Medico-legal autopsy in postoperative hemodynamic collapse following coronary artery bypass surgery

Abstract

Sudden unexpected postoperative hemodynamic collapse with a high mortality develops in 1–3% of patients undergoing coronary artery bypass surgery (CABG). The contribution of surgical graft complications to this serious condition is poorly known and their demonstration at autopsy is a challenging task. Isolated CABG was performed in 8,807 patients during 1988–1999. Of the patients, 76 (0.9%) developed sudden postoperative hemodynamic collapse resulting in subsequent emergency reopening of the median sternotomy and open cardiac massage. Further emergency reoperation could be performed in 62 (82%) whereas 14 patients died prior to reoperation and a further 21 did not survive the reoperation or died a few days later. All 35 (46%) patients who did not survive were subjected to medico-legal autopsy combined with postmortem cast angiography. By combining clinical data with autopsy and angiography data, various types of graft complications were observed in 27 (36%, 1.3 per patient) of the 76 patients with hemodynamic collapse. There were no significant differences in the frequency (33 vs. 40%) or number of complicated grafts per patient (1.2 vs. 1.4) between those who survived reoperation and who did not. Autopsy detected 25 major and minor findings not diagnosed clinically. Postmortem cast angiography visualized 2 graft twists not possible to detect by autopsy dissection only. Surgical graft complications were the most frequent single cause for sudden postoperative hemodynamic collapse in CABG patients leading to a fatal outcome in almost half of the cases. Postmortem angiography improved the accuracy of autopsy diagnostics of graft complications.

Ischemia/Reperfusion Injury following Acute Myocardial Infarction: A Critical Issue for Clinicians and Forensic Pathologists

“…There is no doubt that prompt mechanical or/and pharmacological myocardial reperfusion represents the only realistic strategy in STEMI and that it has greatly improved AMI outcome. However, patients may have increasing optimistic expectations about the benefits of the procedures, as well as in many other cardiological clinical settings [ 161 – 163 ], and especially in cases with fatal outcome litigations and malpractice claims may arise thus leading to medicolegal autopsies which are critical in proving or excluding medical malpractice. It is now recognized that there are a spectrum of responses of the myocardium to ischemia/reperfusion [ 16 , 157 ], and knowledge on the biochemical and molecular substrates of myocardial IRI has considerably improved.…”

Investigation of medical intervention with fatal outcome: the impact of post-mortem CT and CT angiography

“…MPMCTA turns out to be a new method with a highly standardized and evaluated methodology [ 7 , 25 , 33 ] which is more easily implementable in pre-autopsy practice than post-mortem cast angiography with silicone which also proved to discover graft twists after bypass surgery remaining undetected at autopsy [ 34 ], to detect fresh cerebral infarctions as well as neurovascular main stem thrombosis, aneurysms and arteriovenous malformations [ 14 , 34 , 35 , 36 ]. In case of infectious complications imaging can facilitate sterile post-mortem puncture of radiologically suspicious areas for microbiological investigations before autopsy [ 37 ].…”

Medico-Legal Issues in Cardiology

“…23 However, cABG still carries significant risks. 26 this relatively high incidence of serious adverse events may lead to litigation, particularly when combined with overly optimistic expectations on behalf of patients. 25 A 2011 review found a total of 8807 patients who underwent primary cABG operation without additional cardiac procedures between 1988 and 1999, with 162 patients (1.8%) having a fatal outcome.…”