Heart valve installed upside down

[Maverikk]

Advertisement - Members don't see this ad

OHSU told 13-year-old’s parents she was dying before Seattle doctors discovered massive mistake, $17M suit says

A lawsuit claims an OHSU surgeon installed a heart valve upside down, leaving the girl reliant on life support for 18 days.

www.oregonlive.com

Would like to hear anyone’s opinion on how this would happen, I’m trying to think of one and can’t.

 

[coolforschool]

OHSU told 13-year-old’s parents she was dying before Seattle doctors discovered massive mistake, $17M suit says

A lawsuit claims an OHSU surgeon installed a heart valve upside down, leaving the girl reliant on life support for 18 days.

www.oregonlive.com

Would like to hear anyone’s opinion on how this would happen, I’m trying to think of one and can’t.

It can and does happen. I’ve seen it partially put in before the surgeons noticed, obviously before atriotomy closure (academics, older surgeon, newer fellow). Some valves produce very poor TEE images (eg, pulmonic), so echo’s not always reliable.

Probably a Swiss cheese of poor visualization on TEE, hyperfixation on cardiogenic shock/vasoplegia/poor myocardial protection, and low incidence of that specific complication.

I’ve seen a lot of things go wrong, and I continue to see or hear about new ways of things going wrong pretty much every week or two. I always tell the trainees, “It’s never just a CABG.”

 

[cittykat]

I’ve heard of it so not the first time. Fortunately never personally witnessed it.

 

[Maverikk]

Definitely a Swiss cheese situation. I would bet this was a mini. But to pull the trigger to go postop ecmo, the times I’ve seen that everything was investigated. And it’s an AV, there should be visualization enough to know if it’s upside down. Wouldn’t the surgeon be going wild about visualization

 

[T-burglar]

At our shop , We have a very short pause to check orientation while loading a transcatheter valve, I’ve often thought a quick look with multiple eyes to confirm orientation would be a good idea in valve surgery before starting to sew also. To mimic this TAVR timeout in surgery. I’ve seen a valve sewn in backwards once in my career by a less than amazing surgeon, fortunately the TEE windows were good and I could see it

 

[pgg]

Never seen it. There was a transcatheter valve put in backwards at a place I used to work because of a non-standard approach.

 

[CopaceticOne]

Seen a TAVR backwards once. Never seen a surgical backwards, or at least where the patient left the OR with it backwards.

 

[coolforschool]

Never seen it. There was a transcatheter valve put in backwards at a place I used to work because of a non-standard approach.

Seen a TAVR backwards once. Never seen a surgical backwards, or at least where the patient left the OR with it backwards.

Interesting. I’ve seen and done the TEEs for a lot of TAVRs personally (>3 institutions) and haven’t really run into this situation, but I can see how it happens. I just assumed the reps know what they’re doing on the backtable. One more thing to be vigilant/paranoid about.

 

[CopaceticOne]

Interesting. I’ve seen and done the TEEs for a lot of TAVRs personally (>3 institutions) and haven’t really run into this situation, but I can see how it happens. I just assumed the reps know what they’re doing on the backtable. One more thing to be vigilant/paranoid about.

It was when they were just starting up their program. I think less than 6 months in.

 

[Maverikk]

Never seen a backwards tavr. Have seen the valve go into the lungs followed by a valve-in-valve deployment after the second one didn’t work. This was in early tavr days and it was by very talented structural cardiologists, those were all inoperable candidates then, bad anatomy. I didn’t know you could load the valve backwards, I thought the equipment and crimping were always crucial steps. Is TEE still done routinely, it’s been a few years since I’ve done tavrs but the last place I was that did started doing ttes for them, structural cardiology is such a long path. All the dudes I’ve met there were dedicated and patient. When I did tavrs with tte it was literally 50 of fent, maybe precedex but the cardiology studs did all the verbal anesthesia, liked to have them awake-awake even during rapid pacing.

 

[PpfSuxTube]

OHSU told 13-year-old’s parents she was dying before Seattle doctors discovered massive mistake, $17M suit says

A lawsuit claims an OHSU surgeon installed a heart valve upside down, leaving the girl reliant on life support for 18 days.

www.oregonlive.com

Would like to hear anyone’s opinion on how this would happen, I’m trying to think of one and can’t.

Ive seen it happen. Lead to harrowing death. We found in about 8 hours later in the icu.

Most modern valves come loaded on some specific introducer thing that prevents this but if the valve is taken out before wean off cpb and placed on a kelly or something for example to do an extra procedure or check something then the second time that valve can be sewn in upside down...

Obviously should never happen and also should be found instantly but if theres a lot going on such as sam or right heart failure or going on ecmo anyway it may be missed...