Description of Event or Problem · 1
A (B)(6) MALE, HISTORY OF CORONARY BYPASS 1994, STENT PLACEMENT 2004. RECENTLY GG HAD EXPERIENCED ANGINA AND DYSPNEA ON EXERTION LEADING TO EVAL PER CARIOLOGY. ANGIOGRAPHY COMPLETED DEMONSTRATING A PATENT LIMA TO THE LAD, A PATENT VEIN TO THE QM-1, AND AN OCCLUDED RIGHT CORONARY ARTERY THAT WAS WELL COLLATERALIZED AND CRITICAL AORTIC STENOSIS. FAILED RANEXA THERAPY. ECHO DEMONSTRATED MEAN GRADIENT OF 40 MM HG AND A VALVE AREA OF 0/5 SQUARE CM. ON (B)(6) 2011, ADMITTED FOR AORTIC VALVE REPLACEMENT. THE FOLLOWING INFO WAS PROVIDED BY THE CARDIOTHORACIC SURGEON: (B)(6) WAS UNDERGOING HIGH RISK RE DO CARDIAC SURGERY, 15 YRS AFTER HIS PREVIOUS CABG PROCEDURE. WE CHOSE A MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT. THIS TECHNIQUE IS WELL ESTABLISHED IN THE LITERATURE FROM MULTIPLE SITES. AS PART OF THE PROCEDURE, A SHEATHED INTERNAL JUGULAR DIRECTED CORONARY SINUS CARDIOPLEGIA CATHETER IS PLACED TO FACILITATE MYOCARDIAL PROTECTION. THE PLACEMENT BY THE ANESTHESIOLOGIST WAS DIFFICULT AND PT WAS HYPOTENSIVE PRIOR TO INCISION AND REQUIRED A BRIEF PERIOD OF CPR. AT STERNOTOMY, THERE WAS A LACERATION OF THE BRACHIOCEPHALIC VEIN. WE REPAIRED IT BUT COULD NOT SEE IT WELL. IT BLED AGAIN. INTRAOPERATIVE STENT PLACEMENT CONTROLLED THE BLEEDING EVENTUALLY, BUT, THE PT DIED DUE TO THE PROLONGED TIME ON CARDIOPULMONARY BYPASS. I BELIEVE HIS CAUSE OF DEATH WAS THIS BRACHIOCEPHALIC VEIN LACERATION DUE TO THIS CATHETER. THE ANESTHESIOLOGIST COMMENTS, "THE INTRODUCER FOR THE CORONARY SINUS VENT CATHETER IS LARGER THAN THE ONE WE USE FOR OUR TYPICAL SWAN GANZ PA CATHETERS... GIVEN THE OUTCOME IN THIS CASE, IT IS NOT UNREASONABLE TO REASSESS THE RISKS OF USING THIS LARGER INTRODUCER DESIGN AND ITS DILATOR. A PRODUCT IMPROVEMENT INITIATIVE MAY HOPEFULLY PREVENT A RECURRENCE OF THIS EVENT." REPORTER WAS MADE AWARE OF THIS MATTER ONLY RECENTLY.