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Heart valve upside down

Thursday, March 9, 2017

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Source

Source Name: BBC Tyne & Wear

Author(s)

BBC News

According to BBC Tyne & Wear, a patient died after surgeons inserted a heart valve upside down causing irreversible damage to her heart. The procedure was performed at the Freeman Hospital in Newcastle upon Tyne. NHS Foundation Trust has admitted the error, and the family has begun legal action. 

Comments

https://academic.oup.com/ejcts/article-lookup/doi/10.1016/j.ejcts.2006.03.019
It seems very incomprehensible that Surgeons cannot understand that mistake after cross-clamp off. is not clear the position of the prosthesis and if was biological or mechanical. A biological valve is easier to be revealed as wrong after positioning then mechanical one thanks to the stents; less intuitive for the mechanical. I remember a case occurred many years ago in which a mitral valve replacement was done with an aortic Valve because of a mistake in the package opening but in this case the hemodynamics of the patient after cross-clamp off immediately revealed an empty left ventricle during the weaning from cardiopulmonary bypass. An immediate cross-clamp and Prosthesis removal was possible without problem for the patient.
Once a time I saw a resident to sew a mechanical mitral prosthesis in a tubular graft for Bentall operation.
I remain perplexed by how the popular media sensationalise such tragedies by branding 'routine' an operation with a baseline mortality 1 in a 100, and probably much higher if any risk factors were present.

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