The Pediatric Cardiac Surgery Inquest Report



The case of KZ

KZ was born on March 29, 1987. At one year of age, she was diagnosed with an atrial septal defect. Surgery was delayed until her seventh year.

On July 11, 1994, KZ underwent a suture closure of her atrial septal defect. Her oxygen saturation level was low during the first attempt to take her off bypass. Initially Odim thought that the problem may have arisen as a result of the anaesthetist having difficulties ventilating the patient. Dr. Harley Wong, who was the anaesthetist for this operation, indicated that KZ was receiving 100 per cent oxygen and that her lungs were being well-ventilated. Odim then determined that KZ had a left to right shunt. As a result, he determined that it was necessary to go back on bypass and reopen her heart. Odim discovered that he had mistakenly sutured KZ's eustachian valve to her left atrium. According to Odim, the eustachian valve is

. . . a valve that is used normally in utero to channel blood to the left side of the heart, because as you all know, the lungs aren't being used so there is not a great demand to have blood going to the right side of the heart into the lungs to pick up oxygen. So it takes the placenta return from mom, in the child, and channels some of that oxygenated blood directly over to the left side.

When children are born, many a times this structure involutes, it is not readily apparent, and in some children it is actually quite prominent and you can see it, in many you don't see it and it is not there. Again, it is a white veil like tissue structure.

And in the setting of a hole that's really at the mouth of that lower IVC, you can mistake that lower rim for your ASD when, in fact, it could be part of this valve. (Evidence, pages 25,212-25,213)

By trapping the eustachian tube in his stitch, Odim obstructed the inferior vena cava and oxygen starved blood was misdirected into the left atrium. Odim corrected his error and the atrial septal defect was again closed. KZ recovered and was discharged home on July 15, 1994.

Wong viewed the suturing of the eustachian valve as a serious matter. He mentioned it to McNeill, who brought it up for discussion at the Wiseman Committee. While Wong did not attend the committee meeting, he said McNeill reported back to him that Giddins and Odim had explained that this was a recognized complication in this sort of surgery. Wong had never heard of the complication. He examined Dr. Carol Lake's textbook, Pediatric Cardiac Anaesthesia, and could find no mention of suturing over the eustachian valve as being a known complication.

In her testimony McGilton said that she had never heard of this problem in cardiac surgery before. In fact, she testified that up until that point, she had never heard of a eustachian valve.

Giddins, Hancock, and Odim asserted that suturing a eustachian valve was a recognized complication of repair of ASDs when there was a prominent eustachian valve. However, neither Giddins nor Hancock had ever known of a case where this had happened. Odim said he had seen it happen in every institution he had worked in, but could give no indication of how often it happened. This Inquest was also given excerpts from one textbook and two journal articles that discussed this issue.

It would appear from that material that oversewing the eustachian valve is a rare but recognized complication in the repair of ASDs. In the case of KZ, oversewing the valve did lengthen the operation, although the patient's health was not compromised. However, the event did little to allay the nurses' and anaesthetists' concerns about Odim's surgical abilities.



Current Home - Table of Contents - Chapter 7 - The case of KZ
Next The July 13 Wiseman Committee meeting
Previous The case of SK
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
Table of Contents