The Pediatric Cardiac Surgery Inquest Report



The operation-June 30

On the morning of June 30, Aric underwent a repair of a partial atrioventricular canal defect. This was accomplished by placing a patch closure over the septal defect. There was no ventricular component to this A-V canal malformation. In his operative report, Odim noted that the atrioventricular valves were malformed.

The operating team is set out in the accompanying table.

TABLE 7.1: Persons involved in the operation on Aric Baumann, June 30, 1994
OR team member   Persons involved
Surgeon J. Odim
Surgical assistant B.J. Hancock
Anaesthetists J. Swartz, S. Goheen (resident)
Scrub nurses C. Youngson, H. Skomorowski
Circulating nurses C. Weber, B. Zulak
Perfusionists C. McCudden, T. Koga

The anaesthetic preparation and induction time was one hour and twenty-eight minutes. There was no indication of problems during this period. The total surgical time, from beginning the incision to closure of the incision, was five hours. There were two periods of cardiopulmonary bypass that totalled two hours and twenty-nine minutes. The aortic cross-clamp time was forty-four minutes.

TABLE 7.2: Length of phases of the operation on Aric Baumann, June 30, 1994
Phase of the operation   Time taken
Induction 1 hour 28 minutes
Bypass 2 hours 29 minutes
Aortic cross-clamp 44 minutes
Total surgical time 5 hours
Total operating-room time 6 hours 53 minutes

In his operative report, Odim said that there were problems during rewarming in getting Aric's heart to beat in the proper rhythm. Aric experienced third-degree heart block, a lack of synchronization in the contractions of the upper and the lower chambers of the heart. Third-degree heart block is the most serious form of heart block.

Because of Aric's problems with heart block, Odim inserted a pacemaker. However the pacemaker failed to capture. Aric was put back on bypass, and all aspects of the pacemaker were rechecked. The pacemaker wires and battery were changed. When Aric was taken off bypass a second time, the pacemaker again failed to capture. However, he eventually developed a normal heart rhythm without the assistance of a pacemaker and was taken to the PICU.

In his report, Cornel wrote, "The decisions made at the time of operation were reasonable surgical judgments." (Exhibit 353, page 48) He stated that Odim was correct not to attempt to address problems with the mitral valve and the tricuspid valve. It was reasonable, Cornel said, to expect that the surgical measures he had taken would provide Aric with sufficient relief.

Aric Baumann - pre-operative heart
Aric Baumann - pre-operative heart

Diagram 7.2 Aric Baumann - post-operative heart
Diagram 7.2 Aric Baumann - post-operative heart
1 - Patch closure of partial atrioventricular canal defect
2 - Fenestration of patch closure of partial atrioventricular canal defect
3 - Cardiomegaly with right ventricular hyptertrophy

Compare pre- and post-operative diagrams side by side



Current Home - Table of Contents - Chapter 7 - The operation-June 30
Next Post-operative course
Previous Admission to the hospital
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
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