Coroner's Finding: Rentoulis Dimitrios
Deceased
Dimitrios Rentoulis
Demographics
79y, male
Date of death
2018-02-19
Finding date
2022-10-27
Cause of death
Iatrogenic right ventricular injury complicating drainage of pericardial collection following coronary artery bypass grafting for ischaemic heart disease
AI-generated summary
A 79-year-old man died from iatrogenic right ventricular injury sustained during attempted drainage of a post-operative pericardial effusion following coronary artery bypass grafting. During a minimally invasive sub-xiphoid procedure, the surgeon encountered difficulty finding the pericardial plane and inadvertently injured the right ventricle. Subsequent conversion to sternotomy resulted in extension of the initial tear requiring extensive Gore-Tex patching. The injury and repair caused loss of ventricular contractility despite maximal support. The coroner found the surgery was clinically indicated and surgical decisions were reasonable in the emergency context, though acknowledged that immediate cardiopulmonary bypass before sternotomy might have reduced (but not eliminated) tear extension risk. An unusually thin, friable right ventricular wall, unknown pre-operatively, increased vulnerability to tearing. The death was not found preventable on the balance of probabilities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Post-operative pericardial effusion with thrombus formation after CABG surgery
- Dense adhesions from prior CABG surgery complicating sub-xiphoid access
- Abnormally thin and friable right ventricular wall due to age-related fatty infiltration and dilatation
- Initial iatrogenic injury to right ventricle during attempted dissection of pericardial plane
- Extension of initial tear during redo sternotomy dissection
- Loss of right ventricular contractility despite repair with Gore-Tex patches and Teflon pledgets
- Underlying severe coronary artery disease and myocardial scarring
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