A staff pathologist at the HSC, Dr. Joseph de Nanassy, performed the autopsy. He concluded that the immediate cause of death was "Cardiac arrest post cardiac surgery due to or as a consequence of coagulopathy and hemorrhage during weaning from ECMO." (Exhibit 13, page ULI 22) He noted that her superior vena cava had been narrowed by a suture. This likely was caused during the original surgery. There was also the presence of a needle near the cannula site.
Odim commented on the needle found in Jessica during the autopsy. He felt that this needle was in all likelihood one that was used during attempts at removing Jessica from the ECMO machine in the PICU. In his testimony, Odim said the needle was the needle "from my reinforcement, attempt to reinforce that suture line before I started to massage the heart and aborted that when the blood pressure and the cardiac action was going down." (Evidence, page 24,211) The evidence suggests that the needle likely became lodged in Jessica during the attempt to wean her from ECMO in the PICU and played no role in her death.
The only item in de Nanassy's report that has come under question is his conclusion that Odim's second repair was intact. Two of the consulting witnesses who prepared reports for this Inquest disagreed with this finding. Drs. Walter Duncan and Glenn Taylor4 both reviewed the autopsy report, as well as the heart specimen. Duncan also reviewed a videotape of the heart echocardiogram done immediately after the second attempt at repairing the VSD. They both concluded that the VSD had not been successfully repaired at all. In other words, both the first and second attempts were not done properly.
Duncan and Taylor concluded that, rather than placing the patch across the hole in the septal wall, Odim had in fact sutured the patch to a muscle bundle that was attached to another part of the wall of the ventricle. As a result, blood continued to shunt through the opening in the septal wall in the VSD and heart performance remained poor.
Neither doctor could point to this factor as a cause of death, since the events that led directly to Jessica's death related to the failed attempt at removal from the ECMO machine. Both were of the opinion, however, that the failed repair would explain why Jessica did not recover well enough after the operation to be weaned from the CPB machine in the operating room or be weaned from ECMO. Indeed, if the repair had not been properly done, it would have been impossible to wean Jessica from ECMO.
Duncan conceded that the heart specimen he reviewed was not in very good condition. As a result, it might not have reflected the true condition of the repair. However, he also reviewed the echocardiogram videotapes (something that he specializes in doing as a pediatric cardiologist) and concluded that the tapes confirmed his view that the repair was unsuccessful.
Duncan concluded that, because of the failed operation, the cannula site would have been exposed to very high blood pressures while Jessica was on ECMO. This would explain why there was so much damage to Jessica's cannulation site when the venous cannula was first removed. The increased pressure at this location would have resulted from the fact that the blood was not flowing properly, as a result of the failed repair. Duncan therefore concluded that the failed repair had a direct bearing on what occurred in the PICU during the ECMO weaning process.
De Nanassy thought that Taylor and Duncan had reached their conclusions from assessments made on the study of a dissected heart specimen. He stood by his initial report, which was based on examination of the heart shortly after death. However, Duncan's evidence, based on his viewing of the echocardiogram tapes, is persuasive. This evidence clearly suggests that the VSD was not properly repaired at the time of Jessica's initial operation.
|Current||Home - Table of Contents - Chapter 6 - Autopsy findings|
|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|