Terry D. Horner recently won a dismissal for an Orange County, NY electrophysiologist and his group medical practice in a case involving a 52-year-old woman who developed an atrial-esophageal fistula (AEF) following an ablation to address her paroxysmal atrial fibrillation (A-fib).
The patient was a 52-year-old woman who had become Feldman, Kleidman, Collins & Sappe LLP’s (FKC&S) client’s patient several years earlier after being referred by another cardiologist for management of her atrial fibrillation. The A-fib was monitored digitally through LifeWatch, and was successfully managed with medication for almost two years. During that time the patient saw FKC&S’s client about every six months.
Although the patient was satisfied with medical management of her condition, she and FKC&S’s client periodically discussed whether an ablation might provide more relief. As the A-fib became more symptomatic, they again discussed an ablation instead of a continuing medication regime, but the patient was still not interested at that point. A year later, the patient’s A-fib had become more frequent and less responsive to the medication so that, after ongoing discussions, she agreed to have the ablation, which was performed at a major medical center in New York City.
FKC&S’s client had advised the patient of the risks of the procedure, which included the rare complication of a possible communication or fistula between the esophagus, which lies directly behind the cardiac atrium, and the atrium itself. After an overnight stay the patient was discharged with instructions to notify FKC&S’s client’s office about any signs or symptoms. A follow-up visit was scheduled for four weeks later.
The patient was also started on a proton pump inhibitor to reduce the acidity of the esophagus, to protect against a communication (fistula) between the heart and the esophagus after the ablation. At discharge, the plaintiff complained of a headache, relieved with Tylenol, which is not uncommon following an ablation involving general anesthesia and being NPO (nothing by mouth) since the evening before.
Two days after leaving the hospital post-procedure, the patient presented at the emergency department (ED) of the local community hospital with a complaint of “groin pain”—hardness and bruising at the ablation catheter site. As FKC&S’s client happened to be at the hospital at the time, he saw the patient and told her that the bruising at the catheter site was normal, and that her elevated white blood cell (WBC) count and blood pressure were normal under the circumstances post-procedure. FKC&S’s client also explained that the patient’s headache was from anesthesia, and her sore throat was from the intubation.
Three weeks later, the patient went to urgent care complaining of a worsening new-onset headache that had started the day before. Because her symptoms raised concern for a brain infection, she was transferred to the ED of the local community hospital. After evaluation by a neurologist, FKC&S’s client was contacted because of a concern for meningitis. The client recommended a thoracic CT scan because of the possibility of an AEF, being acutely aware that a brain infection would be a consequence of an AEF.
Although the CT scan showed no fistula, a brain MRI showed two brain lesions suspicious for abscess, which was concerning for AEF. FKC&S’s client immediately arranged for the patient’s urgent inpatient transfer to a New York City tertiary care center with experience in treating a possible AEF. The AEF was successfully repaired there, although a second admission was necessary for follow-up treatment.
The patient claimed that (1) the ablation was unnecessary because she was asymptomatic, (2) FKC&S’s client did not properly elicit informed consent, (3) the client failed to consider the patient at increased risk for AEF because of an unknown anatomic anomaly encountered during the ablation, (4) the client negligently caused the AEF and (5) the client failed to timely diagnose the AEF.
FKC&S filed a motion for summary judgment, arguing (1) the mere occurrence of the AEF did not prove medical negligence, because AEF is a known but rare risk of the ablation procedure, (2) the patient’s complaints two days after the ablation could not have been due to an AEF, because an AEF takes weeks, not days, to develop, (3) FKC&S’s client diagnosed the AEF despite the negative thoracic CT, and immediately arranged treatment at a tertiary care center, (4) the risks of the procedure were fully discussed more than once with the patient, specifically including injury to the esophagus and (5) the anatomic anomaly did not increase the risk of an AEF.
In opposition to the motion, the patient offered the expert opinion of a electrophysiologist who averred that FKC&S’s client negligently recommended and performed the ablation, failed to obtain informed consent, failed to consider the patient’s increased risk for AEF and failed to timely diagnose the AEF.
In its decision granting summary judgment, the court noted that the patient’s expert acknowledged that ablation is a reasonable treatment for A-fib patients when medications do not adequately control it, but ignored the evidence that the patient’s burden of A-fib had increased. The court also rejected the patient’s claim that earlier imaging studies would have allowed for an earlier diagnosis, because the CT scans done the same day FKC&S’s client actually diagnosed the AEF were unremarkable.
Additionally, the headache the patient complained of on the day of the diagnosis had lasted for two days, and thus was unconnected to the headache three weeks earlier, two days after the ablation. Finally, the court rejected as conclusory the patient’s claim that the outcome would have been better if FKC&S’s client had made the diagnosis one day earlier.
For all these reasons, the court granted summary judgment and dismissed the complaint.