The Pediatric Cardiac Surgery Inquest Report



Background and diagnosis

Shalynn Piller was born at Carman Memorial Hospital on July 20, 1994. The firstborn child of Ken and Sharon Piller, Shalynn had a normal delivery at full term, without complications. However, Sharon had undergone three ultrasound examinations, all after 32 weeks gestation, because of concerns about the small size of the fetus. At birth, however, Shalynn was considered a healthy baby, and was discharged home with her mother on the third day.

On July 30, Shalynn's parents took her to see their family physician, Dr. M. Omichinski, because Shalynn was having problems with feeding and had had episodes of irregular breathing. Shalynn was not cyanotic, but her respiratory and heart rates were rapid. She was taken to the Carman Hospital for further examination and tests. A heart murmur was heard on examination, and a chest X-ray showed an enlarged heart.

Shalynn was immediately transferred to Winnipeg, where at 1330 hours that same day, she was admitted to the Children's Hospital. On examination, she was found to have a loud murmur, an enlarged liver and decreased femoral pulses. The decreased femoral pulses were a sign of poor blood supply to the lower part of the body.

Echocardiography showed:

  • two muscular ventricular septal defects, one of which was large (only one was found after Shalynn's death)
  • a patent foramen ovale or an atrial septal defect with bi-directional shunting
  • moderate tricuspid valve regurgitation
  • a bicuspid aortic valve
  • mild sub-aortic stenosis
  • a significant aortic coarctation.

The aortic coarctation was very narrow; as a result the aorta was obstructed. The ductus arteriosus had closed, as it does in most children during the first ten days of life. However, the ductus had been the channel for blood flow to the lower body because the normal channel, the aorta, was severely narrowed. Shalynn had begun to experience her difficulties with the closing of the ductus. This had left her with marked reduction in blood flow to the lower part of her body.

Shalynn also had an abnormality in her tricuspid valve, described as Ebstein's anomaly or malformation. Odim testified that:

That's a spectrum of abnormalities of the valve which can present, at worse, with the two or three leaflets, that is the septal or posterior leaflet of the tricuspid valve being offset, downwardly displaced into that right pump, and the remaining anterior leaflet of the right tricuspid valve being a huge billowing sail-like leaflet. Those babies that present at that extreme have a significantly high mortality rate, approaching 80 percent as neonates. (Evidence, pages 25,269-25,270)

Valves with this anomaly tend to leak, allowing blood to flow back into the right atrium and causing it to swell in size.

Shalynn was treated with prostaglandin in an attempt to reopen the ductus arteriosus and restore blood flow to the lower part of her body. As Giddins explained in his testimony:

In situations where there is a narrowing of the aorta, or coarctation of the aorta, opening of the ductus tube not only provides a means for blood to bypass the narrowing, it also has a general opening up effect on the entire region of the aortic narrowing. (Evidence, page 3,923)

Shalynn was admitted to the NICU at 1400 hours. The admitting nurse noted that Shalynn appeared pale and mottled and her limbs were cool to touch, another sign of poor lower body circulation. The doctors also concluded that Shalynn was in congestive heart failure, and started treatment with the diuretic Lasix.

Healthy heart
Healthy heart

Diagram 7.3 Shalynn Piller - pre-operative heart
Diagram 7.3 Shalynn Piller - pre-operative heart
1 - Atrial septal defect (or patent foramen ovale)
2 - Tricuspid valve with Ebstein's anomaly
3 - Aortic coarctation
4 - Patent ductus arteriosus
5 - Bicuspid aortic valve
6 - Malaligned ventricular septum with subaortic stenosis (mild)
7 - Ventricular septal defect
(Although two were diagnosed, only
one was found post-mortem)
8 - Right ventricular hypertrophy

Compare the pre-operative heart to a healthy heart side by side



Current Home - Table of Contents - Chapter 7 - Background and diagnosis
Next The decision to operate
Previous Issues
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
Search the Report
Table of Contents