Coroner's Finding: Rentoulis Dimitrios

79y · Male·Iatrogenic right ventricular injury complicating drainage of pericardial collection following coronary artery bypass grafting for ischaemic heart disease

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.