Coronial
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Coroner's Finding: Mackey, Lois Winifred

Deceased

Lois Winifred Mackey

Demographics

83y, female

Date of death

2020-05-21

Finding date

2022-03-21

Cause of death

decompensated right heart failure (cor pulmonale) immediately following mitral valve replacement in the setting of multifactorial chronic pulmonary hypertension

AI-generated summary

An 83-year-old woman died from decompensated right heart failure (cor pulmonale) immediately following mitral valve replacement surgery. She had chronic pulmonary hypertension secondary to severe mitral regurgitation from mitral valve prolapse. The coroner investigated whether earlier diagnosis by her GP would have prevented her death. Review concluded the GP's management was reasonable—he was anchored to a diagnosis of recurrent chest infections/pneumonia, cardiac examination was not routinely indicated, and time pressures were significant. Observational data suggests earlier surgery would have produced better outcomes, but no criticism of the GP was warranted. The surgical team appropriately recognized risks (predicted mortality 7%) and performed necessary surgery competently.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiothoracic surgerycardiologygeneral practiceanaesthesia

Error types

diagnosticdelay

Clinical conditions

mitral valve prolapsesevere mitral regurgitationpulmonary hypertensionright ventricular dysfunctioncor pulmonaleheart failure with preserved ejection fractiondecompensated heart failure

Procedures

mitral valve replacementcoronary angiogramtrans-oesophageal echocardiogramcardiopulmonary bypassintra-aortic balloon pump insertion

Contributing factors

  • long-standing secondary pulmonary hypertension
  • chronic severe mitral regurgitation
  • mitral valve prolapse with myxomatous degeneration
  • acute stresses of general anaesthesia and cardiac surgery on right ventricle
  • right ventricular dysfunction
  • delay in diagnosis of mitral valve disease
  • advanced valvular heart disease
Full text

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