My toughest case: ‘The aneurysm ruptured, with blood pouring into the chest’

I'm Professor of Paediatric Cardiology at Evelina Children's Hospital, London. Around seven years ago, I was in Germany teaching at an interventional congenital cardiac course. The course was not just lectures, but involved live demonstrations of cases to attendees as well. For example, we had a 23-year-old girl who suffered from coarctation of the aorta; basically, a narrowing of the main artery arising from the heart. Four or five years previously, the patient had received a stretch of the narrowing with a balloon, which would have improved the blood flow in the aorta, but after the procedure she developed a large aneurysm, a weakening of the wall of the aorta.

So, she was brought to the hospital from where we were transmitting the procedure to the conference, and we were planning to use covered stents, which are metal tubes covered by a synthetic material, in an attempt to strengthen the weakened walls.

The whole procedure was taking place in front of an audience of 400 to 500 via satellite. However, there was one major risk with the operation, with the possibility of the aneurysm bursting. If it bursts outside the hospitals, patients can die from loss of blood from the circulation.

As we began the procedure, the aneurysm of the aorta ruptured, with blood pouring out into the chest. We had to drain the blood from the chest as an emergency and had to resuscitate her as well. A part of my team had to pump the lost blood back into the patient to ensure her blood pressure was maintained. From here I put the stent in to stop the bleeding from the ruptured vessel, but, at that moment, another part of the aneurysm burst. This led to a prolonged course of pumping the blood back into her and further insertion of three more stents quickly in our attempts to stop the bleeding. After the fourth stent, the vessel stabilised with the aneurysm fully covered and she made a full recovery.

At the time, there was a huge stress, with the central thought of "if you can't deal with this, the patient will die in front of you".

There was also concern for all the people who were watching, as to whether they would be stressed or worried about the problem. In these situations, you need a good team with a cool, coordinated approach to avoid a major disaster, although this was still a very close shave.

Patients like this one with a similar complication can die due to a lack of staff, equipment and team co-ordination. The whole situation is like a plane in freefall: if the captain has no sense of perspective, it will mean all things lead to disaster.

DAVID BRAKE

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