Doctors told teen she was dying, then a second facility found an upside-down heart valve: Inside this $17M malpractice suit
Industry Buzz
One of the most common reversible causes is air embolism to the coronary circulation, resulting in temporary coronary malperfusion. Less commonly, coronary blood flow may be compromised by a prosthetic valve suture, valve malposition, or another technical issue causing coronary artery obstruction.
—Abdul Elnaggar, MD
A recent malpractice lawsuit filed against Oregon Health & Science University (OHSU) centers on a 13-year-old girl whose family says a heart valve was implanted incorrectly during open-heart surgery, leading to weeks of severe complications before another hospital identified the problem.[]
Related: Family of Pennsylvania woman receives $7.25 million after daughter dies from delayed heart condition diagnosisWhat went down?
According to the lawsuit, the young girl underwent surgery at OHSU in August 2025 to receive a heart valve.[]After the procedure, her heart reportedly could not function adequately on its own, and she was placed on extracorporeal membrane oxygenation (ECMO).
According to KGW, the family alleges they were told the valve surgery itself went “very well” and that her condition reflected “shock” of the surgery.
Over the following days, the girl remained critically ill. According to the lawsuit, hospital staff discussed options including heart transplantation, an artificial heart, and end-of-life planning, including organ donation. The family eventually sought transfer to Seattle Children’s Hospital.
Related: When a heart won’t recover after valve surgery: The post-op clues physicians can’t afford to missWhat did the second hospital find?
According to the lawsuit, imaging performed in Seattle raised concerns that the prosthetic valve was improperly positioned.[]
The lawsuit alleges that direct inspection revealed the valve had been implanted upside down. Surgeons replaced the valve, and the lawsuit states that the patient’s heart function improved “promptly” after the revision.
The lawsuit seeks $17 million in damages. OHSU has declined to comment publicly because litigation is ongoing. Law & Crime reports the family’s attorney, Robert Wagner, called it “a complete and egregious screw-up” and said the patient is “making a miraculous recovery.”[]
The lawsuit’s allegations have not been proven in court. Still, the case is clinically relevant.
Clinical POV
When a patient cannot separate from cardiopulmonary bypass, what fixable mechanical complications should clinicians rule out first?
“One of the most common reversible causes is air embolism to the coronary circulation, resulting in temporary coronary malperfusion. This most often affects the right ventricle because the right coronary artery is particularly susceptible to air embolization. Less commonly, coronary blood flow may be compromised by a prosthetic valve suture, valve malposition, or another technical issue causing coronary artery obstruction,” says cardiothoracic surgeon Abdul Elnaggar, MD, at Penn State Heart and Vascular Institute.
Commenting on this case in a forum on the Student Doctor Network, a verified anonymous member wrote, “It can and does happen. I’ve seen it partially put in before the surgeons noticed, obviously before atriotomy closure (academics, older surgeon, newer fellow). Some valves produce very poor TEE images (eg, pulmonic), so echo’s not always reliable. Probably a Swiss cheese of poor visualization on TEE, hyperfixation on cardiogenic shock/vasoplegia/poor myocardial protection, and low incidence of that specific complication. I’ve seen a lot of things go wrong, and I continue to see or hear about new ways of things going wrong pretty much every week or two. I always tell the trainees, ‘It’s never just a CABG.’”[]
Post-bypass myocardial dysfunction is common after cardiac surgery. Low cardiac output syndrome occurs in about 5% to 15% of open-heart surgery patients.[]
Furthermore, post-cardiotomy shock, including cardiogenic, obstructive, hemorrhagic, and vasoplegic shock patterns, commonly occurs in post-cardiotomy patients.[] Secondary causes such as ischemia should be assessed while clinicians support perfusion.
Prosthetic valve obstruction, malposition, paravalvular leak, LV outflow tract obstruction, coronary compromise, tamponade, and residual lesions can all present as shock or low cardiac output.
Low cardiac output syndrome reviews list ventricular dysfunction, hemorrhage, tamponade, and arrhythmias among key causes.[]
Prosthetic valve guidelines cover obstruction, regurgitation, paravalvular leak, and the role of TEE, CT, and fluoroscopy in suspected prosthetic dysfunction. Stopping the workup too early can be a major risk.
Related: Florida jury grants $1.5 M settlement following unaddressed bleeding at hospital resulting in congestive heart failure