A 50-year-old obese (BMI 39) female with a history of poorly controlled diabetes, hyperlipidemia, hypertension and previous use of fen-fen presented to her internist/family physician with complaints of chest pain and shortness of breath.  She declined her physician’s suggestion to go to the Emergency Room.  She was referred to a cardiology group. 

A nuclear stress test performed in June revealed severe work impairment with ST segment ischemia and an anterior perfusion defect.  A cardiac catheterization was done on July 7 by Cardiologist #1 (Cardiology Group) which revealed a total Left Anterior Descending coronary artery occlusion, a 70 percent stenosis of the ramus intermedius feeding the high circumflex territory and a 40 percent angiographic lesion in the right coronary artery.

Cardiologist #2 (Cardiology Group) performed a coronary angioplasty on July 12 and an accidental dissection of the left anterior descending coronary artery occurred but was managed medically.  A catheterization the next day, performed by Cardiologist # 1, confirmed the closure of the dissection with minimal residual occlusion.  All three catheterizations were performed through a right femoral artery sheath using standard sterile Seldinger technique. The sheath remained in place July 12 through July 13 and was removed without noted complications. 

On July 14 the patient had an elevated temperature of 101.8 degrees. Chest x-ray was negative. Urine and blood cultures were obtained. The patient was started on Bactrim for a urinary tract infection (culture subsequently did demonstrate E Coli). 

The patient was discharged to home on July 15 the next day with a temperature of 99.4 degrees.  Four days (July 19) post-discharge, the results of the blood culture were positive for Staphylococcus Aureus. The nurse practitioner with the Cardiology Group was made aware of the results during her usual hospital rounds and she faxed the laboratory results to the Internist’s office.  She also called the Internist’s office and spoke to the staff to confirm the results and receipt of the fax, an uncontested fact.    

The patient maintained contact with her Internist post-discharge and expressed dissatisfaction regarding the accidental dissection of the left anterior descending coronary artery.  There was documentation that the patient was counseled regarding compliance with medications and was referred to another cardiologist, although she did not follow up.  There was no indication that the Internist acknowledged or discussed the positive blood culture with the patient. 

The patient saw Cardiologist #1 (Cardiology Group) one week post-discharge and complained of general malaise, severe back pain, 20-pound weight loss within the last four weeks, and loss of appetite.  She was admitted to the hospital on that day, July 28, with a diagnosis of Sepsis secondary to a right groin abscess. Multiple studies and consults were done during this hospitalization to define the extent and spread of infection. An Infectious Disease Specialist saw the patient per consult request. The patient was treated with Nafcillin and discharged on July 31 to outpatient treatment with a planned course for treatment for six weeks. 

On August 13, the patient presented to the Emergency Room in cardiac arrest and expired.  Autopsy results revealed a ruptured pseudoaneurysm of the ascending aorta with hemopericardium, left empyema, left subphrenic abscess, and infective endocarditis with involvement of the tricuspid and mitral valves.