Medical Team Fails to Consult Pediatric Cardiology in an Infant With Coarctation of the Aorta

This case involves a female infant born at forty-one weeks to a healthy mother. The amniotic fluid was stained with meconium at birth; however, the infant did not have respiratory distress at this time. A few hours later the mother noticed the baby to have labored breathing, tachypnea, and noisy breathing. The baby was then taken to the emergency department and found to have moderate respiratory distress, hypoxia, and audible grunting with some intercostal and subcostal retractions. The precordial exam was normal with the exception of a soft 1/6 systolic murmur likely due to a PDA. No cardiology consult was placed and the patient was admitted to the NICU for four days and then discharged. Three weeks later after the infant’s PDA closed, he suffered from cardiovascular collapse due to coarctation of the aorta. As a result, the patient had a hemorrhagic stroke and now has severe neurological derangements.

Question(s) For Expert Witness

1. Had pediatric cardiology been consulted, what would the likely outcome have been?

Expert Witness Response

An infant born with a PDA may remain asymptomatic if there is no significant left to right shunt or who have no signs of respiratory distress. A clinical diagnosis is made when a murmur may be heard on exam, and the patient may exhibit signs of tachypnea, labored breathing and have bounding pulses. Murmurs may not be heard in patients with PDA, and instead may be associated with other cardiac defects, such as aortic stenosis or ventricular septal defect (VSD). Another clinical feature of a large PDA is cyanosis, as there is a significant right-to-left shunt in the descending thoracic aorta. If the neonate has a coarctation of the aorta in conjunction with a PDA, then closure of the PDA may result in heart failure and/or shock. Clinically, these patients are pale, irritable, diaphoretic, and dyspneic with absent femoral pulses. They may sometimes exhibit signs of hepatomegaly. A pediatric cardiologist should always be consulted in patients with coarctation of the aorta in conjunction with PDA. If consulted, pharmacotherapy could have been initiated to maintain the PDA until a pediatric cardiothoracic surgeon could correct the defect. In this instance, cardiovascular collapse and neurological impairments could have been avoided.