Methwii? Cardiovascular Michael J. Reardon, MD. Professor and Chief of Surgery Assoc1ates Cardiac Surgery Cardiovascular Surgery Members of Methodist DeBakey Heart. Center 6560 Fannin Street Suite 1006 Houston, Texas 77030 713-441?5200 Fax: 713?441-6298 E-mail: mreardon@tmh.tmo.edu Jeffrey McClure Andrews Kurth LLP 600 Travis, Suite 4200 Houston, Texas 77002 Re: Riley vs. St. Lukes I have been asked to render an expert opinion in the matter of Joyce Riley vs. St. Lukes Hospital. 1 am a licensed physician in Texas and have current board certi?cation in cardiothoracic surgery. I am actively engaged in the practice of cardiothoracic surgery and serve as Professor and Chief of Cardiac Surgery at The Methodist DeBakey Heart and Vascular Center in Houston, Texas. I am responsible for the over sight of our heart transplant program and I am familiar with the operation of transplant programs and teams. My quali?cations, publications and CV are attached. 1. Cases that I have testified as an expert witness in the last 4 years; I have provided expert testimony over the last four years in this case: Linda Carder et al vs. Wyeth et a1 2. Compensation My charge for the current work is $500/hour. I have been paid $9,450.00 to date and currently have 4 hours to bill. 3. The Information I reviewed I have reviewed the records on patient 1153455, 1300735, 1108146, 0524725, and 1251716. I have also reviewed the depositions of Joyce Riley, 0. Howard Frazier and Edward Massin. 4. Basis and Reasons For Mv Opinions A brief time line description of each patient as follows that went into the basis and reasons for my opinions: Patient 0524725 Patient 0524725 began his pre-transplant work up at St. Luke?s Episcopal Hospital on 6/7/93. He had been diagnosed with dilated cardiomyopathy felt to be secondary to substance/alcohol abusehalf year history of on exertion and orthopnea. A heart catheterization on 4/ 14/93 showed a 35% obstruction of the left anterior descending artery with proximal stenosis; mild plaguing of the circum?ex and right coronary arteries and an ejection fraction between 20-3 It appears he was placed on the active transplant waiting list after this work up. On 8/8/93, Patient 0524725 was admitted in progressive congestive heart failure with extreme fatigue and increased He was noted to have been following the - regimen of Lasix, Digoxin, Vasotec, Coumadin and salt restriction for the past two and a half months, but had developed increased fatigue to the point he was exhausted with simple activity. He was admitted to the ICU and treated for two days with IV dobutamine and IV Lasix for diuresis. After obtaining adequate diuresis, the patient was transferred out of ICU on 8/ 10/93. He continued on Lasix with improvement in his congestive heart failure On 8/20/93, his cardiologist indicated he would need a heart transplant as soon as it can be arranged, but if he remained stable through the weekend, he could be discharged on 8/23 to a nearby hotel to await transplant with weekly clinic visits. On 8/3 0/93, this patient returned to St. Luke?s with increased shortness of breath and pedal edema. His cardiologist noted that he failed being outside the hospital on oral medication, so was admitted for aggressive treatment of his severe congestive heart failure until he could obtain a heart transplant. He was admitted to the ICU for IV dopamine and diuresis with Lasix and spironolactone. On 9/3/93, Patient 0524725 was transferred from ICU to the telemetry ?oor for a short period of time, but was returned to ICU possibly due to an increase in or abnormal telemetry tracings. He continued on IV diuretics on 9/6/93 but was allowed to ambulate for short periods of time. He was continued on IV dopamine for pressor support, but was allowed to be transferred to telemetry on 9/ 1 0/ 93. His condition appeared to be stabilized with some complaints of chest and leg cramps, but had to be returned to the ICU on 9/24/03 with He was able to be transferred back to telemetry on 9/29/93 where he remained until his discharge on 10/8/93 to a nearby facility to await a donor heart. Patient 0524725 had two short admissions to St. Luke?s on 10/25/93 to 10/26/93 for a fever believed secondary to upper respiratory infection. He was discharged after evaluation and initiation of antibiotic treatment. A second admission to the telemetry unit from 12/1/93 to 12/2/93 was due to increased weakness, tiredness and edema in legs. After increase in his Lasix, his improved and he was discharged back to Hospitality House where he was residing while awaiting a transplant. On 12/28/93, Patient 0524725 was admitted with worsening congestive heart faiiure and requiring increasing oral doses of Lasix. He was admitted to the ICU where a Swan- Ganz central line placement was performed without complications for closer monitoring of his cardiac output parameters. This line was later removed on 1/1/04. He remained in the ICU on dopamine support and close monitoring. The cardiology attending noted on 1/ 3/ 94 that the patient was exhausted and very depressed. The plan at this time was to proceed with a piggyback transplant as soon as the opportunity is available. On 1/11/94, Patient 0524725 was able to be transferred to the telemetry ?oor with stable vital signs and parameters, but still receiving intensive diuresis. Following his return to the telemetry unit, he became febrile on 1/13/94 with a sore throat and was started on antibiotics. Blood and throat cultures were obtained, but later reported as negative. On 1/18/94, the patient began having increased episodes of SVT with a heart rate of 140 bpm. His potassium was noted to still be decreased so additional potassium was administered. His BUN level was noted to be increased necessitating a reduction in his Lasix administration. ,His course over the next few weeks was complicated by ?uctuating potassium and magnesium levels and another stay in the ICU at which time he was restricted to bed rest in the unit and only chair three times a day. After transfer back to the telemetry unit on 2/2/94, Patient 0524725 was referred for recreational therapy and encouraged to continue to lose weight and stop smoking. His cardiology attending noted on 2/16/94 that a way needed to be found to support the patient?s failing circulation and that the team may need to discuss an arti?cial heart device if a transplant could not be found for him. On 2/20/94, he was discharged for close outpatient follow up" until a donor could be located. He was continued on a maximum medical regimen while living in an apartment close to the hospital. On 4/22/94, Patient 0524725 was admitted directly to the ICU with shortness of breath and decreased urine output. He was started on dopamine, dobutamine, oxygen and placement of a Swan-Ganz catheter. Over the next month, he was transferred between ICU and telemetry units as his condition stabilized and deteriorated. On 5/24/94, a donor heart was located and the patient received an orthotopic heart transplant by Dr. O.H. Frazier. Following his heart transplant, the patient required prolonged inotropic support and had numerous episodes of hypotension and elevated temperature. He went into acute renal failure and hemodialysis was initiated. He was given several units of packed red blood cells, fresh frozen plasma and pheresis platelets, but by 5/27/94 his cardiology attending noted he looked better and was awake and alert. On 6/ 1/94, a heart biopsy was performed indicating a Grade 4 THI classi?cation and extensive myocardial ischemia. He was ?nally able to be extubated on this date to face mask oxygen. He began having frequent premature ventricular beats and short runs of ventricular tachycardia on 6/3/94 for which he was restarted on potassium replacement. On this date he was again febrile and his cardiologist expressed a concern about fungal sepsis and ordered a CMV culture. A second heart biOpsy was performed on 6/6/94 revealing a THI Grade 6 classi?cation with focal ischemia, interstitial edema and subendocardial in?ltrates of mononuclear cells. After transfer back to the telemetry unit on 6/9/94, he was noted to continue to make progress. A heart biopsy on 6/ 10/94 revealed a Grade II THI classi?cation. He was maintained on Vancomycin and Acyclovir. The patient developed a decubitus ulcer on his buttock and a skin care consult was requested. This area was incised and drained on 6/20/94, 6/21/94 and 6/24/94 by plastic surgery. By 6/25/94, the patient was allowed to ambulate in the hallway with a mask. He continued to improve but on 7/4/94, the patient began experiencing complete heart block episodes and periods of bradycardia. He was transferred back to the ICU and a temporary pacemaker was placed, but it did not function properly and was later removed. By 7/ 6/ 94, the patient was stable and returned to the cath lab for heart biopsy and then returned to the telemetry unit. Teaching on self?medication of immunosuppressive therapy medications to Patient 0524725 was begun on 7/6/94. A permanent pacemaker was placed by Dr. Benrey on 7/8/94 and the patient was discharged on 7/14/94. Patient 0524725 underwent heart catheterizations with heart biopsies on numerous occasions throughout the rest of 1994 with a ?nal biopsy score of 5Q. Patient 1 108146 Patient 1108146 was first diagnosed with cardiomyopathy by her cardiologist on 5/2/88 and was followed as an out-patient. She was then admitted to St. Luke?s telemetry unit on 12/11/90 following a heart catheterization secondary to the presence of a gallop and her serious cardiac condition which included an ejection fraction of 21%. During this admission she was referred for a cardiac transplant and began pre?transplant work up. On 6/ 19/91, the patient was admitted through the Emergency Center complaining of shortness of breath, nausea and diaphoresis that was believed to be secondary to a viral and hypokalemia. She was discharged home on medications by her cardiologist. Echocardiography performed on 7/2/91 disclosed a dilated left atrium, severe left ventricular enlargement, global hypokinesis of the left ventricle, and severely decreased left ventricular ejection fraction less than 20%. Patient 1108146 was admitted on 8/ 1 6/ 91 with worsening congestive heart failure manifested by a ten pound weight gain, shortness of breath and abdominal bloating. She was started on bed rest and diuresis, but over the next 48 hours developed bundle branch block. She was then taken to the EPS lab where it was determined she had an AV interval of 50 milliseconds, which was considered normal, thus a pacemaker was not required. A Swan-Ganz catheter was also inserted at the same time in the cath lab. She remained in the hospital until 8/31/91 at which time she was followed as an outpatient pending location of a donor heart. The patient was admitted on 9/ 13/91 to 9/21/91 with worsening right sided heart failure. She was treated with bed rest, diuretics, and oxygen therapy until her condition stabilized and she could be discharged to home. She was again admitted to the ICU on 12/27/91 to 1/9/92 for increased of congestive heart failure that were not responding to her home diuretics and an increasing BUN. She was started on IV dobutamine and dopamine and a Groshong catheter was inserted. She was able to be transferred to the telemetry ?oor on 12/30/91 with Dobutamine stopped on 1/3/92 and dopamine stopped on 1/7/07. The patient was taught to care for her home IV Groshong catheter and discharged home to be followed by home health nurses. On 2/9/92, Patient 1108146 was admitted through the ER. to the ICU with a high fever and malaise. She had previously complained of pain and swelling at the Groshong catheter site and was treated with antibiotics. She was started on antibiotics and seen by the Infectious Diseases Service. Blood cultures from the Groshong and left peripheral IV site grew gram positive cocci and she was started on IV Vancomycin. The left Groshong catheter was removed on 2/ 10/92 and a right subclavian triple catheter was placed. She was able to be transferred to the telemetry ?oor on 2/ 12/92. She received IV dopamine through 2/13/92 and IV Vancornycin through 2/17/92. On 2/18/92, she was taken to the OR. and another Groshong catheter was placed. She was ?nally able to be discharged on 2/21/92. - The patient required an admission from 3/with increasing pleuritic chest pain. A pulmonary embolus was ruled out by lung scan. Her chest pain had resolved on 3/8/92, but she became febrile on 3/ 1 1/92. Blood cultures were again positive for gram positive organisms. Vancomycin was restarted and continued via home health after her discharge on 3/18/92. This patient was admitted to telemetry on 4/ 12/92 with suspicion of line sepsis and started on IV antibiotics, which were continued for 10 days. She responded well to antibiotics and a new Groshong catheter was placed on 4/22/02 in the right subclavian area. She was discharged home on 4/24/92. The patient was returned to St. Luke?s on 4/26/92 when a donor heart became available. She underwent an orthotopic heart transplant by Dr. Frazier on 4/26/92. Her course immediately following the transplant was stable and she was able to be extubated on 4/27/92. She remained dependent on the pacer and a cardiac biopsy on 5/4/92 was consistent with acute rejection (Grade 9). She was begun on numerous anti?rejection medications per protocol including Solu?Medrol, OKT-3 and Cytoxan, to which she responded by 5/5/92. She remained in the ICU through 5/ 19/92 on the anti-rejection protocol. On 5/ 19/92, the patient was noted to be doing well, off Isuprel, with no signs of congestive heart failure and she was then transferred to the telemetry unit (where she remained until her discharge on 6/20/92). A repeat biopsy on 5/28/92 revealed a Grade 9 score and she was given a bolus of steroids. On 6/2/ 92, the patient underwent total irradiation at MD. Anderson Hospital. She had some of gastritis following this procedure and after endoscopy was found to have esophageal spasms, hiatus hernia, a large gastric bezoar, and multiple gastric ulcers, suspected viral in origin and later found to be CMV in origin. A repeat heart biopsy on 6/4/92 returned with a Grade 5 THI classification. On 6/10/92 the patient reported she was now feeling ?like a human being.? She was scheduled for additional radiation treatments the following day and a follow up heart biopsy. The biopsy on 6/ 1 1/92 revealed an improving Grade 4 THI classi?cation. By 6/20/92, the patient was able to be discharged. Unfortunately, on 6/25/ 92 the patient returned with heart rejection, grade 7. She was treated with Solu?Medrol, and resumed her oral Cyclosporine therapy as well as Prednisone. Her lab work remained within normal limits except for a decreased WBC felt to be secondary to her radiation treatments at MD. Anderson. She was discharged on 7/2/ 92 on cyclosporine, prednisone, Procardia XL, Reglan, Levothroid, Carafate and Insulin. For the remainder of 1992 and 1993, Patient 1108146 underwent numerous heart biopsies and admissions related to heart rejection chronic cholecystitis requiring surgery on 9/11/92. On 10/20/93, the patient was admitted with a high fever to St. Luke?s to rule out rejection. Numerous labs and procedures were performed with a ?nal diagnosis of probable viral infection. A right heart biopsy came back with a Grade 5 classi?cation and she was discharged on 10/24/93. She was again admitted with a fever of unknown origin on 11/11/93 through 11/15/93. The patient was found to have positive blood and urine cultures and started on antibiotics. During 1994, the patient had one heart biopsy on 4/27/94 that returned a Grade 4. She was next admitted to St. Luke?s on 3/11/95 with hypertension, renal dysfunction and She was noted to have done very well since last follow up visit 11 months previously at which time she was 2 years post transplant. She was initially admitted to the telemetry floor but transferred to ICU on 3/ 12/95 secondary to increased She was taken to the oath lab for endomyocardial biopsy but went into complete heart block requiring a temporary pacemaker. She continued to require the temporary pacemaker and a decision was made to place a permanent pacemaker. The biopsy returned with a Grade 6 rejection and the patient was started on Solu-Medrol. A repeat biopsy on 3/ 17/95 had improved to Grade 4. A permanent pacemaker was also placed on 3/ 1 7/95. She was kept in the hospital for an additional few days for observation and management of her medications and discharged on 3/21/95. The patient had three additional admissions to St. Lukes (3/24/95 to 3/29/95, 5/13/95 to 5/22/95, and 6/5/95 to 6/ 17/95) for cardiac related problems. At each admission, she was able to be stabilized and discharged to home. On 9/10/95, the patient returned to the hospital reporting increasing fatigue, weight gain and shortness of breath. She was admitted and was to be started on Medrol and dopamine. Around 11 pm. on 9/ 10, the patient complained of dif?culty breathing and lost consciousness. She was noted to be without pulse or pressure although her pacemaker continued to ?re. A code was begun and the patient was bagged, then intubated. She received several rounds of ACLS drugs but never regained pulses. An intra-aortic balloon pump was inserted and additional medications administered but no pulses were found after 40 minutes and the code was then terminated. Patient 1300735 Patient 1300735 was first admitted to St. Luke?s Hospital on 2/22/94 upon transfer from another hospital for consideration of heart transplantation. His history included recurrent angina treated with nitroglycerin, history of coronary artery bypass, and recent onset of chest pain not relieved with medication. Echocardiogram on 2/24/94 revealed left ventricular enlargement and ejection fraction less than 20%. Following one day in the ICU, he was transferred to telemetry where he was followed through 3/4/94 and stabilized. It does not appear he was on the transplant waiting list at that time, although his transplant work up was initiated and in process. This patient was admitted to St. Luke?s on 8/ 13/94 with complaints of progressive chest discomfort over the past several days. He is now noted to be on the heart transplant waiting list. He was admitted to the ICU while serial cardiac enzymes were drawn and treatment with nitrates and Coumadin were continued. Cardiac enzymes showed no evidence of myocardial infarction and he was subsequently noted to be free of chest pain. He was transferred to the telemetry unit on 8/ 14/94 and then discharged on 8/16/94 to continue waiting for a suitable heart donor. On 10/11/94, Patient 1300735 was admitted to St. Luke?s telemetry unit for stabilization of persistent angina and medical management. During the initial portion of this admission, he apparently had exacerbations of angina as well as signs of congestive heart failure for which he was transferred to the ICU for close monitoring and treatment, although he continued to be difficult to stabilize. On 11/8/94, a Groshong catheter was placed for a medical regimen that would allow him to be discharged until a suitable donor could be located. On 11/18/94 the patient had another prolonged episode of angina lasting 45 minutes and he was again transferred to the ICU for close observation. Serial cardiac enzymes showed evidence of submyocardial damage. Intra?aortic pump support was begun after his condition deteriorated on 11/3 0/94. He was continued on dopamine and dobutamine for pressor support. On 12/22/94, a suitable donor heart was found and an orthotopic heart transplant was performed by Dr. O.H. Frazier. Following the transplant, the patient was monitored in the ICU for another week for signs of rejection and for a concern of acute renal failure for which hemodialysis was initiated. Patient 1300735 was seen in consultation by the renal service and hepatology service for his decreased renal function and abnormal liver function levels. On 1/4/95, a permanent pacemaker was inserted and the patient was transferred from ICU to the telemetry ?oor. By 1/11/94, he was stable for discharge and outpatient follow up. Patient 1300735 underwent multiple heart biopsies between 1/24/95 and 1/23/97 and was stable with no activity limitations or rejection. Patient 1251716 According to Patient 1251716?s 3/12/93 to 3/23/93 discharge summary from St. Luke?s Episcopal Hospital and earlier evaluations at St. Luke?s, his medical history included diabetes mellitus, coronary artery disease status post aortocoronary bypass, and history of past congestive heart failure and was end-stage heart disease with cardiomyopathy and congestive heart failure. He was admitted to the telemetry unit and renal dopamine was begun. While on telemetry, he had episodes of non-sustained ventricular tachycardia for which amiodarone was begun. Echocardiography on 3/12/93 reported a severely decreased left ventricular ejection fraction of less than 12%. With treatment, his congestive heart failure improved and were brought under control. It does not appear that Patient 1251716 was on the heart transplant list at this time. On 4/17/93, Patient 1251716 was readmitted to St. Luke?s Hospital with exacerbation of his chronic weakness from his end stage dilated cardiomyopathy. He was noted to have been walking a mile every day but unable to do so for the past few days. He was admitted to the telemetry unit and placed on IV dopamine for pressor support. During this admission, and physical medicine consultations were performed that revealed he was mildly despondent over his physical condition and insurance dif?culties, but that he was not clinically depressed. Occupational and physical therapy were recommended to increase his endurance and strength. After these evaluations as well as a neurology consultation, it was felt that cardiac transplant was not contraindicated. It was noted on discharge that he was awaiting insurance clearance to be placed on the active list for heart transplant. Patient 1251716 was admitted from 5/6/93 to 5/ 10/93 with increased weakness, productive cough and purulent drainage from a nose lesion. It was noted in the records that he was now on the cardiac transplant waiting list at that time. He was admitted to telemetry and treated for atrial ?brillation and left lower lobe pneumonia, although all cultures were negative. Following observation and treatment, his vital signs were stable and chest x?ray showed resolution of the left lower atelectasis. There were four additional admissions to St. Luke?s Hospital in 1993 on 9/8/93, 9/26/93, 10/18/93 and 12/3/93, all for exacerbation of his cardiac complaints. The patient was treated and stabilized during each admission and discharged in satisfactory condition. Patient 1251716 did undergo another consultation on 9/ 9/ 93 for altered mental status. It was reported that MRI did not show any micro-infarcts and that his mental status changes could possibly be related to decreased sodium, anxiety over his medical condition, and signi?cant sleep apnea. He remained on the transplant waiting list for a suitable donor. This patient had an extended hospitalization from 12/3/93 to 1/ 6/ 94 after a transfer from Methodist Hospital in Lubbock. Apparently the patient was evaluated for a heart transplant at that facility but he was told that his right heart pressures were too high at that time for consideration of transplantation in Lubbock. He was also found to have a positive blood culture for staphylococcus. Upon transfer to St. Luke?s telemetry unit, he was treated with Dobutrex, dopamine, and antibiotics. He had intermittent episodes of atrial ?brillation with a controlled ventricular response. He was felt to have an organic type of dementia during this admission, but his cardiac condition continued to stabilize. At discharge, it was felt that he required further rehabilitation and was thus transferred to an outside facility in Bryan, Texas for rehab. Patient 1251716 was next admitted to St. Luke?s on 10/17/94 from a nursing home with functional class IV congestive heart failure. He was reportedly unable to perform activities of daily living secondary to increasing for the past three weeks. His admission EKG showed atrial ?brillation, left bundle branch block. and right axis deviation. He was admitted to the ICU for treatment with IV Lasix, dopamine and dobutamine. He remained in the ICU until 10/22/ 94 when he was able to be transferred to an IMC. Chest x-rays showed pulmonary nodules. A pulmonary evaluation and testing revealed abnormal pulmonary function tests but the patient was considered a high surgical risk for a recommended lung biopsy. Repeat CT of the chest showed resolution of the right upper lobe nodule. After an extended hospitalization, his cardiovascular status was felt to be stable and he was transferred back to a skilled nursing facility. Progress notes and nursing notes during this admission indicate that he remained on the transplant list at that time presumably because of his stable cardiac status, but no - available donor. Patient 1251716 had several additional admissions in 1995; one on 3/5/95 for acute cholecystitis, on 4/20/95 for acute congestive heart failure; and a final admission on 6/8/95 to 8/11/95 for congestive heart failure with progressive and edema. It was during this hospitalization that the patient was apparently informed that based on worsening pulmonary vascular resistance, he was no longer a suitable candidate for orthotopic heart transplantation. Because of the patient?s inability to accept that decision, he was transferred to another facility for further care. Patient 1153455 This patient was initially referred to the transplant program on 10/2/ 89 based on a diagnosis of idiopathic cardiomyopathy. During his initial admission on 10/2/89, he spent four days in the ICU secondary to the instability of his cardiac condition and to monitor his cardiac status following cardiac catheterization. He was found to have a left ventricular ejection fraction of only 15%,during this admission. On 3/19/90, Patient 1153455 was re~admitted to the ICU by his cardiologist in congestive heart failure requiring numerous medications to stabilize his cardiac He was able to be discharged after one day to continue his out-patient medications and treatment. On 6/30/91 through 7/2/91, Patient 1153455 was admitted for increased ventricular His left ejection fraction was estimated to be 10-15% with 1+ mitral regurgitation. He spent two days in the IMC to bring the under control by medication and until he was free of further episodes of malignant ventricular and able to be discharged home. Patient 1153455 was hospitalized from 8/5/91 to 8/10/91 for increased of orthostatic hypotension, increased shortness of breath and cardiac secondary to his end-stage cardiac disease related to idiopathic cardiomyopathy. He required dobutamine and dopamine infusions as well as numerous other medications to sustain his blood pressure and perfusion during his ?ve days in the IMC. On 4/15/92, Patient 1153455 was admitted for a heterotopic heart transplant that was performed by Dr. O.H. Frazier on 4/16/92. During this admission, Patient 1153455 required seven days of ICU following his heart transplant to provide the necessary degree of surveillance following a heart transplant and to provide the necessary treatments to prevent rejection. Over the next two years, this patient received additional heart biopsies and other procedures including removal of his implanted cardioverter-de?brillator and a I cholecystectomy in 1993. On 10/ 9/ 94, he was admitted by his cardiologist with advanced right heart failure, hepatic congestion, renal insufficiency and thrombocytopenia. He was admitted to the ICU overnight on 10/17/94 after it was noted that his hands and feet were often cyanotic. He was started on a dopamine infusion and immunosuppressor drugs. After his return to the telemetry unit, intermittent dopamine was attempted, although his native heart continued to fail. On 11/9/94, Patient 1153455 required a second (orthotopic) cardiac transplantation by Dr. Frazier. During this 45 day admission, the patient required a total of approximately 7 days in ICU, 6 of which were following the heart transplant. Patient 1153455 had follow up hospitalizations on 12/14/94, 1/31/95, 4/ 19/95, 8/15/95, 10/4/95, 4/2/96 and 4/ 12/96 for treatment of of heart rejection, subsequent heart biopsies, and a left popliteal thrombectomy. 5. Statement of Opinions Review of each of these patient records shows that all of these patients were extremely sick with complex and life threatening problems requiring treatment input from multiple physicians and multiple sources. Review of each of these patient records shows that all admissions to the hospital were appropriate and medically necessary. Review of each of these patient records shows that all ICU admissions were appropriate and medically necessary. Review of each of these patient records shows that all were legitimate heart transplant candidates without other reasonable options for survival or quality of life. Review of each of these patient medical records shows that when done, the heart transplants were done in a normal and appropriate fashion. Review of each of these patients? records and the depositions shows that 0. Howard Frazier, M.D. acted as the transplanting surgeon and that Branislav Radovancevic, M.D. acted as an ancillary, non medical member of the transplant team. Heart transplantation is a complex undertaking and is carried out in all centers that I am aware of by multidisciplinary teams. Because of the complexity of the care necessary to serve these critically ill patients, members with various areas of expertise typically round on and provide input advice on the care of the patients. Our transplant team, like others, consists of physicians, nurses, coordinators, pharmacists, dieticians, social workers and consultants of various types such as immunologic experts like Dr. Radovancevic. These ancillary personnel routinely provide advice and suggestions to the physician leader of the team. In all instances, Dr. Radovancevic is seen providing this supporting role to the bene?t of these patients. Dr. Frazier in all instances is seen . providing the surgical care rendered to the bene?t of these patients. There is nothing in these records that suggests any thing out side of the normal operation of a multidisciplinary team providing complex and necessary care to these heart transplant patients. Michael J. Reardon, MD. Professor and Chief of Cardiac Surgery The Methodist DeBakey Heart and Vascular Center