Description of Event or Problem · 0
PATIENT HAD HEART TRANSPLANT SURGERY (B)(6) 2026. JUST PRIOR TO TRANSFER OF PATIENT TO ICU, BLOOD PRESSURE DECREASED AND CHEST TUBES FILLED WITH BLOOD. THE CHEST WAS EMERGENTLY PREPPED AND DRAPPED AND REOPENED. THE AORTIC ANASTOMOSIS APPEARED TO HAVE DEHISCED. THERE WAS EVIDENCE THE 4-0 SUTURE BROKE. AN INTERRUPTED PROLENE SUTURE WAS PLACED TO ACHIEVE TEMPORARY HEMOSTASIS WHILE PATIENT WAS REHEPARINIZED FOR CARDIOPULMONARY BYPASS. THE PATIENT WAS RECANNULATED AND DIALYSIS INITIATED DUE TO SEVERE HYPERKALEMIA AND METABOLIC DERANGEMENT. ANTERIOR ASPECT OF THE AORTIC ANASTOMOSIS WAS REINFORCED. AFTER 45 MINUTES OF REPERFUSION, PATIENT WAS WEANED FROM CARDIOPULMONARY BYPASS WITH MODERATE PRESSOR SUPPORT AND INHALED NITRIC OXIDE. BIVENTRICULAR FUNCTION APPEARED REASONABLE. PATIENT KEPT IN OPERATING ROOM FOR A PERIOD OF OBSERVATION IN THE EVENT TRANSITION TO ECMO REQUIRED. PATIENT TRANSFERRED TO ICU. PATIENT DID NOT RECOVER AND PASSED (B)(6) 2026. AUTOPSY CONFIRMED FRAYED AND BROKEN 4-0 PROLENE SUTURE DIRECTLY CAUSE PATIENT'S DEATH.