IV Case in Point
Illustrated Verdict shares case examples from our archives to show how a visual strategy can support the defense effort. We hope that it is of value in your practice as you develop your defense strategies on behalf of health care providers. Please feel free to forward it to colleagues or clients.

About Us
IV is a leading provider of demonstrative evidence for the defense of medical malpractice claims. Our team of medical illustrators consults with defense teams to educate the lay jury audience about the complexities of medical care. We do this by developing a visual strategy with expert witnesses including high-quality case-specific medical illustrations, x-ray enhancements, and multimedia presentations. IV receives judgment for the defense in over 94% of the cases we participate in, as compared to the national average of 73%. Additionally, insurers who supply us with their trial list enjoy a win rate of up to 97%.
To learn more, e-mail us or call 617-530-1001.
www.illustratedverdict.com

 

NEW ONLINE
ORDER FORMS!

Case Request
If you have an upcoming case please feel free to use our new easy online form to submit your case information:
Case Overview Form
Film Copying
Have film copy orders? Use our new reliable and easy online order form:
Film Copy Order Form

Case In Point Library
Click to view other editions:

Case In Point Library Page

Pregnancy and Delivery:
Fetal Assessment 2009v1
Shoulder Dystocia 2009v3
MVA Leads to Fetal Demise 2010v4
Fetal Descent Stalled 2010v5
Shoulder Dystocia / Erb's 2011v4
Fetal Tracings / Hypoxic Injury? 2013v1

Heart:
Coronary Artery Disease 2009v5
CAD / Recurrent MI 2010v1
Aortic Valve Replacement 2011v1

Lungs:
Stroke After Lung Surgery 2009v2
PE / Infection 2010v3
PE Following Roux En Y 2012v1
Intubation / Macklin Effect 2012v4
Lung Cancer vs. Infection 2015v3

Female Pelvis:
Hysterectomy / Fistula 2011v9
Hysterectomy / Ureter Injury 2010v2
Hysterectomy / Kinked Ureter 2010v8
Diag Lap / Bowel Injury 2012v3
Cervical Cancer 2013v3
Endometrial Cancer 2014v1

Male Pelvis:
Bladder Cancer 2013v2

Digestive System:
Gastric Bypass 2009v6
Recurrent Hiatal Hernia 2009v8
Right Colectomy / Leak 2010v7
Gastric Bypass / Volvulus 2011v2
Nissen Fundoplication 2011v3
Large Hiatal Hernia 2013v5
Necrotizing Enterocolitis 2013v7
Arrest during ERCP 2015v4
Diverticulitis Complications 2015v5

Abdomen:
Spleen Injury and Bleed 2009v4
Bleed Following Lithotripsy 2012v2
Lap Cholecystectomy 2012v5
Bowel Injury Lap Ovarian Cyst Removal 2013v6
LapChole - Hepatic Duct Injury2015v1

Orthopedic:
Partial Hip Replacement 2010v6

Vasculature:
tPA Infusion 2009v7
Vertebral A. Coil Embolization 2015v7

Head and Neck:
Bell's Palsy 2013v4
Tongue Cancer 2014v2
Chiari I - Vision Loss 2015v2

Judgment for the Defense
Aortic Valve Replacement with
Post Operative Complications

http://www.illustratedverdict.com/projectreview/IV/IV_v2_2010web/2624m7changed_small.jpg

The patient presented with severe aortic stenosis due to a bicuspid aortic valve.  The defendant recommended replacing the aortic valve with a 17-millimeter St. Jude mechanical valve.  The operation itself proved uneventful; however, as the patient’s chest was being closed, she suffered sudden cardiac arrest. The defendant immediately reopened the incision to perform coronary artery bypass grafts to the right coronary artery, the proximal left anterior descending artery (LAD), and the distal artery (LAD).  After placing the grafts, the defendant put the patient on an Abiomed biventricular assist device to help support  heart function.  Unfortunately, the procedure was not successful; the plaintiff developed multi-organ failure and died shortly thereafter. 


PLAINTIFF'S CLAIM:

The plaintiff claimed that the defendant chose the incorrect replacement valve and performed the procedure improperly.  Further, the plaintiff claimed, the ostia (the coronary arteries’ openings from the aorta), were compromised, preventing adequate blood flow to the heart, resulting in the patient’s cardiac arrest.  According to this argument, a 17-millimeter valve should not have been used because its opening did not allow sufficient blood flow.  The plaintiff’s position was that had a larger valve been used her cardiac function would have been better and her outcome different.  



DEFENSE'S ARGUMENT:

The defense claimed the autopsy clearly indicated that the St. Jude 17-millimeter valve had been placed correctly at the aortic annulus (the ring of tissue supporting the valve) and did not obstruct coronary artery blood flow.  Furthermore, when the plaintiff went into arrest, the defendant physician responded appropriately by reopening the patient’s incision immediately and performing the coronary artery bypass grafts.  Despite the grafts and a new aortic valve, however, the plaintiff’s cardiac function remained compromised, leading to her death.  The defense contended that, while the patient’s outcome was unfortunate, the procedure to replace her valve had been done correctly and that the size of the valve did not matter,  since the outflow diameter for both the 17-millimeter and the 19-millimeter valve is the same;   the two valves differ only in  the size of the cuff needed to attach the valve to the aortic annulus.


___________________________________________________________________

VISUAL STRATEGY:

Collaborating with the defendant and her attorney, IV created visual aids to help illustrate these defense positions. 

 

The first diagram demonstrated the normal circulation of blood through the heart and the role of the aortic valve.

The second diagram explained the normal anatomy of the aortic valve, while the third illustrated the plaintiff’s bicuspid aortic valve stenosis

Another board illustrated the form and function of the St. Jude aortic valve, and a companion illustration demonstrated the St. Jude valve placement with respect to the aortic annulus.   

Further, working with the defendant, IV created a board illustrating that, as revealed by the autopsy,  the patient’s valve had been correctly placed and contrasting this correct placement with the appearance of and complications following improper placement.    This board definitively demonstrated that a valve correctly placed at the aortic annulus is a comfortable distance from the coronary arteries’ ostia and in no way obstructs blood flow.  Clarifying this point enabled the jury to see that — given the proof provided by the autopsy that the valve had been correctly placed — the plaintiff’s claims were unfounded.  

Another key issue for the defendant was the differences and similarities between the 17-millimeter valve used in the surgery and the 19-millimeter valve that the plaintiff claimed should have been usedSpecifically, the defendant wanted to show that a larger valve would not have made any difference to the patient’s outcome because the actual valve openings (through which the blood flows) for both are exactly the same diameter; only their outer sewing cuffs differ in size.

Another illustration showed the location of the coronary artery bypass grafts placed after the plaintiff’s cardiac arrest

Finally, the last couple of boards illustrated the biventricular assist device and the cardiopulmonary bypass.

This series of illustrations helped the defense to convey the following key points to the jury successfully:   

  • The defendant’s decision to use a 17-millimeter St. Jude valve for the aortic valve replacement was completely appropriate.
  • The autopsy confirmed that the valve was the correct size and in the correct location, with no evidence that the coronary arteries’ ostia were kinked or blocked.
  • Although the outcome in this case was unfortunate, the defendant’s actions were appropriate and within the standard of care.


RESULT:

The jury found in favor of the defense. 

"I thought your illustrations were excellent and helped clarify our explanations for the jury.”

—Defendant Physician