The Mark Midei Cases: Patient A Reply

The document containing the final decision of the Maryland State Board of Physicians revoking the medical license of Mark Midei includes extensive details about 5 cases (Patients A-E) reviewed by the Administrative Law Judge (ALJ), along with expert testimony about the cases by Midei himself, William O’Neill, Midei’s expert witness, and Matthews Chacko, the state’s expert witness. Due to the great interest in the Midei case, as well as the many important issues raised by the case, CardioBrief will present the key details of these cases, along with the accompanying testimony about these cases, as contained in the document. Here are the details of Patient A, the first case reviewed in the document.

The judge wrote that Patient A had chronic stable angina with “at most a moderate calcification of the mid-LAD.” Her angiogram showed no flow-limiting lesion or plaque rupture. She was referred to Midei by the referring cardiologist, Chitrachedu Naganna, when a coronary CT showed an 80% lesion in the LAD.

In his cath report Midei said the patient had unstable angina, but there was no mention of this in the letter to Midei from Naganna, where she is described as having “chest pain precipitated by exertion and relieved by rest.” The judge stated: “there is nothing in Dr. Naganna’s medical records to support the diagnosis of unstable angina.”

Midei testified that Naganna “told him that the patient’s symptoms had increased recently” but the judge found no evidence for this and further rejected O’Neill’s testimony supporting Midei’s asserion:

O’Neill admitted on cross-examination that the source of his information about the alleged change in the patient’s symptoms came from the Respondent’s memory, not the medical records.

In his cath report Midei said he performed the PCI because the patient had an 80% LAD obstruction. But during an earlier inquiry by the hospital Midei “described the lesions as 50%. He further explained the difference between his then assessment of 50% and the cath report by explaining that 80% was a surrogate for an intermediate lesion.” Dr. Chacko testified that the LAD lesion on the angiogram was less than 50%. The judge said that “the use of such a surrogate violated the standard of care.”

Midei argued that “he was justified in stenting the LAD because the condition of the LAD that he observed during the PTCA correlated with the findings of the patient’s cardiac CT angiogram.” The report on the CT angiogram stated:

There appears to be some soft plaque in the proximal portion of the artery, takeoff of the left circumflex. The vessel becomes very hypodense just prior to a large amount of calcified plaque. This appears to be consistent with significant narrowing. There is then large plaque with hypodensity in the middle of this plaque. No significant blooming artificat in this region, but significant narrowing of 80% cannot be excluded.

Midei, O’Neill and Chacko all aggreed that the CT angiogram was important, but Chacko said that CTA’s “are most useful in their negative predictive value” and said that

while an invasive cardiologist gives weight to the CT angiogram results, the invasive cardiologist must make an independent assessment of the vessels during the PTCA. Dr. O’Neill and the Respondent testified that a CT angiogram usually correlates strongly with the findings on PTCA.

The judge also noted that Midei made no mention of the CT angiogram either in his original cath report or in his letter to the referring cardiologist.

The judge concluded that Midei

  • failed to accurately document the clinical indications, including Patient A’s symptoms, upon which he based his decision to perform PCI and place a stent;
  • exaggerated the degree of mid-LAD stenosis and used this as clinical justification for placement of the stent;
  • placed a coronary stent in Patient A and needlessly exposed her to the risks attendant thereto in the absence of medical necessity and sufficient clinical indications;
  • failed to cosndier that a trial of more optimal medical theapy would be a more appropriate form of treatment for Patient A rather than placement of a stent;
  • failed to obtain and document Patient A’s ACT prior to the start of the PCI procedure after administering intra-arterial unfractionated heparin.
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