Woolgar, Shealah Ann

83y · Female·Haemorrhage due to mitral valve disease (surgically repaired); specifically haemorrhage from a left ventricular perforation sustained during intra-operative valve testing

An 83-year-old woman died from haemorrhage following mitral and tricuspid valve repair surgery. During intra-operative testing of the repaired mitral valve using Blake's tubing (soft rubber tubing with a bevelled end) attached to a syringe, the tubing perforated the left ventricle. The perforation initially appeared small but extended when the heart was placed under pressure after cardiopulmonary bypass was discontinued. Dr T.'s attempts to repair the perforation were unsuccessful, resulting in fatal bleeding. The coroner found the perforation was caused by insertion of the bevelled-end tubing too far into the ventricle, contacting the weakened left ventricular wall. Key clinical lessons include: the importance of minimal insertion depth when testing valve competency; avoiding bevelled tubing ends; recognition that soft rubber instruments can cause significant myocardial trauma if advanced excessively; and careful attention to equipment preparation. The coroner declined to refer Dr T. to the Medical Board, noting this was unusual trauma occurring during appropriate surgery.