The Pediatric Cardiac Surgery Inquest Report



Post-mortem findings

An autopsy ordered by the Chief Medical Examiner was conducted by Phillips on November 30, 1994, with Odim and Ward attending the examination of the heart. Phillips had noted that, according to information related to her by Swartz, there had been a dislocation of a cannula at one point in the operation before the child was weaned from bypass. This was the event that the witnesses said occurred at 1630 hours. When Odim heard what Phillips had been told, he told her that her information was not accurate.

The autopsy indicated that the repairs undertaken by Odim were intact. However, the heart had suffered severe ischemic damage that had led to death. The report detailed extensive myocardial ischemia and contraction band necrosis.

Phillips also noted that the septal leaflet of the tricuspid valve had been tethered to the pledget closing the VSD. Because Jesse's heart never started beating after surgery, it is not possible to determine the impact that this would have had on the functioning of his heart. (The tethering is not depicted in Diagram 8.8)

The autopsy also left a question as to whether or not the initial blockage of the aorta was ever completely addressed. In the course of the autopsy, Phillips was unable to push a probe through the aorta past the site of the anastomosis. However, when she opened the aorta, she could find no obstruction.

Ward testified that, while it appeared that the VSD had been closed appropriately, he had concerns about the repair to the aorta.

And the arch repair by then-the probe that was put through didn't pass through easily and as it passed through the transverse arch or the-I can't remember - I think-or the repair site anyway, it didn't pass easily, and I wasn't totally convinced at that stage that everything was open. The trouble is that the specimen in that circumstance has not got blood flowing through it so it's not stretched; it's, if you like, collapsed down.

Q. Um-hmm.

A. So the tissues and artificial tissue and patches will fold without the pressure of the blood within it.

Q. Um-hmm.

A. So you can-your probe can get caught up on folds, if you like, of artificial tissue and/or real tissue and not slide through. But generally, if you work your way through, you can get it through. But we weren't able to, from memory, get it through just passing it through, but when it was opened right up, it looked patent. So it may have been just-

Q. Um-hmm. What does that mean?

A. Well, it may have been just snagging up on tissue planes and it certainly looked as though it was probably potentially open. (Evidence of Dr. Ward, page 99)

Taylor was asked if he felt the second repair was properly done. He answered that "the second repair looked to be about as good as one might expect, because the opening is the same as the ascending aorta, the vessel that is supplying that, sort of leading into the anastomosis." (Evidence, page 43,298) He was then asked about Phillips' inability to pass a probe through the aorta.

Well, a 3 millimetre probe would be about the right size for the circumference that was measured. We measured circumference of 1 centimetre. So if everything was flat and there were no obstructions, then I would have expected a 3 millimetre probe to go across the anastomosis.

Having a probe get caught up like that, in my experience, usually is a result of a fold or a flap, that when you push the probe into something it gets caught up in it. So that suggests to me that maybe there was some flaps or folds as a result of the anastomosis repair. (Evidence, pages 43,300-43,301)

He said that Phillips's observation that there was a fold in the pericardial patch was one potential explanation. However, he said, it was also possible that the probe had become caught in a buckling of the inner lining of the aortic anastomosis.

Taylor also raised issues about the VSD patch. In his report Taylor wrote:

[T]he VSD patch was buckled to convexly project into the left ventricular outflow tract. These are anatomical substrates for proximal obstruction that may have contributed to the child's cardiac failure. (Exhibit 336, page 11.1)

In her testimony, Phillips said that at the time she examined the heart, it appeared to her that the VSD patch was intact. In his testimony, Taylor testified that he could not state whether or not the buckling was an operative problem.



Current Home - Table of Contents - Chapter 8 - Post-mortem findings
Next Findings
Previous The operation - November 27
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