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Interventional Cardiologist Performs Unnecessary Procedure and Injures Patient

Michael Morgenstern

Written by
— Updated on October 23, 2017

heart anatomyThis case takes place in Tennessee and involves a 50-year-old patient who underwent nuclear stress testing for evaluation of coronary ischemia performed by the defendant doctor. The patient exercised on a Bruce protocol for 6 minutes and 30 seconds and then underwent cardiac catheterization which was performed by the defending doctor. He noted that the left anterior descending coronary artery (LAD) was diffusely diseased and had a 30% lesion in the mid-segment. The left circumflex coronary artery (LCX) was normal. He proceeded with percutaneous coronary intervention (PCI) on the LAD. Stenting of the LAD was performed, but was complicated by dissection of the LAD proximal to the stent, extending into the left main coronary artery and the LCX. He attempted to fix the LCX dissection, but because of the left main dissection, the patient underwent emergent coronary bypass surgery. The plaintiff alleges the legion identified on the angiogram did not meet accepted severity for intervention. The LAD was diffusely diseased but only mildly so. It was a 30-40% mid-LAD lesion that did not reach level of significance which warranted PCI. The plaintiff further alleges that had PCI not been performed then the patient would not have suffered a dissection of the LAD, LCX and left main coronary arteries that necessitated emergent coronary artery bypass surgery.

 

Question(s) For Expert Witness

  • 1. How often do you treat patients with these presenting complaints?
  • 2. Is it necessary to intervene when a lesion is only 30%?
  • 3. Should one stent a diffusely diseased vessel?
  • 4. With this type of procedure, are dissecting the LAD, LCX, and the left main coronary arteries all known complications?
  • 5. Could these dissection have been avoided?
  • 6. Should the patient have been informed of the risks of this procedure?

Expert Witness Response E-009140

I treat patients with these presenting symptoms on a daily basis. It is not usually necessary to intervene in a case like this unless the lesion is an acute plaque rupture at risk of thrombosing or causing a heart attack (or already causing a heart attack with associated clot), which then it may be indicated. One does not normally diffusely diseased and mild vessel. If the sum of disease is obstructing flow, the patient has significant symptoms despite pharmacologic therapy, and there is a specific segment worse than the rest of the diffusely diseased vessel in which a stent could improve the situation, then yes (there are ways to assess this ‘obstructing flow’ concept). With this type of procedure, is dissecting the LAD, LCX, and the left main coronary arteries all known complications? The dissecting of the LAD, LCX and left main coronary arteries are all known, but rare, complication of LAD stenting. Without knowing the details of this procedure, I can only say at this moment that not stenting the vessel in the first place would be the only way to clearly prevent dissection. The patient should have absolutely been informed of the risks of this procedure.

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