This collection of 61 clinical vignettes represents more than case studies in cardiac surgery; it embodies a philosophy of learning a lifetime of cardiac surgical practice and embraces our fallibility as a pathway to excellence. Each scenario has been carefully written to illuminate the complex decision-making processes, technical challenges and human factors that define outcomes. More importantly, each case demonstrates how errorswhether technical, cognitive or systemiccan become powerful catalysts for improvement when approached with intellectual honesty and systematic analysis. These cases draw upon decades of collective surgical experience, peer-reviewed literature and quality improvement data to ensure that each one offers meaningful learning opportunities. Within each case, the anatomy of the error has been dissected for a better understanding of the mechanism and its downstream impact, and lessons from the case are discussed and followed by a succinct scientific and evidence-based discussion for further clarification.
This book is intended for cardiac surgeons at all stages of their careers, from residents beginning their journey in this demanding specialty to experienced practitioners seeking to refine their practice. It will also serve cardiac anesthesiologists, perfusionists, surgical nurses and other members of the cardiac surgical team who play crucial roles in patient care.
Inadequate Myocardial Protection Due to Unrecognized Coronary Anatomy.-
Left Main Coronary Obstruction Following Florida Sleeve Procedure.- Hidden
Left Ventricular Perforation from Bioprosthetic Strut.- Delayed Bleeding from
Distal Endarterectomy Site in Coronary Bypass Surgery.- Managing Aortic
Cannulation Site Bleeding in Friable Aorta.- Hidden Pulmonary Artery Injury
During Redo CABG Due to Incomplete Dissection.- Fatal Right Lung Infarction
Following Inadequate Baffle in PAPVC Repair.- Coronary Air Embolism Following
Complex Minimally Invasive Mitral Valve Repair.- Catastrophic Consequences of
Delayed Surgery in Acute Prosthetic Valve Thrombosis.- Coronary Button
Tension and Bleeding in Aortic Root Replacement: Lessons from a Giant
Ascending Aortic Aneurysm.- Too Late to Cut: Fatal Pulmonary Vein Injury
During Valve-in-Valve Mitral Intervention.- Hidden and Displaced: Right
Coronary Artery Transection During Redo Aortic Valve Surgery.- Through the
Heart...and the Stomach: Pacing Wire Perforation of the Gastric Wall.- A Race
Against Rupture: Pericardial Tamponade and Delayed Cannulation in Acute Type
A Dissection.- Silent Danger: Intraoperative Left Ventricular Clot and Stroke
Following Early CABG Post-MI.- Aortotomy Closure and Valve Strut Entrapment
in Combined CABG and AVR.- Off-Center: Paramedian Sternotomy Due to
Asymmetrical Chest Wall Anatomy.- Missed the Mark: Failed Alfieri Repair from
Imprecise Leaflet Approximation.- Managing Organized LAA Thrombus: Risks of
Extraction and Incomplete Closure.- A Missed Intramural Stenosis after
Coronary Button Translocation.- Torn Leaflet in a Small Left Atrium: A
Cautionary Tale of Traction.- Fatal Consequence of Deep Pericardial Stay
Sutures in Off-Pump CABG.- Unseen Drain: A Catastrophic Oversight in
Minimally Invasive ASD Closure.- The Fatal Bulge: A Pseudoaneurysm
Masquerading as a Stitch Abscess.- A Subtle Signal: Coronary Sinus Rupture
During Cardioplegia Infusion.- A Fatal Misstep: False Lumen Deployment in
Frozen Elephant Trunk for Acute Type A Dissection.- Overlooked Dextrocardia:
A Fatal Error in Postoperative Chest Tube Placement.- Missing Veins, Missed
Clues: The Cost of Incomplete Preoperative Assessment in Redo CABG.- A Fatal
Groove: Atrioventricular Disruption After Reoperative Mitral Valve
Surgery.- Oversized Danger: Aorto-Ventricular Disruption After Sutureless
Valve Deployment.- Pulmonary Vein and Bronchial Injury During Reoperative
Aortic Valve Surgery: A Cautionary Tale.- When the Annuloplasty Ring Bites: A
Case of LCx Injury Post Mitral Valve Repair.- Stent Distortion of a
Sutureless Aortic Valve Due to Low Aortotomy: A Correctable Intraoperative
Pitfall.- A Tight LIMA and an Angry Lung: A Case of Postoperative Hemodynamic
Collapse After CABG.- When the Heart Slips Away: Partial Herniation Inducing
Malignant Arrhythmia Post-CABG.- PA or PDA? A Costly Confusion.- The
Eustachian Trap: Importance of Careful Anatomical Recognition in Minimally
Invasive Cardiac Surgery.- Silent Killer: Delayed Atrioesophageal Fistula
after Left Atrial Ablation in Combined Cardiac Surgery.- Hidden Danger: Iliac
Artery Injury Presenting as Retroperitoneal Hematoma Post-CABG.- When the Leg
Tells a Bigger Story: Delayed Recognition of Type A Dissection.- Same-Day
CABG in Siblings: A Case of Clerical Error Leading to Acute Hemolytic
Transfusion Reaction.- Missed Anomalous Circumflex Artery Complicating
Bentall Procedure.- Anomalous Origin of Left Circumflex Artery from Rt
Coronary Sinus: Operative View.- Avoidable Aortic Dissection in CABG:
Importance of No-Touch Aorta Strategy in Inflammatory Aortitis.- Aortic
Rupture During Redo Valve Surgery: The Lethal Consequence of Wrong Dissection
Plane.- Unexpected Embolic Stroke After Off-Pump CABG: A Rare Complication of
Central Line Insertion.- Cerebral Air Embolism from Unclosed PFO After Redo
RVOT and Pulmonary Valve Surgery.- Fatal Pulmonary Embolism from Missed
Heparin-Induced Thrombocytopenia After CABG and LV Aneurysm Repair.- Severe
Mitral Stenosis from Migrated Papillary Muscle Sling After Ischemic MR
Repair.- Sawing Effect of Umbilical Tape: An Unrecognized Risk for Major
Venous Injury.- Unclamped Total Artificial Heart Leading to Massive Air
Embolism in Transplantation.- Fatal Pitfall Avoided: Liver Laceration from
Lower Intercostal Chest Tube Reinsertion.- Technical Oversight in Donor Heart
Procurement Leading to Recipient Hemorrhage.
Mehrab Marzban, MD, Department of Cardiovascular Surgery, Ronald Reagan UCLA Medical Center, UCLA Health, Los Angeles, CA, USA
Peyman Benharash, MD, MD, Division of Cardiac Surgery, Cardiovascular Center, David Geffen School of Medicine at UCLA, UCLA Health, Los Angeles, CA, USA
