)

• Medical Probability: 9 / 10
• Medical Error Summary: 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.
• Causation Probability: 10 / 10
• Causation Summary: Its clear that the perforation resulted in cardiac arrest from tamponade.
• Expert Summary: I specialize in interventional heart failure and routinely perform endomyocardial biopsies including for amyloid (ie > 300 biopsies per year).
• Similar Summary: Catastrophic complication from biopsy is rare. But biopsy and evaluation for complication and management of complication is something I do often (ie weekly).

Cardiac arrest during elective outpatient ablation for a-fib. (Case #505)

• Medical Probability: 6 / 10
• Medical Error Summary: With new symptoms of heart failure, it would be standard of care to evaluate the ejection fraction prior to general anesthesia.
• Causation Probability: 6 / 10
• Causation Summary: Need more information as to the clinical course after the cardiovascular collapse including details of the cath and outcome.
• Expert Summary: 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
• Similar Summary: 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 cas...

F/T diagnose and treat myocarditis in a 17-year-old resulting in severe heart dysfunction with a subsequent heart transplant (Case #532)

• Medical Probability: 7 / 10
• Medical Error Summary: The key in answering this is scrutiny of the 1/13 visit to the ER.
• Causation Probability: 9 / 10
• Causation Summary: Should there have been deviation from standard of care during the 1/13 visit, then there is definite causality.
• Expert Summary: My specialty is cardiogenic shock and use of mechanical circulatory support - like ECMO- for the sickest subgroup of patients.
• Similar Summary: On a daily basis as this is my specific specialty.

Cardiology Plan of Care (Case #567)

• Medical Probability: 8 / 10
• Medical Error Summary: There should be close review of the EKGs. There was such incredible coronary disease with two being 100% occluded that it is hard to imagine there were not ST elevations or other criteria that would ...
• Causation Probability: 8 / 10
• Causation Summary: The extent of coronary disease here was very significant and peripheral arterial disease may have limited options even if taken to the cath lab sooner. However, "no revascularization achievable" is v...
• Expert Summary: I am an interventional cardiologist with a specialty in STEMI and cardiogenic shock requiring mechanical circulatory support (ie Impella CP).
• Similar Summary: Several times per week as this is my specific clinical specialty.

Potential negligence in the management of cardiogenic shock (Case #572)

• Medical Probability: 9 / 10
• Medical Error Summary: Rhythm control is preferred over rate control for atrial flutter in general but especially in heart failure. More importantly, the choice of IV diltiazem was one that is contraindicated and almost ce...
• Causation Probability: 10 / 10
• Causation Summary: Yes. If upon review of the records it was clear that diltiazem was initiated or continued inappropriately there is definite causation.
• Expert Summary: I am the director of the inpatient cardiology resident service with a specific specialty in the management of cardiogenic shock.
• Similar Summary: I see cases like this daily both taking care of them from admission, but also being called for the management of shock and insertion of MCS if it reaches the point it did here in this case.