Death after stopping an antiaggregant treatment preoperatively of a non-urgent intervention

According to the experts, one cardiologist and the other anesthesiologist-resuscitator, both practicing in private:

“(…) In the absence of an autopsy, the most likely hypothesis to explain the death is a ventricular rhythm disorder in a patient with severe coronary disease, having benefited eight days earlier from a complex procedure of angioplasty with a significant risk of thrombosis and having interrupted the antiaggregant treatment three days earlier, which favored massive coronary thrombosis in the common trunk with downstream ischemia.

Regarding the medical management of the patient, as part of a systematic cardiological assessment in an asymptomatic patient, additional non-invasive examinations were performed which revealed a carotid stenosis of 70% with a soft plaque and lesions in the body. homolateral vertebral level. The prescription of a stress test and echocardiography was legitimate and justified.

The vascular surgeon proposed a carotid endarterectomy. This questionable choice was justified on the basis of the characteristics of the plaque susceptible to embolization, the degree of stenosis and the existence of associated lesions. The surgeon explained the advantages and disadvantages to the patient clearly, following the recommendations. As part of the preoperative process, he legitimately scheduled a pre-anesthetic consultation.

In parallel, following the recommendations of the patient’s cardiologist, he scheduled a coronary angiography, although the stress test was negative, but which was justified by the existence of the arrhythmia observed during recovery. This coronary angiography was performed under perfect technical conditions by Dr. B. interventional cardiologist, but its results with evidence of severe tritronascular disease were a surprise that completely changed the patient’s status. These three-cell lesions should have justified detailed information for the patient in order to explain the methods of the resulting management with the possibility of aorto-coronary bypass surgery.

It was not possible to provide us with the result of a multidisciplinary meeting between Dr B. and cardiac surgeons to discuss the therapeutic choice.

The Syntax score (NB: evaluation for each coronary lesion, the extent of the territory at risk and the severity of the anatomical lesion) of the patient can easily be assessed, it is greater than 22, with the association of a lesion of the common trunk and an occlusion of the right coronary artery. In this context, the choice of aorto-coronary bypass surgery would have been legitimate.

Two days later, the patient consulted the anesthesiologist as part of the preoperative assessment of his carotid stenosis. The latter was not aware of the coronary angiography carried out two days earlier in the same establishment, the patient was not sensitized and did not inform him of it. However the anesthesiologist rediscovers the notion of Brilique® in the patient’s prescription. He has no idea of ​​the reason for this prescription, nor of the duration of the treatment. He is not looking for the information, but he will however prescribe the interruption of the treatment 10 days before the intervention on the carotid artery for February 17, without investigating further.

Concerning patient information, he was correctly informed of the existence of his asymptomatic carotid stenosis, of the benefits and drawbacks of endarterectomy as recommended. He does not seem to have received information on the severity of coronary lesions and their consequences. There is no notion of awareness of this type of information, nor of a therapeutic choice between a possible coronary artery bypass grafting and angioplasty. Did the patient meet Dr B. during the coronary angiography and after the angioplasty? Did the latter provide the patient with oral information on his condition and the therapeutic requirements? He does not seem. This lack is evidenced by the behavior of the patient during the pre-anesthetic consultation. It does not report the coronary angiography and its results. He does not seem to have been warned of the risks of stopping Brilique either.® during the angioplasty procedure.

The anesthesiologist, by prescribing 10 days before the intervention on the carotid artery stopping Brilique®, does not respond to recommendations that suggest postponing any elective intervention within 3 to 6 months following angioplasty with stenting due to the risk of thrombosis.

Au total, the responsibility of the various stakeholders peut variously to be appreciated:

The surgeon, who prescribed the coronary angiography, should have, on receiving the result, cancel the intervention on the carotid artery, but he was reassured by the letter from the angioplastician. It was he who initiated the dual approach in parallel to lead to his non-essential intervention. Its liability can be assessed at 10% of the loss of chance suffered by the patient.

Dr B., interventional cardiologist, performed very high-level but high-risk technical actions, the indication of which was not discussed with cardiac surgeons despite a high Syntax score. Moreover, he did not communicate explicitly with his patient, in particular the imperative need not to interrupt the antiaggregant treatment. Its liability can be assessed at 70%.

The anesthesiologist, in charge of the pre-anesthetic consultation, noting a treatment with Brilique®, should have investigated to find out the reason for this prescription which was not integrated with the intervention on the carotid artery before stopping this antiaggregant treatment. Its liability can be assessed at 20%.

There is clearly a communication problem between the different stakeholders exercising, however, in the same clinic:

  • The intervention on the carotid artery, given the benefit / risk ratio, should not have been maintained after the coronary angiography.
  • The findings of the coronary angiography should have been the subject of a medico-surgical staff to discuss coronary artery bypass grafting and should have been explained to the patient to avoid not mentioning it two days later at the anesthetist.
  • The latter, in front of the observation of the treatment by Brilique® had to collect information on the indication, the start date of treatment and contact the interventional cardiologist to find out what to do.

Regarding the loss of chance suffered by the patient, the latter had a severe truncated coronary heart disease whose natural evolution is towards worsening with the occurrence of myocardial infarction, sudden death and ischemic heart failure.

He received treatment which should have delayed the progression of his disease. However, the placement of a stent after an angioplasty procedure constitutes an endo-arterial trauma at the coronary level favoring the occurrence of thrombosis, especially at the immediate end of the procedure, which requires, to reduce the risk, a double anti-aggregation platelet.

Coronary artery disease, angioplasty procedure, stopping Brilique early® constitute the three mechanisms that favored the death of the patient in the proportion of 20% for coronary disease, 50% for the angioplasty procedure and 30% for discontinuation of Brilique® (…)”