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Incorrectly Positioned Pacemaker Wire Results in Lifetime of Coumadin; Experts


A 64-year-old woman lost consciousness at her home. She was taken by ambulance to a hospital. A cardiothoracic surgeon at the hospital advised the woman that she needed a surgically implanted pacemaker and discussed the risks of the surgery with her. The woman informed the cardiothoracic surgeon about her medical history, which included open heart bypass surgery seven years earlier for which she was taking the anticoagulant medication Plavix. The woman agreed to the surgery, which took place the following day.

 

The procedure required the cardiothoracic surgeon to implant a dual-chamber pacemaker using two lead wires. The wires were to be inserted through either the woman’s subclavian vein or cephalic vein and terminate, respectively, in the right ventricle and right atrium of her heart.

 

During the surgery, the cardiothoracic surgeon inserted the first lead wire through what he believed was a vein and utilized a fluoroscope for guidance. At one point, the fluoroscope images revealed that the wire was in the left side of the woman’s heart, which the cardiothoracic surgeon recognized was the wrong place. He believed that this occurred because the woman had the usually asymptomatic, most common congenital anomaly of the thoracic venous system, a persistent left superior vena cava (PLSVC). PLSVC occurs when the left brachiocephalic vein does not develop fully and the left upper limb and head and neck drain into the right atrium via the coronary sinus. In isolation, PLSVC is usually asymptomatic, but it is frequently associated with other cardiac abnormalities. The cardiothoracic surgeon retracted the wire and injected a dye to visualize where the wire should be. The cardiothoracic surgeon then viewed another fluoroscope image and inserted the wire in what he understood was the right ventricle of the woman’s heart.

 

The cardiothoracic surgeon then attempted to insert the second lead wire into the woman’s right atrium several times, but had difficulty doing so. He believed the difficulty was because the woman had either an absent or a diminutive right atrium that prevented him from fully inserting the wire. The cardiothoracic surgeon did not insert the wire because it was not working when he inserted it.

 

The cardiothoracic surgeon tested the pacemaker and determined that it was properly functioning with the one lead wire and that there was electrical current running to the woman’s heart. After the surgery, an x-ray was taken and it did not appear that the ventricular wire that the cardiothoracic surgeon inserted was misplaced. The woman was subsequently discharged and had one follow-up examination with the cardiothoracic surgeon, who advised her that the surgical site looked good and any pain she was having would subside.

 

Fourteen months after the pacemaker was implanted, the woman’s treating cardiologist conducted a nuclear stress test after she complained of shortness of breath. The test revealed a lack of blood flow to the front-left side of her heart. A cardiac catheterization the following month revealed minor irregularities in her right coronary artery and a haziness on the proximal part of her left internal mammary artery (LIMA), the location of her open heart bypass surgery. The woman’s treating cardiologist referred her to a hospital for additional testing.

 

The testing revealed that the wire the cardiothoracic surgeon inserted for the woman’s pacemaker had not been inserted through her veins into the right ventricle of her heart, but instead had been inserted through her subclavian artery and into her left ventricle. Testing also revealed the presence of a rare ostial occlusion of the LIMA, a blockage of the opening at the origin of the LIMA, that required the insertion of a stent. The physician who performed the testing informed the woman’s treating cardiologist that trauma from the insertion of the pacemaker wire resulted in the occlusion of her LIMA. The woman was advised that the pacemaker wire had been malpositioned through her arteries and in the left ventricle.

 

The woman conferred with a number of physicians, including the cardiothoracic surgeon, and was advised of the risks associated with the surgery that would be required to remove the malpositioned wire. The woman decided against the surgery, was prescribed a daily dose of the blood thinner, Coumadin, and undergoes frequent blood tests to reduce the risk of a stroke from a blood clot.

 

The woman sued the cardiothoracic surgeon for medical malpractice. The complaint alleged that the cardiothoracic surgeon was negligent in the performance of the pacemaker implantation surgery.

 

During the five-day jury trial, the woman presented the testimony of a board certified cardiovascular disease specialist, who was qualified without objection as an expert witness in cardiology, arrhythmia, and the insertion of pacemakers. The woman’s expert cardiovascular disease specialist testified regarding the standard of care for the implantation of a two-wire pacemaker; the cardiothoracic surgeon’s actions that deviated from the standard; and the woman’s increased risk of stroke, bleeding, and complications to her aortic valve due to the cardiothoracic surgeon’s misplacement of the wire.

 

The woman also presented the testimony of an expert cardiothoracic surgeon, who testified that the cardiothoracic surgeon deviated from the standard of care. The woman’s expert cardiothoracic surgeon testified that there were numerous indications the wire was not in the correct position and that the cardiothoracic surgeon also failed to conduct post-surgical testing which would have revealed the wire had not been correctly placed. He opined that the woman had an increased risk of stroke and bleeding due to the lifetime requirement that she take Coumadin as a result of the incorrect placement of the wire.

 

The woman’s treating cardiologist testified concerning her medical history, including the earlier bypass surgery on her LIMA. The cardiothoracic surgeon objected seeking to bar the woman’s treating cardiologist from testifying regarding statements made to him by the physician to whom he referred the woman for testing regarding the cause of the occlusion of the woman’s LIMA. The Mercer County Superior Court of New Jersey, Law Division, determined that the woman’s treating cardiologist could testify regarding his determination of the cause of the occlusion, but could not testify about the statements made by the physician who conducted the testing. He described the results of the post-pacemaker stress test and his referral of the woman for the evaluation that revealed the misplacement of the pacemaker wire and obstruction of her LIMA. He testified that based upon the anatomy of the LIMA, the nature and location of the occlusion, and the results of the catheterization, the occlusion was not caused by atherosclerotic plaque but was caused by trauma from the insertion of the pacemaker wire. He did not refer to any statements made by the physician who conducted the testing.

 

The cardiothoracic surgeon presented the testimony of an expert cardiologist. During his direct examination, the cardiothoracic surgeon’s expert cardiologist testified that the cardiothoracic surgeon’s placement of the wire through the woman’s arteries was “atypical.” During cross-examination, the cardiothoracic surgeon objected to the woman’s questioning of the expert cardiologist regarding the standard of care. The trial court permitted the woman to cross-examine the cardiothoracic surgeon’s expert cardiologist on the standard of care.

 

The cardiothoracic surgeon testified that he reviewed the consent with the woman and she consented to the surgery. He also testified regarding the standard of care utilized to avoid performing surgery on the wrong limb of a patient. He admitted that the positioning of the wire was “improper” and the wire should not have been placed in the woman’s left ventricle. He further admitted that the standard of care did not permit placement of the wire through the woman’s aorta, aortic valve, and left ventricle, but explained that he did not violate the standard of care because he proceeded based upon the data and information that he had. He also testified that there was a “possibility” that he misinterpreted the fluoroscope films after he injected the dye.

 

During closing arguments, the woman’s counsel stated that he “fe[lt] like there’s been a game” that had been played during the trial related to the cardiothoracic surgeon’s testimony regarding the timing of his review of the fluoroscope images. The woman’s counsel also stated that he limited the woman’s expert cardiothoracic surgeon’s testimony “because [he] didn’t want to waste [the jury’s] time anymore because ... [he didn’t] need ... [the woman’s expert cardiothoracic surgeon] to cover every single point that’s already been covered.” The woman’s counsel argued that, “[t]here’s nowhere in [the surgery consent] form that says I may end up on the wrong side of the heart and sentence you for the rest of your life to Coumadin. It doesn’t say that there, and the reason is because it’s an unacceptable risk, like cutting off the wrong limb or operating on the wrong limb.”

 

The jury returned a verdict finding that the cardiothoracic surgeon deviated from the standard of care and proximately caused $500,000 in damages to the woman. The trial court entered judgment against the cardiothoracic surgeon for compensatory damages, taxed costs, and pre-judgment interest in the amount of $535,840.31.

 

The Appellate Division of the Superior Court of New Jersey affirmed. The court held the trial court did not err in permitting the woman’s treating cardiologist to testify that the occlusion of her LIMA and resulting need for a stent was due to the trauma caused by the cardiothoracic surgeon’s misplacement of the pacemaker wire, the treating cardiologist’s opinion testimony regarding the cause of the damage to the LIMA was not improperly based upon statements made by another physician, the trial court did not err in permitting the woman’s expert cardiovascular disease specialist’s testimony regarding the standard of care, the trial court did not err in permitting the cardiothoracic surgeon’s expert cardiologist to testify on cross-examination regarding the standard of care, and the woman’s counsel’s comments made during summation were not improper or unduly prejudicial.

 

The trial court did not err in permitting the woman’s treating cardiologist to testify that the occlusion of her LIMA and resulting need for a stent was due to the trauma caused by the cardiothoracic surgeon’s misplacement of the pacemaker wire. The court noted that the evidence showed that the woman’s treating cardiologist had been her treating physician for thirty years prior to the pacemaker implantation surgery and continued in that capacity through the date of trial. The woman’s treating cardiologist testified that he determined the cause of the damage to her LIMA as part of his diagnosis and treatment of her post-surgery conditions. The court concluded that the trial court did not abuse its discretion in allowing the woman’s treating cardiologist’s testimony that the cause of the occlusion in her LIMA was trauma inflicted during the pacemaker implantation surgery performed by the cardiothoracic surgeon.

 

The treating cardiologist’s opinion testimony regarding the cause of the damage to the LIMA was not improperly based upon statements made by another physician. An expert witness is not permitted to relate the opinions of a nontestifying expert merely because those opinions are congruent with the ones the testifying expert has reached. A treating doctor, however, may testify as to the opinions of a nontestifying doctor if the treating doctor relied on those opinions in reaching his or her diagnosis or in formulating a plan of treatment and management of the patient. The woman’s treating cardiologist testified that based upon his review of the woman’s medical records the cardiologist concluded that the damage to the LIMA was caused by the pacemaker implantation surgery. He further testified that he reached the conclusion without regard to any statements made by the physician who performed the testing. The trial court barred the woman’s treating cardiologist from testifying about the testing physician’s statements and there was no reference to the testing physician’s statements during the trial. The court concluded that the woman’s treating cardiologist’s testimony was properly limited to his independent assessment of the cause of her medical condition for the purpose of diagnosing and addressing her medical issues as her treating physician.

 

The trial court did not err in permitting the woman’s expert cardiovascular disease specialist’s testimony regarding the standard of care. Although the woman’s expert cardiovascular disease specialist did not possess the qualification required to testify regarding the standard of care applicable to a cardiothoracic surgeon, the cardiothoracic surgeon failed to object to this expert’s qualifications as an expert witness and his testimony during the trial. Under the plain error standard, the woman’s expert cardiovascular disease specialist’s testimony was not clearly capable of producing an unjust result. All of the medical experts and the cardiothoracic surgeon agreed that the standard of care required insertion of the pacemaker wire through a vein and into the right side of the woman’s heart.

 

The trial court did not err in permitting the cardiothoracic surgeon’s expert cardiologist to testify on cross-examination regarding the standard of care. During his direct examination, the defendant cardiothoracic surgeon’s expert cardiologist testified that the defendant’s placement of the wire through the woman’s arteries was “atypical.” The woman argued that the testimony pertained to the standard of care and acknowledged that other evidence had established that the wire was “supposed to go through a vein.” The trial court correctly noted that the woman’s cross-examination of the cardiothoracic surgeon’s expert cardiologist regarding the standard of care was directly related to his direct testimony about the “atypical” placement of the wire. The court found that the cardiothoracic surgeon did not suffer any prejudice from the introduction of the testimony because there was no dispute that his insertion and placement of the wire through the woman’s arteries and into her left ventricle was done in error. The court concluded that the trial court did not abuse its discretion in permitting the woman’s cross-examination of the defendant cardiothoracic surgeon’s expert cardiologist on the standard of care.

 

The woman’s counsel’s comments made during summation were not improper or unduly prejudicial. The court reasoned that the woman’s counsel statement regarding a game that had been played during the trial related to the cardiothoracic surgeon’s testimony regarding the timing of his review of the fluoroscope images, which was directly contradicted by the information contained on the fluoroscope films. The court found that the woman’s counsel’s statement regarding limiting the woman’s expert cardiothoracic surgeon’s testimony constituted nothing more than an accurate explanation that the substance of his testimony had been established by others. The court found that the woman’s counsel’s argument regarding the consent form was proper because the cardiothoracic surgeon testified regarding his review of the consent form with the woman and her grant of consent for the surgery, and relied upon her consent as a defense. The cardiothoracic surgeon testified without objection regarding the standard of care utilized to avoid performing surgery on the wrong limb of a patient. The court found that the woman’s counsel properly argued by analogy that she did not consent to the placement of the pacemaker wire in the wrong chamber of her heart and the cardiothoracic surgeon’s deviation from the standard of care resulted in the misplacement of the wire. The court concluded that the woman’s counsel’s argument constituted fair comment on the evidence, including the consent form and the defendant cardiothoracic surgeon’s testimony regarding the applicable standard of care.

 

The Appellate Division of the Superior Court of New Jersey affirmed the trial court’s entry of judgment on a jury verdict against the doctor.

 

See: Rothman v. Cole, 2016 WL 3918834 (N.J.Super.A.D., July 21, 2016) (not designated for publication).

 

See also Medical Law Perspectives September 2016 Report: Stroke (to be published September 6, 2016).

 

See also Medical Law Perspectives, February 2015 Report: Mending a Broken Heart: Malpractice Risks in Diagnosing and Treating Heart Disease

 

See also Medical Law Perspectives, February 2014 Report: Congenital Heart Conditions: How Infants, Adults, and Healthcare Providers Handle the Risks

 

See also Medical Law Perspectives, November 2013 Report: Diagnosis and Treatment of Heart Attacks: Liability Issues 

 

 

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