The operation-May 5

Alyssa underwent a complete repair of Tetralogy of Fallot. This included the placing of a Dacron patch over the subaortic ventricular septal defect, an interrupted suture closure of a small muscular ventricular septal defect, dilation and patching of the pulmonary arteries and valve, and excision of the right ventricular muscle bundle. Essentially, Odim patched the hole between the two pumping chambers and relieved the obstruction to her right pump. Odim testified that he did not see a still-smaller VSD that had been identified pre-operatively on the echocardiogram. Since such VSDs tend to close on their own, Odim was not concerned that he could not identify it. The PFO was left open.

The operating team is set out on the accompanying chart.

TABLE 6.11: Persons involved in the operation on Alyssa Still, May 5, 1994
OR team member		Persons involved
Surgeon		J. Odim
Surgical assistant		B.J. Hancock
Anaesthetist		H. Wong
Scrub nurses		S. Scott, A. Glenday
Circulating nurses		C. Youngson, M. Arroz
Perfusionists		M. Maas, D. Smith

The myocardial protection used was moderate hypothermia and intermittent cold blood cardioplegia.

TABLE 6.12: Length of phases of the operation on Alyssa Still, May 5, 1994
Phase of the operation		Time taken
Induction		2 hours
Bypass		3 hours 7 minutes
Aortic cross-clamp		1 hour 1 minute
Total surgical time		5 hours 30 minutes
Total operating-room time		7 hours 40 minutes

Dr. Walter Duncan described the pump run as being long.

Alyssa apparently suffered Tet spells before cardiopulmonary bypass was instituted. Cornel and Duncan indicated in their reports that these spells occurred during induction. In his testimony, Wong said that the Tet spells were minor and occurred when the heart was being manipulated for bypass. The anaesthetic record showed that the Tet spells occurred after induction of anaesthesia and before going on bypass and during the induction of bypass.

Wong also testified that he believed that, while lengthy Tet spells could be a precursor to a difficult peri-operative course, Alyssa's spells were very transient and were treated with neosynephrine. Dr. Walter Duncan testified that, regardless of the triggering event, Tet spells could lead to a difficult recovery period. At the same time, he said that the appropriate course of action at that point was to proceed with the operation. Odim testified that he was not aware until after the operation that the spells had taken place.

No other problems arose during the procedure. Indeed, Youngson testified that she was thrilled by the outcome in the OR.

The surgery, the repair seemed to go very well, if I remember correctly. And I remember we all felt really good, like, finally, we have got a case here that had gone well. The patient seemed to come out of it in very good condition, she was pink, vital signs I think were good, and she went to PICU, and everybody-I remember going home that night and thinking, well, good, this was good. (Evidence, page 8,439)

In his operative report, Odim wrote that following surgery, "The patient returned to the Pediatric Intensive Care Unit in excellent and stable condition." (Exhibit 11, page STI 54) As later events demonstrate, this was an overly optimistic assessment.

During the course of this Inquest, consulting witnesses questioned whether or not Odim's operative approach had provided adequate relief of the obstruction of Alyssa's right (pulmonary) valve. In his operative report, Odim indicated that he dilated the pulmonary valve to 10 millimetres, which he considered sufficient:

The initial sizing of the pulmonary valve accepted only a 7 mm Hegar dilator. This was gently dilated up to 10 mm using the Hegar dilator. At this juncture, it was felt that given the child's age and weight that a 10 mm orifice would be sufficient and as such we elected not to do a transannular repair. (Exhibit 11, page STI 53)

In short, Odim determined that the valve was sufficiently enlarged. Therefore he did not think it was necessary to perform a transannular repair, in which the annulus is sliced and patched to enlarge the valve.

This view was questioned by Cornel, who testified that when he examined the heart, he thought the annulus was small and the pulmonary valve leaflets were not properly formed (or dysplastic). He believed that a valve of this nature would have represented a significant obstruction to blood flow. He acknowledged that "it is hard to be certain but this may represent inadequate relief of the pulmonary stenosis". (Exhibit 353, pages 36-37) He said that he would have conducted a transannular repair and that would have created a larger passage.

Taylor also thought the valve was small, although he said it was not significantly narrowed. He also raised issues about how well the valves themselves worked:

The issue might be, is it a regurgitant or incompetent valve, because with distortion of the cusps or the three flaps of the valve, it may not close properly, and it may allow blood to fall back from the pulmonary artery into the right ventricle. (Evidence, page 43,097)

Taylor also indicated that the best way to assess the competence of the valve would be with an intra-operative echocardiogram, but one was not performed. HSC pathologist Dr. Susan Phillips agreed with Taylor that the valve was dysplastic and bicuspid. With regard to Cornel's reservation about the degree of relief of the pulmonary valve stenosis, Phillips testified that the size of the valve opening was not the only fact that had to be taken into consideration. It was also important to know the pressure measurements, and these could best come from an echocardiogram.

If you are only using size, but size doesn't necessarily tell you how it's functioning. For that you need to have the clinical input, pressure measurements, whatever information they had prior to death. The size is only one aspect of a valve. For example, these valves were dysplastic, they may not have been functioning properly. (Evidence, pages 42,180- 42,181)

In summary, Odim undertook a surgical approach that did not involve removing or repairing the dysplastic valves, as he would have done if he had performed a transannular repair. It is unfortunate that an echocardiogram was not performed during surgery. Alyssa's post-operative problems could have been related to inadequate relief of pulmonary valve obstruction. If this was the case, an echocardiogram might well have provided HSC staff with valuable information.

However, it also appears that Odim employed one of a number of appropriate approaches to this operation.