Thoracic Surgery Results in Massive Intraoperative Bleed

This case involves a sixty-five-year-old male patient with a significant medical history of mitral valve dysfunction that required urgent repair. During the procedure, the surgeon nicked the patient’s internal mammary artery. As a result, the patient experienced significant intraoperative bleeding that caused massive strain on the heart tissue. The patient coded several times during the procedure but was able to be stabilized after ten units of blood were transfused. The patient was in the cardiac ICU for three weeks and was discharged from the hospital with a reduced ejection fraction due to the severe cardiac event experienced during surgery. Subsequently, the patient required close monitoring for impending heart failure and was in need of a heart transplant.

Question(s) For Expert Witness

1. Was this procedure absolutely indicated or could this patient have benefited from a more intricate medical management?

Expert Witness Response E-005749

Despite the potential benefits of mitral reconstruction surgery, a recent retrospective review showed no decrease in long-term mortality among patients with severe mitral regurgitation and significant LV dysfunction who underwent mitral valve repair. Furthermore, the study went on to say that mitral valve annuloplasty was not predictive of clinical outcomes and did not improve mortality. Factors associated with lower mortality were ACEI use, beta-blockade, normal mean arterial pressures, and normal serum sodium concentrations. The results of this analysis were not overly surprising. For example, in most patients in this situation, heart failure is not due to flail leaflets but is secondary to ventricular dysfunction. The complications of the procedure were unfortunate and this patient may have had a better outcome without opting for surgical intervention.