Japanese Journal of Cardiovascular Surgery Vol44,No6

Lessons Learned from an Erroneous Surgery:Inversely Implanted Apicoaortic Valved Conduit

Takahiro Souma Shuichiro Takanashi

(Sakakibara Heart Institute, Japan Research Promotion Society for Cardiovascular Diseases*, Tokyo, Japan, and Present address:Chiba University Hospital**, Chiba, Japan)

A 62-year-old woman with severe aortic stenosis underwent apicoaortic bypass grafting. The graft was implanted inversely at first;on the next day, it was re-implanted in the right direction. She recovered once from heart failure;however, on postoperative day(POD)74, she died from respiratory failure. On POD 16, an in-house multidisciplinary investigatory commission reviewed the human factors that had led to the surgical error. Throughout the investigation, we provided relevant information about the event and explanations. We presented our apologies the patient’s family and offered to compensate them for their losses.


Jpn. J. Cardiovasc. Surg. 44:313-317(2015)

Keywords:Apico-Aortic Bypass;human factor;wrong surgery

Copyright ©2015 By Japanese Society for Cardiovascular Surgery All rights reserved.