March 13, 2023

What is a cardiac lesion and can it be missed? What you need to know

In clinical negligence litigation, as in everything else, you can see trends emerge over time; history famously doesn’t repeat itself, but it tends to rhyme.

Over the past few years, I have noticed a steady trickle of enquiries stemming from a failure to diagnose congenital cardiac lesions until relatively late in life.

What’s a congenital cardiac lesion?

It’s a broad term, which encompasses any structural abnormality in the heart that is present at birth. Any part of the heart can be malformed, although some malformations are more common than others. To make matters more complex, the heart and aorta (the biggest artery in the body) both go through quite significant structural changes in the first month or so of life as the baby’s body becomes used to aerobic respiration (breathing air using lungs).

How are congenital cardiac lesions diagnosed?

The majority of congenital cardiac lesions that are going to cause trouble will be picked up within the first few years of life, simply because they will cause symptoms within that period.

Generally, diagnosis is possible with proper diagnostic imaging (usually by ultrasound or CT – or both), and thereafter surgery might be suggested if the child is a viable candidate for this.

Can you have a congenital heart defect and not know it?

Some congenital heart defects are clinically ‘silent’; some only cause very mild symptoms. There is no routine screening for cardiac defects in this country, and never has been.

Generally, the more serious structural problems (e.g. transposition of the great arteries, in which the pulmonary artery and the aorta are “plumbed in the wrong way round”) get picked up, because they are virtually certain to cause very severe symptoms. By contrast, it’s entirely possible for someone to go all the way through life unaware of a small hole in the wall that divides the top two chambers of the heart (“atrial septal defect”).

Common congenital cardiac problems

Depending on their size and location, holes in the wall dividing the two halves of the heart can go undetected for decades and are usually only diagnosed when they create symptoms. These can include shortness of breath, fatigue and heart palpitations. Individually, these symptoms are not very specific, but in combination they might suggest an evolving cardiac problem that needs further investigation.

More rarely, a clot can pass through an undetected hole in the heart from the right to the left side. If that occurs, the clot will generally lodge either in the coronary or the cerebral arterial circulation, causing either a heart attack or a stroke. If there was good reason to suspect the presence of a hole in the heart prior to such an event, there could be a negligence claim, on the basis that a catastrophic injury could have been avoided.

Another form of congenital cardiac lesion that can present late in life is coarctation of the aorta. Strictly speaking, this isn’t a heart condition as such: as the name suggests, it’s a problem that affects the aorta (the body’s biggest artery), usually at the level of the aortic arch. A coarctation is simply an area of narrowing, which generally occurs adjacent to the left subclavian artery. Below the level of that narrowing, the body receives less oxygenated blood than it should, because the blood supply has to travel through a partial blockage. Above the narrowed area, blood pressure tends to be very – sometimes dangerously – high. Because this high blood pressure affects the arteries that supply the arms and head, sufferers of this condition are at risk of hypertensive stroke (amongst other things) if the lesion goes undetected and untreated. If a patient has persistently high blood pressure that does not respond to medication, doctors might be expected to start looking for a structural cause, and so a coarctation might be suspected at this point.

How do you fix a congenital heart defect?

Once they are causing symptoms, the vast majority of cardiac abnormalities will require surgical resection. If they are left, they can cause anything from discomfort and unpleasant symptoms to life-changing illnesses, such as stroke, and even death.

Why are we seeing more cardiac lesions now?

This is an interesting question. Late presentation of cardiac anomalies is nothing new, but what does appear to be new is the extent to which they are not being picked up promptly, whether in general practice or in hospital settings.

There is no data currently of which I’m aware that could corroborate this impression with precision, but nonetheless we are seeing more cases of this sort. Litigation usually functions as a “canary in the coalmine” in relation to evolving clinical problems. Consequently, we ignore trends in these cases at our peril.

It seems probable that the underlying causes of this apparent trend are complex and structural – pressures upon the NHS are now legion, and funding has not kept pace with the country’s changing demography (there are now more older people in Britain than formerly: people have more health needs as they age and diseases accrete, so on aggregate the burden on the healthcare system has increased). These are relatively rare lesions, and this may explain why they are missed in increasingly high-pressure clinics. We hope to raise awareness of this issue and so ensure that more such cases are not missed.

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