This case involves a sixty-five-year-old female patient with a past medical history of coronary artery disease. This patient presented to her primary care physician with exertional chest pain, dizziness, SOB, and palpitations. A cardiologist was consulted and the decision for angioplasty was made. While in the catheter lab, there was a break in the guide-wire and the tip embolized distally in the left anterior descending artery, which resulted in a small inferior wall myocardial infarction. The cardiologist determined that retrieval of the guide-wire tip in such a small tortuous vessel off the LAD would cause further damage and decided to leave the tip behind. Post-cardiac catheterization, the patient had multiple episodes of ventricular tachycardia, elevated troponin, chest pain, and admission to the cardiac unit.
Question(s) For Expert Witness
- Was this a medical product issue or mistake by the interventional cardiologist?
Expert Witness Response
In this particular case, it seems that the patient who suffered from myocardial ischemia is unrelated to the break of the tip of the guidewire. This is because the patient had an inferior myocardial infarction (MI); if the embolized tip was in the LAD, the patient would have an anterior MI. Thus it would be correct to say that it was a medical device malfunction rather than the interventional cardiologist. It is rare to see guidewire complication during cardiac catheterization and diagnostic coronary angiography (eg, distal embolization leading to myocardial ischemia). However, some of the risks in these cardiac procedure include: in-hospital death (1%), perforation, distal embolization, side branch occlusion, and myocardial ischemia. Other important complications, not due to the doctor but the procedure itself, include acute kidney injury secondary to the contrast used in cardiac catheterization. Therefore, in this case, tip dislodgement is an atypical presentation of this procedure and it is likely due to product malfunction.
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