0001
    1        IN THE CIRCUIT COURT OF MONTGOMERY COUNTY
    2             IN AND FOR THE STATE OF MARYLAND
    3   --------------------------------x
                                        :
    4   MARY K. MANOOGIAN, et al.
                                        :
    5                      Plaintiffs   :
                                        :
    6             v.                    : CASE NO. 263814
                                        :
    7   JAMES L. COCKRELL, M.D.,        :
                                        :
    8   et al.                          :
                                        :
    9                      Defendants   :
                                        :
   10   --------------------------------x
   11         DEPOSITION OF JOHN M. MILLER, M.D., FACC
   12                  Indianapolis, Indiana
   13                 Wednesday, July 19, 2006
   14                        2:13 p.m.
   15   Job No:  24-82606
   16   Pages 1 - 129
   17   Reported by:  Victoria S. Stuart, RPR
   18   
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                                                               0002
    1            Deposition of JOHN M. MILLER, M.D., held at
    2   the offices of:
    3   
    4            INDIANA UNIVERSITY SCHOOL OF MEDICINE
    5            KRANNERT INSTITUTE OF CARDIOLOGY
    6            1801 North Senate Boulevard
    7            Indianapolis, Indiana  46202-1228
    8            (317)962-0500
    9   
   10   
   11            Pursuant to notice, before Victoria S.
          Stuart, Registered Professional Reporter and
   12     Notary Public of the State of Indiana.
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                                                               0003
    1                  A P P E A R A N C E S
    2   
    3   ON BEHALF OF THE PLAINTIFFS:
    4            SCOTT PERRY, ESQUIRE
    5            BRUCE J. KLORES & ASSOCIATES, P.C.
    6            1735 20th Street, Northwest
    7            Washington, D.C.  20009
    8            (202)628-8100
    9            
   10   
   11   
   12   ON BEHALF OF DEFENDANTS COCKRELL, LEE AND
   13   CARDIOVASCULAR CONSULTANTS, PA:
   14            MARIANNE D. PLANT, ESQUIRE
   15            GOODELL, DEVRIES, LEECH & DANN, LLP
   16            One South Street, 20th Floor
   17            Baltimore, MD  21202
   18            (410)783-4000
   19           
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                                                               0004
    1   A P P E A R A N C E S   C O N T I N U E D
    2   ON BEHALF OF DEFENDANT WASHINGTON ADVENTIST
    3   HOSPITAL: (Telephonically)
    4            SUSAN B. BOYCE, ESQUIRE
    5            ARMSTRONG, DONOHUE, CEPPOS & VAUGHAN
    6            204 Monroe Street
    7            Suite 101
    8            Rockville, MD  20850
    9            (301)251-0440
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                                                               0005
    1                     C O N T E N T S
    2   EXAMINATION OF JOHN M. MILLER, M.D.
            By Ms. Plant                 6
    3       By Ms. Boyce               113
            By Ms. Plant               114
    4   
    5   
    6   
    7                     E X H I B I T S
    8   
    9               (Attached to the Transcript)
   10   
        MILLER DEPOSITION EXHIBIT              PAGE
   11   
          1    Dr. Miller's handwritten notes     7
   12     2    Certificate of Merit              69
          3    "Atrioventricular Groove From
   13            Above" Netter diagram           77
          4    "Atrial Septal Puncture Sites"    77
   14            Netter diagram
   15       QUESTIONS WITNESS INSTRUCTED NOT TO ANSWER
   16                 Page 70 line 9
                      Page 70, line 23
   17   
   18   
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   20   
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   25   
                                                               0006
    1                JOHN M. MILLER, M.D. FACC,
    2   having been duly sworn to tell the truth, the whole
    3   truth, and nothing but the truth relating to said
    4   matter was examined and testified as follows:
    5   
    6   DIRECT EXAMINATION,
    7      QUESTIONS BY MS. MARIANNE D. PLANT:
    8   Q   Good afternoon, Dr. Miller.  My name is Marianne
    9       Plant.  We had an opportunity to meet already
   10       off the record.  I represent Dr. Cockrell,
   11       Dr. Lee, and Cardiovascular Consultants in this
   12       case that was brought by the estate of
   13       Mr. Manoogian.  I understand that you're going
   14       to be testifying in this case on standard of
   15       care issues?
   16   A   Yes, ma'am.
   17   Q   Are you also going to be testifying on causation
   18       issues?
   19   A   I believe so.
   20   Q   Have you given a deposition before?
   21   A   Yes, ma'am.
   22   Q   Just go over what you probably already know as
   23       ground rules.  If I ask a question and it is
   24       unclear for any reason, you don't understand
   25       what I'm asking, feel free to ask me to rephrase
                                                               0007
    1       it, and I will.
    2            If you need to take a break at any time,
    3       let me know.  If you do answer a question that
    4       I've asked, I'll presume that you have
    5       understood my question; is that fair?
    6   A   Fair enough.
    7   Q   Okay.  Let's see, what other ground rules do we
    8       have?  We need to try and not speak over one
    9       another.  And I think that will probably be
   10       reasonably easy to do, if you let me finish my
   11       question and I'll let you finish your answer;
   12       okay?
   13   A   Yes.
   14   Q   Great.  I have -- the first thing I want to make
   15       as an exhibit is notes that you took.
   16   A   Yes, ma'am.
   17   Q   Is that what you did?
   18            MS. PLANT:  Let's mark that Exhibit 1.
   19            (Defendants' Deposition Exhibit No. 1
   20       marked for identification.)
   21   Q   So what I've been provided before we started the
   22       deposition today is this Exhibit 1, which is a
   23       page of your notes.  I've also been provided two
   24       Netter diagrams with some markings on them?
   25   A   Yes, ma'am.
                                                               0008
    1   Q   Did you create those?
    2   A   Well, they're adapted from Netter --
    3   Q   Right.
    4   A   -- but the labels and so forth are mine, yes.
    5   Q   There's also a number of articles, are these --
    6       some of them appear to be book chapters?
    7   A   Yes.  Some are original manuscripts from the
    8       medical literature.
    9   Q   Okay.  And then I have a new CV that is June 15,
   10       2006?
   11   A   Yes, relatively new, yes.
   12   Q   Is there anything else that you have that is
   13       responsive to the deposition notice that was
   14       sent, any other notes or correspondence that you
   15       have had in this case?
   16   A   I don't believe so.
   17   Q   Okay.  Did you ever, apart from a certificate of
   18       merit, did you ever write down your opinions in
   19       this case, apart from Exhibit 1?
   20   A   No, ma'am.
   21   Q   Can I impose on you to read Exhibit 1 for us?
   22   A   You may.  You may.  Now, some of this is in a
   23       little bit of shorthand, so I'll give you the
   24       longhand version of it.
   25   Q   Sure.
                                                               0009
    1   A   These are just kind of bullet points.  So it
    2       starts off with, aortic perforation site
    3       difficult to see at sternotomy, unless the right
    4       atrial appendage is peeled back -- and I'm
    5       interpolating here a little bit --
    6       intentionally.
    7            So right atrial appendage peeled back
    8       intentionally, and inspect back there; by then,
    9       by that time, during his procedure, the aortic
   10       pressure was very, very low, therefore less
   11       leakage, and because of volume depletion, in
   12       parens, volume depletion in parenthesis.
   13            Second point, question mark, disseminated
   14       intravascular coagulation, or continued ICU
   15       bleeding, question mark, due to heparin for
   16       attempted cardiopulmonary bypass, question mark,
   17       parenthesis, although clotted venous line at
   18       attempt in the laboratory, close parenthesis.
   19            Next point, question mark, Dr. Lee
   20       inadvertently dislodged the second sheath from
   21       plugging its own hole in the aorta, leading to
   22       the start of bleeding.
   23            And another point, the mapping catheter
   24       really -- question, was the mapping catheter
   25       really ever placed in the second sheath.
                                                               0010
    1            And a subpoint from that, it clearly was in
    2       the aorta.  In order to record left atrial
    3       activity, it would have to exit the aorta, and
    4       probably enter the left atrium, but there was no
    5       reentry hole at post mortem.  And I'm
    6       embellishing this just a little bit, for sense.
    7   Q   I understand.  You're providing us not just the
    8       shorthand, but what you meant by it?
    9   A   Yes.
   10   Q   That's fine.
   11   A   This is a second subpoint after that clearly was
   12       in the aorta.  The tear in the aorta goes
   13       through the intima, I-N-T-I-M-A, not just the
   14       adventitial media, adventitial/media.
   15            Another subpoint here:  Cannot reconcile
   16       autopsy findings with recording of left atrial
   17       electrograms, therefore not done.
   18            Another bullet point, this is the fourth
   19       one underneath here.  And anyway, left atrial
   20       electrograms are a nonspecific indicator of,
   21       quote, good position, close quote.  They can be
   22       from inside of the left atrial cavity or outside
   23       the left atrium, parenthesis, over the dome, et
   24       cetera, close parenthesis.
   25            And then indent back out.  So pulled map
                                                               0011
    1       catheter out of the second sheath to put back
    2       into the first.  Why would someone do that.
    3            Another point, pressure can be misleading.
    4       This is kind of an allusion to something in
    5       Dr. Cockrell's deposition, looks like page 163,
    6       line 18, to 164, line 4.  I think that's what it
    7       means.
    8            And the last point, the tip lodged in aorta
    9       or trapped in the septum can't have a catheter
   10       through it to record left atrium bend, as far as
   11       electrograms.  This is, again, from
   12       Dr. Cockrell's deposition, page 168, I think
   13       lines 7 through 15.  And that's it.
   14   Q   Okay.  Thank you very much.
   15   A   Uh-huh.
   16   Q   So we've got this marked already.
   17            But to, you know, instead of going straight
   18       into the issues, what I want to do before we do
   19       that is just make sure we do housekeeping first.
   20            We have got your CV.  Is there anything
   21       that is not reflected in your CV, as far as
   22       publications, society memberships, or
   23       presentations that would have anything to do
   24       with ablation for atrial fibrillation?
   25   A   I've given many, many lectures, just in-house,
                                                               0012
    1       that don't appear on there, but --
    2   Q   Okay.
    3   A   -- otherwise, no.
    4   Q   Have you published at all on the technical issue
    5       of transseptal placement?
    6   A   Not as a central issue.  That is not the central
    7       point of a publication.
    8   Q   Okay.  In some of your publications or any of
    9       your publications, has it been an ancillary
   10       issue?
   11   A   Yes.
   12   Q   And in those, you discuss techniques?
   13   A   Not in depth.
   14   Q   Okay.  Do you know which of your publications
   15       might involve transseptal placement as an
   16       ancillary issue?
   17   A   Let me look.  Page 20:  Publications 32 and 33,
   18       39, 41, 44.
   19            54, page 21, 56.
   20            61 on page 22.
   21            I have to go back.  Back on page 10, number
   22       69.  I'm jumping around a little bit here.  I'm
   23       sorry.
   24   Q   Okay.
   25   A   There are probably a couple of others in here,
                                                               0013
    1       but those are the main ones.
    2   Q   Okay.  When did you first, in your career, start
    3       to perform ablations for atrial fibrillation?
    4   A   My first one, I think, in 1997, maybe '96, '97.
    5   Q   And where was that?
    6   A   Temple University School of Medicine.
    7   Q   Who taught you how to do an ablation for atrial
    8       fibrillation?
    9   A   Well, it's been an evolving process.  The
   10       techniques we used back then are not the
   11       techniques we use most of the time nowadays, and
   12       so the techniques that we have established over
   13       the years in building slight modifications along
   14       the way, and so I don't know that I could say
   15       who taught me to do it.
   16   Q   Do you remember working with any -- well, let me
   17       ask it this way.
   18            Were you an attending cardiologist at the
   19       time when you did your first ablation for atrial
   20       fibrillation?
   21   A   Yes, ma'am.
   22   Q   Did you first do the procedure as scrubbing in,
   23       but not doing the procedure, i.e., watching the
   24       procedure once?
   25   A   No.  Just did it.  Now, I should, by way of
                                                               0014
    1       explanation, in those days, we were looking for
    2       a single source, a single focus that was leading
    3       to fibrillation, eventually, we would do with
    4       other types of arrhythmias, then as now.  And in
    5       those days, that's what we were searching for.
    6       I found some in a handful of cases, and ablated
    7       those accordingly.
    8   Q   Do you recall who taught you how to place a
    9       catheter that would terminate in the heart and
   10       perform an ablation?
   11   A   Oh, yes, Mark Josephson.
   12   Q   Okay.  And I take it that the earlier ablations,
   13       the ones that you would have been doing in '96
   14       or '97 were not ablations that would require a
   15       transseptal puncture?
   16   A   That's correct.
   17   Q   Okay.  Do you recall when you first did a
   18       transseptal puncture?
   19   A   I think 1992 or -3, -3 at the latest.
   20   Q   And who was your teacher in learning that
   21       technique?
   22   A   One of our catheterization doctors, William G.
   23       Combs, C-O-M-B-S.
   24   Q   Do you recall what the technique was that you
   25       were taught?
                                                               0015
    1   A   As far as the actual mechanics of it?
    2   Q   Yes.
    3   A   Yes, yes.  Very much so.
    4   Q   Okay.  Can you tell me what you recall about the
    5       technique that you were taught by Dr. Combs?
    6   A   In what detail do you want?
    7   Q   Physically, what do you do to place the
    8       catheter?
    9   A   Okay.  Well, we will start a little bit further
   10       back than that.  One has to get some landmarks
   11       within the heart.  There are a couple of ways of
   12       doing that.  One is to have a catheter in the
   13       aortic root, to avoid puncturing the aorta
   14       inadvertently.  Another is to have a catheter
   15       recording the His bundle electrogram, because
   16       that is right across the aortic wall from the
   17       non-coronary cusp of the aortic root.  Either of
   18       those will suffice.
   19            In those days, we used a catheter in the
   20       aorta, a pressure catheter we had to flush every
   21       few minutes to make sure clots didn't form on it
   22       so we could see it fluoroscopically.  Setting up
   23       the fluoroscopic views, you need a couple of
   24       different angulations.  That's the way I was
   25       taught, and that's the way many people do it.
                                                               0016
    1       And then sliding a long, stainless steel
    2       guidewire with a curve on the end of it, a J
    3       curve, that's about maybe four millimeters in
    4       diameter across it, up the -- from the right
    5       femoral vein is the way I do it, up to the
    6       superior vena cava, right on past -- in the
    7       cavity of the right atrium, right on past it, up
    8       into the superior vena cava, and then sliding
    9       the transseptal dilator and sheath assembly --
   10       those are two concentric plastic tubes -- from
   11       the femoral vein, over that wire, all of the way
   12       up to the superior vena cava.
   13            And then that wire is pulled back, and you
   14       have two plastic tubes in the superior vena
   15       cava.  Then the Brockenbrough needle, a hollow,
   16       stainless steel needle with a stopcock on the
   17       end of it, is attached to a pressure monitor,
   18       and it's balanced and calibrated, so we jiggle
   19       it to make sure we are recording pressure from
   20       it.  And flushing on the way in to make sure
   21       there is no air in the tubing, and no air in the
   22       plastic catheter, all of the way up to within
   23       about a centimeter from the end of the plastic
   24       tube.  That's inspected, both fluoroscopically,
   25       as well as having measured beforehand, and I'll
                                                               0017
    1       go ahead and insert it outside of the body and
    2       say, okay, when the hub is within a centimeter
    3       of the end of the catheter, the butt end or the
    4       proximal end of the catheter, then I know I'm a
    5       centimeter from the tip of the sheath.
    6            And then, in a couple of different
    7       fluoroscopic views, these are all orthogonal
    8       so-called views, right anterior oblique and left
    9       anterior oblique.  Some will use just the
   10       anterior or posterior view.  I was taught, and I
   11       still maintained, in these oblique views, to get
   12       the septum in profile and then on fossa, so you
   13       can see exactly what you're doing.
   14            Gradually, pull down that assembly with it
   15       tipped a little bit over towards the septum.
   16       This is viewed, again, in both views to know
   17       that you're not too far forward, not too far
   18       back, not too high, and not too low.
   19            And then, in the left anterior,
   20       particularly in the left anterior oblique
   21       projection, the last small movement downwards,
   22       withdrawing the whole assembly.  Gradually it
   23       jumps over, falls over towards the left atrium.
   24       That is its engagement into the recess of the
   25       fossa ovalis.  And then I confirm, in both
                                                               0018
    1       views, fluoroscopic views that it is really
    2       where it is, and it has not moved since the last
    3       time I looked at it a few seconds ago.
    4            And then, when I'm confident that I'm in
    5       the right location, in the left anterior oblique
    6       view on fluoroscopy, I advance the needle and I
    7       look at the pressure tracing, and see the
    8       characteristic signature of the left atrial wave
    9       form.  I give a flush, sometimes, of the
   10       catheters to -- if there is any question, as to
   11       whether it is a dampened pressure wave form.
   12       You need a good wave form there.
   13            And then, holding the needle against the
   14       patient's thigh, just pressing down on it,
   15       sliding the plastic tube assembly over the
   16       needle and once on fluoroscopy, the dilator is
   17       about a centimeter and a half, two centimeters
   18       into the left atrium.  Again, still monitoring
   19       my pressure to make sure I haven't exited the
   20       left atrium somehow, having done that.
   21            Holding the inner dilator and the needle
   22       against the patient's thigh, and then sliding
   23       the plastic outer sheath over those, and again,
   24       monitoring left atrial pressure.  You should
   25       have a nice, smooth arc into the left atrium.
                                                               0019
    1            And then slowly withdrawing the needle and
    2       dilator, aspirate back to make sure I have no
    3       air in my side port and sheath that's now
    4       situated in the left atrium.  And if I do, in
    5       many procedures, we have just one catheter in
    6       the left atrium.  And then we're there; we have
    7       heparin immediately to make sure clots don't
    8       form on our catheters or the sheath or the areas
    9       where we do the ablations.
   10            If we had -- in those days, if we had this
   11       pigtail catheter in the aortic root, we would
   12       pull it out, it's no longer necessary, it was
   13       just a fluoroscopic landmark at that time.  And
   14       the His bundle catheter nowadays that we use
   15       stays there.
   16            If we are doing a second puncture, as I
   17       often do, most characteristically beside the
   18       first, I use exactly the same technique.  I know
   19       pretty much where to go, fluoroscopically,
   20       because I already have a sheath in there.
   21            Now, I typically will put a catheter
   22       through that first sheath, for a couple of
   23       reasons.  It stabilizes it.  I can get a
   24       catheter out a little bit further into the left
   25       atrium or into the one with the pulmonary veins,
                                                               0020
    1       such that if something should happen in the
    2       groin and I accidentally pull back that sheath,
    3       I don't lose the atrial access for the first
    4       one.
    5            It also prevents me from accidentally
    6       puncturing the sheath, that I just had in there,
    7       with my second needle.  I have never seen that
    8       happen.  I don't want to see that happen, so I
    9       have a safeguard against that.  And then, just
   10       use exactly the same technique for the second
   11       one as the first.  Pressure monitoring,
   12       fluoroscopic imaging in both views.  And it
   13       usually goes just like the first one does.
   14   Q   Is a procedure where you do two transseptals
   15       more difficult or twice as difficult as a
   16       procedure where you do one transseptal
   17       puncture --
   18   A   No.
   19   Q   -- apart from the fact that you're doing two of
   20       them?
   21   A   No, I don't think it is anymore difficult.  In
   22       some, it is different.  For instance, when I'm
   23       doing two, I have both of my sheaths already
   24       situated in the superior vena cava, such that
   25       once I get the first one into the left atrium, I
                                                               0021
    1       have as little time as -- the minimum amount of
    2       time between getting that first one in there and
    3       when I can give heparin safely.  I don't want to
    4       give heparin before.  Some people do.  I don't
    5       do that.  So I try to minimize the time that I
    6       have something in the left atrium, but not
    7       anticoagulated.
    8            So there is a little bit of time pressure
    9       with that, perhaps, but you've got to still do
   10       things properly, because there is nothing worse
   11       than rushing through something and making a
   12       mistake when it is not necessary.
   13            There, in a sense, it is a little bit
   14       easier, because that first sheath that's already
   15       across and stably situated is something of a
   16       landmark.  You might go a little bit behind
   17       that, a tiny bit in front of it, but no more
   18       than a couple of millimeters.
   19   Q   You have alluded to the fact that there is --
   20       that you use a slightly different technique now
   21       from the first technique that you were taught.
   22       I think you said that, at that point, you were
   23       using a pigtail catheter --
   24   A   Yes.
   25   Q   -- in the aorta, but now you would instead use a
                                                               0022
    1       catheter, an electrocatheter?
    2   A   Electrocatheter --
    3            THE WITNESS:  I'm sorry.
    4            MR. PERRY:  I'm just going to object to the
    5       characterization, but you can answer.
    6   A   The difference in technique is solely on how we
    7       note where the aorta position is.
    8   Q   Otherwise, it is the same procedure as how you
    9       first learned it?
   10   A   Yes.  I should say that back then, it was a
   11       single plane of fluoroscopy that we had to move
   12       the camera back and forth for different
   13       angulations.  Now, in one of my rooms, I have
   14       biplane, as was present in Mr. Manoogian's case,
   15       as well.
   16   Q   Okay.  Is there any variability in how -- in
   17       your technique, from one case to another?
   18   A   There can be.  For instance, would you like
   19       elaboration?
   20   Q   Yes, please.
   21   A   If I know that someone has a rather large right
   22       atrium, I sometimes will put an additional
   23       slight bend on the stainless steel needle, so it
   24       has a little bit better so-called reach; it is
   25       able to get over to the septum more easily.
                                                               0023
    1       Almost never is that necessary, even in
    2       relatively large atria.  I don't do that up
    3       front, only if it is nearly impossible to reach
    4       the septum, and then I just pull out and start
    5       over.
    6   Q   Do you know what point in time it was,
    7       approximately, that you switched from using the
    8       pigtail catheter to using an electrocatheter in
    9       the bundle of His?
   10   A   About 1997 or so.
   11   Q   Okay.  And what prompted the change?
   12   A   Well, the more stuff you have in the arterial
   13       circulation, the left heart and so forth, that
   14       needs to have attention, flushing and so forth,
   15       the less time you can spend on -- the less
   16       attention you can spend on the business at hand,
   17       of getting across the septum.
   18            So if we had difficulty coming down,
   19       engaging the fossa ovalis, time is still going
   20       by, and we have to stop and flush the pigtail.
   21       And I noticed that we had a His bundle catheter
   22       there all of the time, and it's marking -- they
   23       are always overlying each other.  What do I need
   24       the aortic catheter for?  So we dispensed with
   25       using that.
                                                               0024
    1   Q   Do you place an electrocatheter in the coronary
    2       sinus?
    3   A   I do.
    4   Q   Any other electrocatheters you place?
    5   A   For an atrial fibrillation case, no.
    6   Q   Okay.
    7   A   I should say, I do have a plastic tube now, not
    8       an electrocatheter, but a plastic tube in the
    9       femoral artery to monitor continuous blood
   10       pressure.
   11   Q   Okay.  I'm trying to be organized.
   12            I want to try and go through this in a
   13       little bit of an organized fashion.  The first
   14       thing I was hoping we could talk about, as far
   15       as background, is Mr. Manoogian's health.  Is
   16       that something that you're going to be rendering
   17       any opinions on?  Do you have any opinions on
   18       Mr. Manoogian's health prior to his treatment
   19       with Cardiovascular Consultants?
   20   A   My understanding was, he was working --
   21   Q   Okay.
   22   A   -- full-time, and a rather vigorous gentleman,
   23       but I don't know specifics of the type of
   24       activities.
   25   Q   What's your understanding of what, if any, heart
                                                               0025
    1       problems Mr. Manoogian had, prior to coming to
    2       see Cardiovascular Consultants?
    3   A   I know that he had atrial fibrillation, of
    4       course, and there was some mention of a mild
    5       dilated cardiomyopathy, mild diminution in left
    6       ventricular systolic performance --
    7            THE REPORTER:  I'm sorry?
    8   A   -- I'm sorry.  Mild diminution in the left
    9       ventricular systolic performance.
   10   Q   Did Mr. Manoogian have a low ejection fraction?
   11   A   That's what I'm -- that's the proper term, yes,
   12       it was slightly diminished.
   13   Q   What is a normal ejection fraction?
   14   A   Depends on the laboratory, but certainly
   15       anything over 50 or 55 percent, up to about
   16       70 percent is in the normal range.
   17   Q   Okay.  Do you have an opinion as to the reason
   18       for Mr. Manoogian's lower ejection fraction?
   19   A   I don't have any specific way of knowing what it
   20       was -- why it was somewhat diminished.
   21   Q   Do you have any opinions with respect to the
   22       cause of Mr. Manoogian's atrial fibrillation?
   23   A   No.
   24   Q   Is it important in treating a patient's atrial
   25       fibrillation, to determine a cause?
                                                               0026
    1   A   If one can identify a precipitant, that's a
    2       wonderful thing.  It is quite uncommon to be
    3       able to define a reversible precipitant, I
    4       should say.  Most individuals, it is idiopathic
    5       atrial fibrillation, sometimes related to some
    6       structural heart disease, but most of the time
    7       we can't nail down a specific cause.
    8   Q   Okay.  Do you have any criticisms of
    9       Dr. Cockrell or Dr. Lee, with respect to the
   10       indication for atrial fibrillation ablation for
   11       Mr. Manoogian?
   12   A   No, ma'am.
   13   Q   Okay.  Would you agree that atrial fibrillation
   14       ablation is a generally good and safe technique
   15       for treating atrial fibrillation?
   16   A   In properly selected patients, I believe so,
   17       yes.
   18   Q   Have you ever done an AV junction ablation?
   19   A   Yes, ma'am.
   20   Q   And what are the benefits and risks of an AV
   21       junction ablation, as compared to an atrial
   22       fibrillation?
   23   A   Well, it's apples and oranges.  It simply
   24       controls the ventricular rate.  The atrial
   25       fibrillation is allowed to go on in the atria,
                                                               0027
    1       as it would just by course of nature.  So if an
    2       individual is encumbered by a decrease in
    3       cardiac output, cardiac performance by virtue of
    4       not having an effective atrial contraction that
    5       contributes, through optimal left ventricular
    6       filling, AV junction ablation does nothing for
    7       that; it simply prevents the ventricular rate
    8       from going excessively fast.
    9            The part and parcel of the AV junctional
   10       ablation is, in almost all cases, insertion of a
   11       ventricular pacemaker.  By its nature, this
   12       engenders some decrease in left ventricular
   13       contractile efficiency.  In many cases, that's
   14       not important for the individual, but in some
   15       cases, it can be.
   16            Atrial fibrillation ablation, by contrast,
   17       when it works well, does restore mechanical
   18       function of the atrium.  So not only do you have
   19       de facto rate control during -- with atrial
   20       fibrillation, because atrial fibrillation is
   21       absent, but the systolic performance of the left
   22       ventricle, if dependent on an effective atrial
   23       contraction, is preserved.
   24   Q   Do you -- are there any particular rates that
   25       you know of, either for yourself or generally
                                                               0028
    1       speaking, for A-Fib ablation of recurrence
    2       following the procedure?
    3   A   Well, this is a difficult thing to know.  Many
    4       individuals will have asymptomatic recurrences.
    5       And only when one looks very carefully or finds
    6       one serendipitously might one be aware of that,
    7       either the patient or the physician.  In
    8       general, individuals with the more readily cured
    9       forms of atrial fibrillation, paroxysmal atrial
   10       fibrillation -- Mr. Manoogian was not paroxysmal
   11       at this point -- those more readily treated
   12       individuals might have as high as a 30 percent
   13       recurrence rate within a year or two.
   14            We don't have large numbers of individuals
   15       who have been followed for five years, say, to
   16       know what their recurrence rate is.  In chronic
   17       or permanent atrial fibrillation, such as
   18       Mr. Manoogian had, the recurrence rates are
   19       slightly higher, perhaps 40 percent or more,
   20       even after what appeared to have been an
   21       effective procedure.
   22   Q   Are you going to be rendering any criticism of
   23       Dr. Lee, relative to the performance of the
   24       May 2004 ablation procedure?
   25   A   No, ma'am.
                                                               0029
    1   Q   Okay.  Would you agree that there are, in
    2       addition to recurrence, other known risks for
    3       atrial fibrillation ablation?  There is a
    4       certain set of known risks that you would advise
    5       your patient about?
    6   A   Procedural risks?
    7   Q   Yes.
    8   A   Yes, ma'am.
    9   Q   And what would those risks be?
   10   A   A variety of things, including most commonly
   11       perforation of the heart, with blood leaking
   12       around the outside of it, resulting in a
   13       pericardial effusion, or even if the pressure
   14       rises enough in the pericardial space, cardiac
   15       tamponade, requiring closed drainage, or even
   16       open drainage by a surgeon and repair of the
   17       hole.  Vein stenosis, pulmonary vein stenosis.
   18       Damage to the normal conduction system requiring
   19       a permanent pacemaker.  Damage to one of the
   20       cardiac valves.  Damage to the esophagus through
   21       the back of the left atrium, resulting in a
   22       fistula or communication between the left atrium
   23       and esophagus.  Stroke, heart attack, even death
   24       resulting from the procedure.  Damage to the
   25       phrenic nerve, P-H-R-E-N-I-C, nerve that
                                                               0030
    1       controls diaphragmatic contractions.  Just
    2       pericardial inflammation, pericarditis,
    3       discomfort that way.
    4            And aside from those that are relatively
    5       more specific for left atrial in extended
    6       ablation procedures, groin complications, atrial
    7       ven- -- arterial ventric- -- venous fistulas and
    8       pseudoaneurysms and hematomas and distal emboli,
    9       and things like that.
   10   Q   And those are the risks that you would tell any
   11       patient that you were giving informed consent
   12       to, prior to doing an A-Fib ablation?
   13   A   Yes, ma'am.
   14   Q   Okay.  Is it fair to say that those
   15       complications can occur in the best of hands?
   16   A   Yes, ma'am.
   17   Q   Including death?
   18   A   Yes, ma'am.
   19   Q   Do you know what the national rate is for death
   20       as a complication of A-Fib ablation?
   21   A   I don't.  I know that overall, it is about a
   22       two percent risk of any of these complications
   23       occurring, with death being a very, very small
   24       slice of that, but it does occur.
   25   Q   Have you ever had a complication from an A-Fib
                                                               0031
    1       ablation case?
    2   A   Yes, ma'am.
    3   Q   What kind of complication have you encountered?
    4   A   Cardiac tamponade; pulmonary vein stenosis;
    5       transient ischemic attack, TIA, of a neurologic
    6       nature; phrenic nerve palsy; pericarditis;
    7       hematomas in the groin.  That's all I can think
    8       of right now.
    9   Q   Have you ever needed the assistance of a cardiac
   10       surgeon to handle a patient you had tamponade or
   11       other kind of complication during an A-Fib
   12       procedure?
   13            MR. PERRY:  Just object to what you mean by
   14       assistance.  Could you make that --
   15   Q   Is that -- do you understand my question?
   16   A   Have I needed to consult a surgeon?  Yes.
   17   Q   Okay.  How many times?
   18   A   I've consulted them more than they have needed
   19       to do anything, fortunately.  Which answer would
   20       you like, or both?
   21   Q   Both would be great.
   22   A   Well, it is easier to try to count up the number
   23       of times I've actually needed them, and it would
   24       probably be myself, personally, once.  We here
   25       have had, I think, two other instances in which
                                                               0032
    1       a surgeon intervened.  I have summoned a surgeon
    2       or spoken with one by telephone probably half a
    3       dozen other times.
    4   Q   And in those half dozen times you spoke with a
    5       surgeon and, ultimately, realized that you
    6       didn't need them to come and treat the patient?
    7   A   Yes, ma'am.
    8   Q   Okay.  We were talking about all of these
    9       various risks of the procedure.  Did you review
   10       the medical records in this case relating to
   11       Mr. Manoogian's treatment at Washington
   12       Adventist Hospital?
   13   A   I did.
   14   Q   And did you see his informed consent forms,
   15       relative to his A-Fib procedures?
   16   A   I bet I did.  I don't recall them specifically.
   17   Q   Okay.  Can we agree that Mr. Manoogian was aware
   18       of the risks that you articulated with respect
   19       to atrial fibrillation ablation?
   20            MR. PERRY:  I'm going to object.  Calls for
   21       speculation.
   22   A   I don't recall specifically that these were
   23       enumerated in that statement there.
   24   Q   Okay.  So you don't know, one way or the other?
   25   A   No, ma'am.
                                                               0033
    1   Q   Okay.
    2            MR. PERRY:  (Coughs.)  Excuse me, I'm
    3       sorry.  I don't want to interrupt you.
    4   Q   Okay.  Did you see, in the medical records,
    5       references to Mr. Manoogian's being a
    6       well-educated patient, a well-informed patient
    7       about his condition and treatment?
    8            MR. PERRY:  Same objection.  You can
    9       answer.
   10   A   I know that he was a well-educated gentleman,
   11       and -- but I don't know to what extent he
   12       explored his options and the nature of the
   13       procedure, as well as the potential
   14       complications.
   15   Q   If Mr. Manoogian had come to you for treatment,
   16       prior to -- let's see, let's get a date -- in
   17       May of 2004, having already tried a medication
   18       regimen, what would you have recommended for
   19       him, if anything?
   20   A   I would have counseled him that this was
   21       definitely an option for him.  I would have gone
   22       through exactly the list of potential
   23       complications, and also quoted those types of
   24       percentage risk and percentage beneficial
   25       outcome.
                                                               0034
    1   Q   Can we agree that Dr. Cockrell and Dr. Lee are
    2       and were in 2004 experienced
    3       electrophysiologists with ablation procedures?
    4            MR. PERRY:  Objection.
    5   A   Well, I can agree that they had done a large
    6       number of procedures.
    7   Q   Well, okay.  Is that different from experienced,
    8       in some way?
    9   A   Well, there are connotations about -- there is
   10       good experience and bad experience, I suppose.
   11       Expert, I can't attest to that.  Have they had a
   12       large number of procedures?  Yes.
   13   Q   Is an atrial fibrillation ablation a difficult
   14       procedure, technically speaking?
   15   A   Yes, ma'am.
   16   Q   What aspects of the procedure are the
   17       technically challenging portions?
   18   A   Many are technically challenging.  One is
   19       getting the coronary sinus catheter, in some
   20       cases.  That's almost always -- that can be
   21       overcome.  Getting safely into the left atrium
   22       with one or two catheters is another.
   23            Perhaps the most difficult aspects are the
   24       actual ablation portion, and knowing when one
   25       has done the type of damage and the degree of
                                                               0035
    1       damage in the location desired, in order to
    2       effect the desired outcome, and knowing when you
    3       shouldn't do any more ablation in the particular
    4       location.  And knowing what the end points are
    5       of the procedure is also somewhat difficult in
    6       many circumstances; when have you done enough.
    7   Q   Going back to the risks issue, have you in your
    8       experience ever passed a Brockenbrough needle
    9       through the intra-atrial septal wall?
   10   A   Yes.
   11   Q   And have you ever advanced a catheter through
   12       the intra-atrial septal wall?
   13   A   You mean, through the fossa ovalis.
   14   Q   Outside of the fossa ovalis is my question.
   15   A   Oh, well, those --
   16            MR. PERRY:  Can I just -- can we clarify
   17       that the prior answer, then, is -- I think,
   18       based on your question, I think it was unclear
   19       what you were asking.
   20            MS. PLANT:  Let me -- I'll withdraw.
   21   A   To me --
   22            MR. PERRY:  Doctor, just let her reask the
   23       question.
   24            THE WITNESS:  I'm sorry.
   25   Q   Have you ever, in your experience, passed a
                                                               0036
    1       transseptal catheter through an intra-atrial
    2       septal wall outside of the fossa ovalis?
    3   A   No.
    4   Q   And how do you know that?
    5   A   Well, to me, these are almost identical, to say
    6       that one is in the fossa ovalis, but outside of
    7       the -- or in the atrial septum, but outside of
    8       the fossa ovalis are almost contradictory
    9       statements, because the fossa ovalis is pretty
   10       much the limit of the junction between the two
   11       atria.  There is very little around the outside
   12       of that that's -- that one could traverse and
   13       not be outside of the right atrium.
   14   Q   So in other words, it is hard to find a point of
   15       entry that would land in the left atrium that is
   16       not the fossa ovalis?
   17   A   Yes.  There is a little rim around that, the
   18       limbus of the fossa ovalis, but more than a
   19       millimeter or two in any direction from there,
   20       leaving the right atrium, you do not enter the
   21       left atrium directly.
   22   Q   Okay.  So when we're talking about -- when
   23       you're saying the term limbus, you're talking
   24       about a small, several-millimeter area around
   25       the fossa ovalis?
                                                               0037
    1   A   Yeah, just a rim around it.
    2   Q   Okay.  Is that also called the ridge, a ridge?
    3   A   Don't usually call it a ridge.
    4   Q   Okay.  Limbus.  We'll call it limbus.
    5   A   Okay.
    6   Q   Have you, in your experience ever punctured
    7       through the limbus in passing from the left to
    8       right -- right to left atrium?
    9            MR. PERRY:  Just object.  When you say
   10       "passing through," with what are you referring
   11       to?
   12            MS. PLANT:  With the transseptal catheter.
   13   A   Through that actual rim around there?  I don't
   14       know.
   15   Q   Okay.  Why are two transseptal punctures often
   16       used?
   17   A   For purposes of having two catheters
   18       simultaneously in the left atrium.
   19   Q   And what do the two catheters do, typically?
   20   A   One catheter is used for ablation, delivery of
   21       typically a radio frequency current to actually
   22       do the ablation, one moves that around and
   23       ablates in various locations.  It is also a
   24       mapping catheter that can record signals and
   25       determine timing and quality of signals.
                                                               0038
    1       Another catheter can sometimes be used to
    2       determine where that ablation catheter should be
    3       targeting, and that would be solely a mapping
    4       catheter of a variety of configurations.
    5   Q   Has the standard of care applicable to atrial
    6       fibrillation ablation procedures changed in the
    7       past five years?
    8            MR. PERRY:  I'm going to object, just sort
    9       of a broad question, but you can answer it if
   10       you --
   11   A   I'm -- I would ask for a clarification, as to
   12       what you mean.  It seems rather broad to me.
   13   Q   Okay.  What is your understanding of what the
   14       term standard of care means?
   15   A   It means what a reasonable and prudent
   16       practitioner would do under certain
   17       circumstances.
   18   Q   Is there any aspect of an atrial fibrillation
   19       ablation procedure that has changed, as far as
   20       what is expected of a reasonably prudent
   21       physician, within the past five years?
   22   A   I think so.
   23   Q   Okay.  What part has changed?
   24   A   Well, the indications have gotten a little bit
   25       more liberal.  As the safety and efficacy of the
                                                               0039
    1       procedure have improved somewhat, we are opening
    2       it up to more individuals who we would like to
    3       cure of atrial fibrillation, but whose
    4       likelihood of success seemed lower, or their
    5       procedural risk seemed higher five years ago.
    6            Five years ago, we were ablating more
    7       towards the vein than towards the atrium, and
    8       thus, there was a higher incidence of pulmonary
    9       vein stenosis.
   10            I think in many settings, the prevailing
   11       thought was, let's use as much energy and do as
   12       much ablation as we can.  And some complications
   13       have come to light that suggest that there is
   14       such a thing as too much ablation.
   15            But as far as the techniques of getting
   16       into the left atrium and manipulating catheters
   17       in the left atrium, I don't think those have
   18       changed substantially.
   19   Q   Can you tell me at what point in time there came
   20       this paradigm shift, there was a change in the
   21       standard of care for the items that you
   22       mentioned?
   23   A   I don't know that there was a point in time.
   24       Probably it's been about five years, about
   25       the -- or more, five years, as to how far out
                                                               0040
    1       towards the vein from the atrial venous or
    2       veno-atrial junction one could safely ablate.
    3            It's been perhaps the last three years
    4       about avoidance of very high energy delivered to
    5       the posterior left atrium to try to avoid left
    6       atrial esophageal fistula formation.  I think in
    7       just the last year or so, there's been a greater
    8       awareness of wanting to try to avoid damage to
    9       the phrenic nerve.
   10   Q   I limited my last question or series of
   11       questions to the past five years.  And you said
   12       in that time frame, the technique of getting
   13       into the left atrium has been static, as I
   14       understand it; is that correct?
   15   A   The techniques that are available nowadays were
   16       available in that five years ago, yes.
   17   Q   Okay.  Going back further, at any point in time,
   18       is it your view that there has been a shift in
   19       what the standard of care requires, as far as
   20       the technique of getting into the left atrium?
   21   A   Not as far as what the standard of care
   22       requires.  The techniques for assuring that
   23       safety and efficacy of getting into the left
   24       atrium have changed a little.
   25   Q   Okay.  What has changed, and when?
                                                               0041
    1   A   In the last 10 years, did you say?
    2   Q   I said at any point, but --
    3   A   At any point?  Okay.  Well, as originally
    4       described, the technique used pressure
    5       monitoring.  Additional means of confirming
    6       one's location of the needle in the left atrium
    7       would be aspiration of blood back through the
    8       needle, to assure that it had a left atrial
    9       oxygen content.  That has a potential confuting
   10       factor that, if you're in the aorta, you get the
   11       same oxygen content, so that's not perfect.
   12            Injection of dye through the needle, either
   13       right before intending to puncture through the
   14       septum, to stain the atrial septum and say yes,
   15       I'm in the atrial septum, I'm not outside of the
   16       atrial septum, I'm not in the aortic wall is one
   17       method.  Injection of dye immediately after one
   18       thinks one's in the left atrium, to make sure
   19       that it is in the left atrium, not outside the
   20       left atrium, not in the aorta.  Each has their
   21       own characteristic findings on fluoroscopy after
   22       injection of dye.
   23            Passage of a very thin angioplasty
   24       guidewire on the left upper pulmonary vein, or
   25       into the left atrial appendage, to serve as a
                                                               0042
    1       rail to track the entire apparatus over, so the
    2       needle doesn't inadvertently puncture the dome
    3       of the left atrium; once it is safely in, it
    4       should not go out again.  Use of intra-cardiac
    5       echocardiography, either the rotating transducer
    6       or the phased array, in order to image both the
    7       fossa ovalis and the actual puncture across the
    8       septum and other structures to avoid the aorta
    9       and coronary sinus.
   10            So just in the last, you know, since the
   11       inception of the technique, the angioplasty
   12       guidewire, for instance, has been an innovation.
   13       The use of intra-cardiac echocardiography has
   14       become available and widely used.  Injection of
   15       dye, I think, was a pretty early technique; and
   16       some use it, some don't.
   17            The fundamental, what all of these
   18       techniques feed into is assuring that the needle
   19       is safely situated in the left atrium before
   20       passage of the dilator and sheath assembly, and
   21       that the whole thing remains in the left atrium
   22       and doesn't -- it is in there in the first
   23       place, and not some other location, and remains
   24       in the left atrium.
   25   Q   Is it fair to say the purpose of each of the
                                                               0043
    1       types of precautions that you have been talking
    2       about are to reassure the operator about where
    3       he or she is, anatomically?
    4   A   Correct.
    5   Q   Okay.  And for example, the item you mentioned
    6       with using dye before passing the needle, that's
    7       a reassurance that's given to the operator prior
    8       to passing the needle?
    9   A   Correct.
   10   Q   So reassurances about anatomical location can
   11       happen before or after the needle puncture?
   12   A   It can happen before, but need to happen
   13       afterwards.
   14   Q   Okay.  When is it your opinion that that became
   15       the standard of care?
   16   A   Oh, I don't think that that has ever not been
   17       the standard of care.
   18   Q   Okay.  What are the techniques, in your opinion,
   19       that would comply with the standard of care in
   20       reassuring an operator as to their anatomical
   21       location?
   22   A   Those that I have enumerated, plus fluoroscopic
   23       imaging that your assembly is situated in both
   24       fluoroscopic angulations and center of the left
   25       atrial shadow.  That's not quite as good as some
                                                               0044
    1       of these other techniques, because there are
    2       some overlying shadows, so I wouldn't rely on
    3       that alone.
    4   Q   Do you know whether there are physicians who
    5       practice in relying on a biplane fluoroscopy
    6       with anatomical landmarks as their guidance and
    7       their reassurance as to where they are
    8       anatomically?
    9            MR. PERRY:  Objection, but you can answer.
   10   A   I don't know.  I hope not.  As their sole
   11       method?  Is that what you're asking, ma'am?
   12   Q   Well, I'm not characterizing it as a sole
   13       method, but using both anatomical landmarks with
   14       electrocatheters, and having biplane
   15       fluoroscopy.
   16   A   What do you mean by electrocatheters and where?
   17   Q   Well, I think you had discussed previously
   18       placing an electrocatheter in the bundle of His
   19       as a good landmark to tell you where, at least
   20       in part, where the edge of the aorta -- aortic
   21       root is?
   22   A   Correct.
   23   Q   And an electrocatheter in the coronary sinus --
   24   A   Correct.
   25   Q   -- which tells you -- what does that tell you?
                                                               0045
    1   A   It is another landmark.  It says that's the
    2       bottom of the left atrium, at least, in both of
    3       the views.  An electrocatheter actually in the
    4       left atrium is a nonspecific indicator, as I
    5       suggested from my handwritten notes there,
    6       because one can record an atrial electrogram
    7       from the right atrium, from inside of the left
    8       atrium, from inside of the coronary sinus, from
    9       outside of the left atrium.
   10            So the mere presence of the left atrial
   11       electrical recording doesn't assure that the
   12       apparatus is in the correct location.
   13   Q   Would it reassure an operator that one was not
   14       in the aorta?
   15   A   I don't know that I could answer that.  I'm not
   16       used to trying record atrial signals from the
   17       aorta.
   18   Q   Or to record any signals from the aorta?
   19   A   Usually, the aorta is a conduit, and not
   20       something we are trying to record in itself.
   21   Q   Do you have an opinion as to what would be found
   22       if an operator tried to record electrogram
   23       signals from a catheter that had been placed in
   24       the aorta?
   25   A   Actually, in reflecting on this, I do have some
                                                               0046
    1       insight into that.  And we have had -- we have
    2       tried to record a His bundle recording, for
    3       instance, from the aortic root.  It is difficult
    4       to see an atrial signal from there.  And in
    5       other circumstances, we can recognize, if for
    6       instance, we are doing a left ventricular,
    7       mapping an ablation procedure, so the catheter
    8       has gone through the -- traversed around the
    9       aortic arch, and through the aortic valve and
   10       into the left ventricle.  We can recognize when
   11       we have come out of the left ventricle
   12       inadvertently because we can't record any
   13       signals of any sort, atrial or ventricular, even
   14       in the aortic root.
   15            So I would say it would be unlikely to be
   16       able to record atrial signals from the aortic
   17       root.
   18   Q   So is it fair to say that recording of
   19       electrical signals, after placing the
   20       Brockenbrough needle across the -- into what you
   21       believe is the left atrium -- right atrium --
   22       left atrium, that a operator would be reasonably
   23       reassured that they were in -- that they were
   24       not in the aorta, if they got a wave form that
   25       represented the left atrium; does that make any
                                                               0047
    1       sense?
    2            MR. PERRY:  Object, just because I didn't
    3       understand the question, but if you did, Doctor,
    4       you can answer.
    5   A   Well, I wouldn't want to record that with a
    6       Brockenbrough needle.  I would want to record
    7       that with a electrocatheter.
    8   Q   Thanks.
    9   A   If I had good, so-called sharp, so-called near
   10       field recordings, I could be, I think, confident
   11       that I was not in the aorta.
   12   Q   Okay.  We may have -- we talked about this a
   13       little bit, but do you have any source of
   14       information or familiarity with what of these
   15       different kinds of systems and precautions are
   16       being used across the country?
   17   A   I think all of them are, in various
   18       laboratories.  And in our laboratory, we have
   19       different operators using different techniques.
   20       One develops a familiarity and a confidence with
   21       one or a variety of techniques, and uses them.
   22   Q   And so is it fair to say that the
   23       electrophysiologist performing a transseptal
   24       puncture should utilize the system that he or
   25       she is most comfortable with, and gives them the
                                                               0048
    1       best reassurance about their anatomical location
    2       of the catheters they are placing?
    3            MR. PERRY:  Objection.  You can answer.
    4   A   That gives them true reassurance that they're in
    5       the right location.
    6   Q   Is that yes?
    7   A   It is a qualified yes --
    8   Q   Okay.
    9   A   -- because one needs to confirm that they are
   10       uniquely in the left atrium, and no other
   11       structure.  And methods that someone might rely
   12       on that seems to be a reassurance to them, but
   13       is not confirmation of left atrial location,
   14       would not be adequate.
   15   Q   Have you ever seen or are you aware of any
   16       surveys or any studies that have tried to
   17       articulate what the various different types of
   18       precautions and systems being used across the
   19       country are?
   20   A   Nothing formal, no.
   21   Q   Have you ever seen that for any other country?
   22   A   Not that I'm aware.
   23   Q   Okay.  Are there any other countries that are on
   24       a par with the United States, as far as ablation
   25       for atrial fibrillation technology --
                                                               0049
    1   A   Certainly.
    2   Q   -- and procedures?
    3            MR. PERRY:  Just object, but go ahead.
    4   A   Certainly.
    5   Q   And what countries are on a par or even better
    6       than the United States, if any?
    7   A   Better than the United States?  (Laughter.)
    8            On a par with the United States, a variety
    9       of laboratories in France, in Italy, in Germany,
   10       in Japan, in Taiwan, Canada.
   11   Q   Okay.
   12   A   I don't want to be too exclusive, but these are
   13       the ones that are very much at the forefront.
   14   Q   And in particular, what role have physicians
   15       from Italy played in the evolution of techniques
   16       for atrial fibrillation ablation?
   17            MR. PERRY:  Objection.  You can answer.
   18   A   The so-called Pappone, P-A-P-P-O-N-E, capital P,
   19       method, devised by Carlo Pappone, C-A-R-L-O, in
   20       Milan, has been an innovation in the way that
   21       atrial fibrillation ablation is performed.
   22   Q   Have you ever seen Dr. Pappone perform an
   23       ablation for atrial fibrillation?
   24   A   Yes.
   25   Q   Okay.  When and how did you do that?
                                                               0050
    1   A   I went to Milan.
    2   Q   And when was that?
    3   A   October of last year.
    4   Q   Do you recall what his technique was for
    5       transseptal placement?
    6   A   Yes.
    7   Q   What was it?
    8   A   Fluoroscopy plus pressure monitoring.
    9   Q   When he used fluoroscopy, did he use a single AP
   10       view?
   11   A   He did.  I should say, his laboratory did.  He
   12       only did one puncture, and most of the rest were
   13       done by one of his associates, and that was
   14       using pressure monitoring and the anterior
   15       posterior view.
   16   Q   Is it your recollection that Dr. Pappone used
   17       pressure monitoring?
   18   A   That is my recollection.
   19   Q   Okay.
   20   A   I know that his associate, Dr. Vicedomini,
   21       V-I-C-E-D-O-M-I-N-I, recommends that.
   22   Q   Is it fair to say there are a number of
   23       different ways to comply with the standard of
   24       care in using adequate precautions for a
   25       transseptal placement?
                                                               0051
    1   A   Yes.
    2   Q   Okay.  How many physicians in this country do
    3       atrial fibrillation ablations, as of 2006?
    4            MR. PERRY:  Objection.  You can answer if
    5       you know.
    6   A   It would be a very rough estimate, 200.
    7   Q   We had been talking about various complications.
    8       In your experience, have you ever encountered --
    9       have you ever perforated an aortic root in doing
   10       a transseptal puncture?
   11   A   My own hands have not punctured an aortic root.
   12   Q   Have you ever been in an EP lab when someone
   13       punctured the aortic root during a transseptal
   14       puncture?
   15   A   Yes, ma'am.
   16   Q   When did that happen?
   17            MR. PERRY:  Can I just -- I just want to
   18       clarify.  When you are talking about puncture,
   19       what are you -- what are you referring to?
   20            MS. PLANT:  I was being intentionally
   21       general.
   22            MR. PERRY:  Okay.
   23            THE WITNESS:  May I be specific then?
   24            MS. PLANT:  You may indeed.
   25            MR. PERRY:  Fair enough.
                                                               0052
    1   A   A needle has entered the aortic root to give a
    2       characteristic signature aortic wave form on two
    3       occasions that I can recall.
    4   Q   Do you recall what happened on those occasions?
    5   A   I certainly do.
    6   Q   What happened?
    7   A   There was a loud "Oops," and watched it for a
    8       second or two to make sure this is not an
    9       illusion, this is not just a catheter fling,
   10       this is the real thing.  Pull the needle back
   11       into the right atrium, and ask for an
   12       echocardiogram, ask the patient how they are
   13       doing, make an assessment of their hemodynamic
   14       status.  And in both of those cases, I can't
   15       speak to every case, but in both of these cases,
   16       there was no -- no adverse sequella whatsoever.
   17       The procedure was continued.
   18   Q   Do you recall how the puncture into the aortic
   19       root was recognized in those two cases?
   20   A   In both cases, by the characteristic wave form,
   21       pressure wave form.  This was only the needle,
   22       this very thin needle entering just into the
   23       aorta.  And we didn't even draw back blood.
   24   Q   Is a perforation into the aorta, such as the two
   25       that you have described, in and of itself a
                                                               0053
    1       deviation from the standard of care?
    2   A   No.
    3   Q   Can you tell me what your criticisms are of
    4       Dr. Cockrell in this case.
    5   A   I believe he did not use adequate means of
    6       determining that he was uniquely in the left
    7       atrium with one of his puncture attempts.  One
    8       of those left the right atrium and entered the
    9       aorta, went through the wall and into the aorta
   10       itself, not just with the needle, but with the
   11       actual plastic dilator and with the sheath,
   12       which is then about a 3- or 4-millimeter
   13       diameter, 3-millimeter diameter.  And that, in
   14       itself, directly contributed to Mr. Manoogian's
   15       complication.
   16   Q   Any other criticisms?
   17   A   Having done it, and not recognized that he was
   18       in a place where his catheter didn't belong.
   19   Q   And not that I'm looking for more, but any
   20       others?
   21   A   When the blood pressure dropped and
   22       pericardiocentesis was appropriately undertaken,
   23       once a large amount of blood had been retrieved
   24       from the pericardium, and/or the patient had not
   25       stabilized, and/or CPR was necessary, under
                                                               0054
    1       those circumstances, a surgeon needed to be
    2       called immediately to try to rectify the
    3       situation.
    4   Q   Let me see if I can make sure I understand what
    5       point in time you're talking about.  At what
    6       point in time in that continuum that you have
    7       described, in Mr. Manoogian's case, was the --
    8       did the standard of care require Dr. Cockrell to
    9       contact a cardiothoracic surgeon?
   10   A   I don't know over what period of time that 1500
   11       CCs to which Dr. Lee alluded was removed.  I
   12       know that in most cases, it is a 20- or a 50-CC
   13       syringe that is used.  And at some point along
   14       the way, it can be connected to a bag or to a
   15       bottle to suction.  It takes a certain amount of
   16       time to pull 50-CC after 50-CC syringe off.
   17            If I may back up for a moment, the
   18       pericardium is a somewhat distensible sac in
   19       which the heart is situated.  And it can --
   20            (A knock at the door and a discussion was
   21       held off the record.  Record read.)
   22   A   -- accommodate a certain amount of blood within
   23       it that's outside of the heart, and expand to a
   24       point.  In individuals in whom there is a slow
   25       accumulation of fluid, over a period of weeks or
                                                               0055
    1       even months, that pericardium can become quite
    2       enlarged and accommodate 800, a thousand CCs,
    3       without any compromise of heart filling, because
    4       the pericardium has a chance to stretch.
    5            When blood is acutely entering the
    6       pericardial space, it doesn't have a chance to
    7       stretch.  And so as more blood goes into there,
    8       pressure increases within the space, compressing
    9       the heart.  And it doesn't take more than 150 or
   10       200 CCs of extra cardiac blood within the
   11       pericardial space to result in severe
   12       cardiovascular compromise.  Removing that much
   13       blood, if the bleeding has stopped, at that
   14       point, should suffice.  Sometimes it is only
   15       50-CCs removal.
   16            But certainly, by the point of 2- or 3- or
   17       400 CCs, there is continued leakage; that must
   18       be inferred at that point.  And it is not going
   19       to -- it is very unlikely to stop by itself.  If
   20       it does, you're very fortunate, but I would not
   21       want to rely on that hope at that point.  And I
   22       would be calling a surgeon.  That would be the
   23       standard of care once blood is continuing to be
   24       aspirated, despite getting more and more out.
   25            Fifteen hundred CCs is a very large amount
                                                               0056
    1       of blood to evacuate from the pericardial space,
    2       and bespeaks a continued leak.
    3   Q   And so if I understand you correctly, at the
    4       point that the physician recognizes that there
    5       was 1500 CCs of blood, that was when --
    6   A   Before then.  Fifteen hundred is certainly --
    7       that's the number they mention, but if a
    8       physician sees 400, 500 CCs of blood still
    9       coming out, it is not prudent to hope that it
   10       will stop sometime along the way.  And a surgeon
   11       needs to be contacted.
   12   Q   Okay.  What is your understanding or assumption
   13       about when a surgeon was contacted in this case?
   14   A   It is difficult to get from the narrative.  Both
   15       Dr. Lee's and Dr. Cockrell's handwritten notes
   16       say that Dr. Militano was contacted somewhere
   17       along the way, but it is difficult for me to
   18       piece that in to the time line very well.
   19            MR. PERRY:  Marianne, if I could just state
   20       for the record, Dr. Militano's deposition
   21       transcript is not available at this time, and
   22       has not been available to Dr. Miller prior to
   23       his deposition.
   24            MS. PLANT:  Sure.
   25            MR. PERRY:  Thanks.
                                                               0057
    1   Q   Dr. Miller, do you have any understanding of
    2       what Dr. Militano has testified about, not
    3       withstanding the fact that his deposition
    4       transcript is not yet available?
    5   A   I have some information in that regard.
    6   Q   And what information do you have?
    7            MR. PERRY:  I think I'm going to object on
    8       work product.
    9            MS. BOYCE:  On what?
   10            MR. PERRY:  Work product.
   11            MS. BOYCE:  I think it is all discoverable,
   12       Scott, even in an expert.
   13            MR. PERRY:  Yeah, okay.  I'll put my
   14       objection on, but you can answer, Doctor.
   15   A   Well, what I remember of what I was told was
   16       that Dr. Militano did not recall having
   17       specifically been summoned or contacted, and
   18       that when he arrived, his impression was that
   19       this was a hopeless situation.  His description
   20       in his note of the heart being in ventricular
   21       fibrillation and could not get it out of
   22       ventricular fibrillation is a very, very late
   23       finding.  I believe CPR was ongoing for some
   24       time prior to his arrival.  CPR, cardiopulmonary
   25       resuscitation, chest compressions, in the
                                                               0058
    1       setting of extra-cardiac compression by cardiac
    2       tamponade is very unlikely to support the
    3       circulation.  It is marginal, even when there
    4       isn't extra-cardiac compression.
    5   Q   Is it fair to say that you have not assigned a
    6       time to the point when you believe that a
    7       cardiac surgeon needed to be contacted?
    8   A   I'm looking at the anesthesia record here, and
    9       it says that -- this is page 1 of 3 of the
   10       anesthesia record -- it says that at 1725, blood
   11       pressure decreased.  Decreased.  Echocardiogram
   12       cardiac tamponade.  Cardiologist inserts
   13       pericardial centesis drain.  I'm interpreting
   14       that somewhat.  And that's giving a time of
   15       1810.
   16            Cardiac arrest and start CPR at 1820.  And
   17       the entry following that is, called cardiac
   18       surgeon.  Open chest and cardiac massage.
   19   Q   Does going back over that give you a time that
   20       you assigned as the point when a cardiac surgeon
   21       needed to be called?
   22   A   When he needed, I can't get too well from that.
   23       If I can continue here, on page 2 of 3 of the
   24       anesthesia a record, 1740 p.m., in the margin
   25       there, pericardial drainage started at 1740 p.m.
                                                               0059
    1        Patient's vitals unstable.
    2            At 1800 or 1801, endotracheal tube number
    3       eight.  And then, CPR started at 1815.
    4            And I don't know where in there this -- the
    5       300 CCs, the 500 CCs mark of -- but when I see
    6       patient unstable despite pericardial centesis, I
    7       think that a surgeon certainly needs to be
    8       called at that time.  That's at 1740.
    9   Q   Okay.  How long would you typically expect to
   10       have to waited, after contacting a cardiac
   11       surgeon, before they could enter into the
   12       electrophysiology lab?
   13            MR. PERRY:  I'm going to object.  In this
   14       hospital?
   15            MS. PLANT:  I'm asking for his experience
   16       right now.
   17   A   It varies widely.  It might be five minutes; it
   18       might be 15 minutes.  It could be longer.
   19   Q   Do you have an understanding of what
   20       Dr. Militano was doing at 1740?
   21   A   I have been told that he was beginning a cardiac
   22       coronary bypass procedure.
   23   Q   Okay.  Do you have an opinion that you hold
   24       within reasonable medical probability as to
   25       whether a different timing or different manner
                                                               0060
    1       of contacting Dr. Militano would have resulted
    2       in a different outcome for Mr. Manoogian?
    3   A   I don't know.
    4   Q   Okay.  We went through three criticisms that you
    5       had of Dr. Cockrell.  Are those the three
    6       criticisms that you have?  Are there any others?
    7   A   Refresh my memory, please.
    8   Q   Number one was inaccurate reference about being
    9       in the left atrium with one of the passes.
   10       Number two was failing to recognize it, and
   11       number three was --
   12   A   Something about delay?
   13   Q   -- a discussion about talking with the --
   14       contacting the cardiac surgeon.
   15            MR. PERRY:  My record shows me that he also
   16       said the putting in of a dilator and the sheath,
   17       as opposed to just a needle was also a
   18       criticism.  I don't want to put words in your
   19       mouth; is that correct?
   20            THE WITNESS:  It is correct.  If I didn't
   21       say that, I meant that.
   22   Q   Okay.  In addition to those that we have just
   23       articulated, however we number them, three or
   24       four, is there -- are there any other criticism
   25       that we need to discuss?
                                                               0061
    1   A   I don't believe so.
    2   Q   Do you have any criticisms of Dr. Lee?
    3   A   A similar one to the last one, with
    4       Dr. Cockrell, that of recognizing the point at
    5       which it was -- should have been clear that the
    6       bleeding was unlikely to stop on its own, and a
    7       surgeon needed to be summoned immediately.
    8   Q   What's your understanding of what Dr. Lee knew,
    9       as far as whether contact had been made with a
   10       cardiac surgeon as of 1740?
   11   A   I don't have any way of knowing that.
   12   Q   Okay.  So do you have an opinion that Dr. Lee
   13       breached the standard of care?
   14   A   If he got -- well, let me refresh my
   15       recollection here.  All I can go by is his
   16       handwritten note here.  It says emergency
   17       pericardial centesis was done, and 1500 CCs of
   18       bloody fluid was drained.  Blood transfusion was
   19       started.  Pericardial drain stopped draining,
   20       despite echo showing, open quote, pericardial
   21       infusion, close quote.  Dr. Militano was
   22       consulted.
   23            It seems to read that he got 1500 CCs out,
   24       and only when it stopped draining, despite the
   25       presence of continued extra-cardiac fluid,
                                                               0062
    1       pericardial fluid on the echocardiogram on a
    2       subsequent echocardiogram did he then call
    3       Dr. Militano.
    4            And my contention is that the mere fact
    5       that he got 1500 CCs out is reason to call
    6       Dr. Militano or a surgeon.
    7   Q   Okay.  Let me just take one second, if we can
    8       take a brief break.
    9            (A discussion was held off the record.)
   10   Q   Have you had an opportunity to review Dr. Lee's
   11       deposition transcript?
   12   A   Yes, ma'am.
   13   Q   Do you have it with you?
   14   A   I believe so.
   15   Q   Can you look at pages 139 to 140.
   16            MR. PERRY:  Let me read over your shoulder,
   17       if you don't mind.
   18            THE WITNESS:  Sure.
   19            MR. PERRY:  Thanks.
   20   A   I have it.
   21   Q   Okay.  I'll give you a minute.
   22   A   I'm ready.
   23   Q   Okay.  Having had an opportunity to read that,
   24       does that refresh your recollection about
   25       Dr. Lee's testimony as to the sequence of
                                                               0063
    1       events?
    2   A   Okay.
    3            MR. PERRY:  I'm going to object that he
    4       needs his testimony to be refreshed, but go
    5       ahead and ask your question.
    6            THE WITNESS:  You're talking about the --
    7   Q   The sequence of events with respect to when
    8       Dr. Lee indicated that a cardiac surgeon needed
    9       to be contacted.
   10   A   Well, I don't see that he talks about contacting
   11       the cardiac surgeon within these two pages.  He
   12       talks about in line -- page 139, line 8, the
   13       question is posed:
   14              QUESTION:  Okay.  So you have 1500 CCs come
   15          out of the pericardial centesis.
   16            He affirms.  He affirms in line 15 that
   17       that is a large amount of blood.
   18            And then the question as to whether that is
   19       tamponade or not is answered in lines 18 through
   20       22.  And we have talked about how a large
   21       effusion can accumulate over time.
   22            Then he says, the question is posed in page
   23       140, line 1:
   24              QUESTION:  When you got 1500 CCs, did you
   25          recognize that, hey, there is an issue here?
                                                               0064
    1            His answer:
    2              ANSWER:  When we saw blood pressure drop to
    3          70, and when I saw the cardiac fluid not
    4          moving --
    5            I presume he means the cardiac shadow.
    6              ANSWER:  -- and when I saw the
    7          echocardiogram that there was pericardial
    8          effusion, I knew I was in trouble.  We knew
    9          there was a bleeding that was causing a drop in
   10          blood pressure.  But this --
   11            I'm sorry.
   12              ANSWER:  -- I asked Dr. Cockrell to call
   13          Militano, just in case --
   14            On line 12 of page 140.
   15              ANSWER:  -- as I was drawing a lot of blood
   16          out.
   17            But it doesn't say to me when, in this
   18       narrative -- it seems to indicate that he's
   19       already got 1500 CCs out.  And then he said
   20       okay, I asked Dr. Cockrell to call Dr. Militano
   21       just in case.
   22   Q   Well, let's -- just to be -- just to make sure
   23       we read the whole thing on the record, starting
   24       at line 10, Dr. Lee says -- after having been
   25       asked to decide to call in the surgeon, he says:
                                                               0065
    1              ANSWER:  As I was draining a lot of blood
    2          out, then Dr. Cockrell was actually talking to
    3          the family, and I asked Dr. Cockrell to call
    4          Dr. Militano, just in case.
    5            That sounds -- correct me if I'm wrong, but
    6       that was what you said should be a trigger to
    7       call the cardiac surgeon, when you're getting a
    8       lot of blood out.
    9            MR. PERRY:  Object to the characterization.
   10   A   I just don't know when that occurred.  In line 1
   11       it says, "When you got 1500 CCs."  And this
   12       seems to be occurring after that, but I don't
   13       know for sure.
   14   Q   Okay.  Do you have an opinion that you hold
   15       within reasonable medical probability that
   16       Dr. Lee breached the standard of care?
   17   A   I don't know when along the way he called the
   18       surgeon, but certainly, from reading his note
   19       and the vagueness of the deposition, it seems
   20       like it was after this 1500 CCs, and after
   21       imaging the echocardiogram.  In his handwritten
   22       note, he says, then I couldn't drain anymore and
   23       I know I've still have got a problem, so then
   24       I'm going to call a surgeon.  And that's too
   25       late.
                                                               0066
    1   Q   Where are you getting that he said he had
    2       finished draining and couldn't get any more, and
    3       then decided to call?
    4   A   His handwritten note --
    5            MR. PERRY:  Okay, just -- Doctor, I just
    6       ask you to give me a chance to object.
    7            THE WITNESS:  I'm sorry.
    8            MR. PERRY:  I object.  First of all, it's
    9       been asked and answered three times now.  We
   10       have gone over various portions of the record.
   11       He can go over it again, if you want him to.
   12            MS. PLANT:  Okay.
   13   Q   Which portion were you referring to?
   14   A   His handwritten note of -- do you have it there?
   15   Q   Yep.
   16   A   Okay.  About 40 percent of the way down,
   17       emergent pericardial centesis was done -- and
   18       some symbol of -- maybe approximately 1500 CCs
   19       of bloody fluid was drained.  Blood transfusion
   20       was started.
   21            And then "however" is scratched out.  It
   22       looks like "BP" scratched out.  Something,
   23       something.  Then "pericardial drain" scratched
   24       out.  Stopped draining, despite echo showing,
   25       open quote, pericardial effusion, close quote.
                                                               0067
    1       Dr. Militano was consulted, and emergent
    2       stenotomy was performed.
    3   Q   And so based on the order in which it is written
    4       there, you're presuming that's the order in
    5       which it happened?
    6   A   That's all I have.
    7   Q   Do you have a number of minutes in mind, as to
    8       how long there was a delay between when a
    9       cardiac surgeon should have been contacted, and
   10       when a cardiac surgeon actually reached the
   11       electrophysiology lab?
   12   A   I don't know over what span of time that 1500
   13       CCs was removed, and that he remained unstable.
   14   Q   So it is a period of delay of an indeterminate
   15       amount of time that you're alleging?
   16            MR. PERRY:  Object to characterization.
   17   A   I don't know how long it was.
   18   Q   Okay.  And fair to say that you don't know what,
   19       if any, difference that alleged delay made?
   20            MR. PERRY:  Objection, asked and answered.
   21       You can go ahead, Doctor.
   22   A   That is correct.
   23   Q   Do you have any criticism of anyone else in
   24       Cardiovascular Consultants, PA?
   25   A   I don't believe so.
                                                               0068
    1   Q   Any other individuals at all of whom you're
    2       critical in this case?
    3   A   No, ma'am.
    4   Q   Okay.
    5            MR. PERRY:  Object to the way that -- can
    6       you just state the question back to me, if you
    7       don't mind?
    8            (The requested material was read by the
    9       reporter.)
   10            MR. PERRY:  I just want to object that
   11       Dr. Miller is a standard of care witness against
   12       Dr. Cockrell and Cardiovascular Consultants
   13       only, and that was the only people he was asked
   14       to be a witness for.
   15   Q   Dr. Miller, did you sign a certificate of merit
   16       in this case that included Washington Adventist
   17       Hospital in the criticism that you rendered?
   18            MR. PERRY:  Objection to the
   19       characterization of criticism.
   20   A   If one could be produced that I signed, I will
   21       affirm that.
   22            MR. PERRY:  Can we just -- Marianne, we can
   23       do this off the record or on.  Do you want to go
   24       off the record for a second?
   25            MS. PLANT:  No.
                                                               0069
    1            MR. PERRY:  Or do you want me to state my
    2       objection on the record?
    3            MS. PLANT:  On the record is fine.
    4            MR. PERRY:  Okay.  If you're going to go
    5       here with the certificate of merit, I think the
    6       cases are quite clear that simply because a
    7       doctor has opined on a certificate of merit that
    8       there have been violations of the standard of
    9       care, if I don't ask him to testify with regard
   10       to a specific defendant, he has no opinion as to
   11       that defendant.
   12            MS. PLANT:  Okay.  I'm going to mark this
   13       as Exhibit 2.
   14            (Defendants' Deposition Exhibit No. 2
   15       marked for identification annoyed
   16   Q   And Dr. Miller, is this, that is marked
   17       Exhibit 2, the certificate of merit and report
   18       that you executed in this case?
   19   A   It is.
   20   Q   And as I understand it, based on representations
   21       from counsel, you are not going to be rendering
   22       any standard of care opinions against the
   23       hospital; is that correct?
   24   A   That is correct.
   25   Q   Okay.
                                                               0070
    1            MS. BOYCE:  Can you just say that answer
    2       again?  Because I couldn't hear.
    3            MR. PERRY:  It is important to you.
    4   A   That is correct.
    5            MS. BOYCE:  I still didn't hear it.
    6            MR. PERRY:  I'll state on the record,
    7       Susan, Dr. Miller will not be offering any
    8       opinions with regard to the hospital.
    9   Q   That being said, can you specify what it is that
   10       you previously thought was a violation of the
   11       standard of care on the part of Washington
   12       Adventist Hospital?
   13            MR. PERRY:  I'll object and instruct --
   14            MS. BOYCE:  Object to the question.
   15            MR. PERRY:  -- and instruct him not to
   16       answer.
   17            MS. PLANT:  What's the basis for
   18       instructing him not to answer?
   19            MR. PERRY:  What I just stated on the
   20       record.  He's not being presented as a witness
   21       to the hospital, and therefore, he does not have
   22       to divulge his opinions.
   23   Q   So just to make sure we have a clear record,
   24       Dr. Miller, you do have opinions, one way or the
   25       other, with respect to Washington Adventist
                                                               0071
    1       Hospital?
    2            MR. PERRY:  Objection, and instruct him not
    3       to answer.
    4            MS. PLANT:  You're going to instruct him
    5       not to answer whether or not he currently holds
    6       an opinion?
    7            MR. PERRY:  Yes.  He's not being put forth
    8       as a witness with regard to the hospital.
    9            MS. PLANT:  I'm entitled to ask the doctor
   10       whether or not he's changed his mind.  That is
   11       certainly something that is relevant.
   12            MR. PERRY:  You're not representing the
   13       hospital, Marianne.
   14            MS. PLANT:  I'm not.
   15            MR. PERRY:  And so my objection is clear.
   16            MS. PLANT:  And on what basis are you
   17       instructing an expert witness not to answer
   18       questions?
   19            MR. PERRY:  He's not being presented as a
   20       witness against the hospital.  You're asking him
   21       about his opinions as to the hospital.  He has
   22       no opinions.
   23            MS. PLANT:  Well, that's what I asked.  I
   24       asked whether or not he had any opinions.
   25            MR. PERRY:  You're asking, does he have
                                                               0072
    1       a -- because you're showing the certificate of
    2       merit.
    3            MS. PLANT:  Correct.
    4            MR. PERRY:  Okay.  The question was, does
    5       he have an opinion.  And I'm telling you, he
    6       does not have an opinion.  If you want him to
    7       say, I do not have an opinion, he can go ahead
    8       and do that.  But I'm telling you, the reason he
    9       does not have an opinion is I have not put him
   10       forth as a witness against the hospital, which
   11       is different than the signing of the certificate
   12       of merit.
   13            MS. PLANT:  Okay.  As I understand it,
   14       Scott, and I don't want to belabor the point,
   15       you are not going to allow Dr. Miller to answer
   16       any questions about any opinions he ever did or
   17       does hold, with respect to Washington Adventist
   18       Hospital, not withstanding the fact that, as I
   19       understand, he's not going to be testifying
   20       against them?  Is it accurate that you're not
   21       going to let him answer the question?
   22            MR. PERRY:  It is accurate that he has no
   23       opinions that he is going to set forth with
   24       regard to the hospital.
   25            MS. PLANT:  There was a two-part question.
                                                               0073
    1       My question is:  You're not going to allow me to
    2       inquire of the doctor what his opinions may be,
    3       not withstanding the fact that you're not going
    4       to ask him to render those opinions at trial?
    5            MR. PERRY:  No, I'm not.
    6            MS. PLANT:  Okay.  So you're not going to
    7       permit him to answer?
    8            MR. PERRY:  That is correct.
    9            MS. PLANT:  Okay.  I think we have
   10       preserved my objection adequately, if that's
   11       acceptable to you.  We will preserve it and
   12       handle it later.
   13            MR. PERRY:  Sure.
   14            MS. PLANT:  Okay.
   15   Q   Do you have an opinion that you hold within
   16       reasonable medical probability as to the cause
   17       of death for Mr. Manoogian?
   18   A   Exsanguination from aortic perforation
   19       engendered by one of the sheaths.
   20   Q   Okay.  Do you -- have you formed any opinions
   21       with respect to when the bleeding started?
   22   A   I can't put -- I can put a time on it.  I can
   23       put a time on it.  The clocks are different, but
   24       if I refer to the anesthesia record, it was
   25       somewhere prior to 1725, not more than a few
                                                               0074
    1       minutes prior to 1725, according to the
    2       anesthesiologist's record.
    3   Q   Okay.  Do you have an opinion as to why there
    4       was not bleeding at the initial time of the
    5       transseptal placement?
    6   A   I do.
    7   Q   What is that opinion?
    8   A   I believe that the sheath was plugging the hole
    9       that it had made.
   10   Q   Do you have an opinion as to what caused it to
   11       stop plugging the hole?
   12   A   It became displaced from so doing, being pulled
   13       back, more than likely.
   14   Q   As I understand it, you're not attributing any
   15       adjustment or changing of the catheters, you're
   16       not describing that as a breach in the standard
   17       of care?
   18   A   No.
   19   Q   Okay.
   20            (The doctor's cell phone rang.)
   21            MR. PERRY:  Do you need to answer that?
   22            THE WITNESS:  (Shakes head side to side.)
   23   Q   Have you ever heard of other cases in which a
   24       patient had a perforation or a dissection of the
   25       aorta that resulted in a death from -- in the
                                                               0075
    1       electrophysiology lab?
    2   A   No.
    3   Q   What would you expect typically would be the
    4       result of having -- let me strike the question
    5       and start over.
    6            Would you agree that, more likely, in your
    7       assessment, what you would expect if there was a
    8       perforation of the aorta with a transseptal
    9       catheter, you would expect an immediate
   10       catastrophic event?
   11   A   No.
   12   Q   Does the loss of 1500 CCs of blood necessarily
   13       cause a patient to have their heart stop
   14       beating?
   15   A   No, ma'am.
   16   Q   Did Mr. Manoogian's heart stop beating because
   17       of tamponade?
   18   A   I believe he had a combination of cardiac
   19       tamponade with inadequate -- that caused
   20       inadequate cardiac output, such that his
   21       coronary arteries were not adequately supplied,
   22       and so the cardiac tamponade was the ultimate
   23       cause of that.
   24   Q   Okay.  Did that tamponade cause a mechanical
   25       pressure on the heart that permanently damaged
                                                               0076
    1       Mr. Manoogian's heart?
    2   A   No.
    3   Q   Do you have an opinion within reasonable medical
    4       probability as to why Mr. Manoogian's heart
    5       would not restart initially?
    6   A   Well, he was in ventricular fibrillation when
    7       Dr. Militano encountered it.  And because of
    8       these phenomena, the low cardiac output from the
    9       continued cardiac tamponade, the extra cardiac
   10       compression preventing the heart from
   11       contracting, pumping blood even to its own
   12       coronary artery supply, so it was deprived of
   13       oxygen for some minutes, enough so that even
   14       counter shock directly applied to the heart was
   15       ineffective at first.
   16            MR. PERRY:  Do you need to take a break to
   17       make a call?
   18            MS. PLANT:  This is a fine time, yeah.
   19            (A brief recess was taken.)
   20   Q   Doctor, I wanted to ask you about the two
   21       medical diagrams that you provided, and ask you
   22       if you could explain what these two show.  One
   23       is labeled, "Atrioventricular Groove From
   24       Above," and the second is labeled, "Atrial
   25       Septal Puncture Sites."
                                                               0077
    1            So can you explain, in particular on the
    2       first one, what is meant by the rectangular box
    3       that says, "True Atrial Septum"?
    4   A   Yeah.
    5            MR. PERRY:  Can we just make it clear when
    6       you refer to the first one, that you're
    7       referring to --
    8            MS. PLANT:  The "Atrioventricular Groove
    9       From Above."
   10            MR. PERRY:  Thank you.
   11            MS. BOYCE:  I'm sorry, Marianne, are you
   12       referring to an exhibit number?
   13            MS. PLANT:  We did not mark it as an
   14       exhibit.  It is one of the two diagrams that he
   15       produced.
   16            MS. BOYCE:  Is it marked?
   17            MS. PLANT:  It is not.  Do you want me to
   18       mark it?
   19            MS. BOYCE:  That would be easier.
   20            MS. PLANT:  I think we can do that one as
   21       3, and this one as 4.
   22            (Defendants' Deposition Exhibit Nos. 3 and
   23       4 marked for identification.)
   24   A   If I might digress, most people think of the two
   25       atria as like two dodge balls somewhat
                                                               0078
    1       compressible, you push them together, and
    2       there's a disk of interface between them, a
    3       relatively large disk.  It is not that way.  It
    4       is more like two soccer balls, not very
    5       compressible, and the interface is a very, very
    6       small disk, a true atrial septum.
    7            And that's what I have illustrated in this
    8       dotted rectangular box.  This is a little bit
    9       lower than the actual septum.  This is at the
   10       valve level, but --
   11            Directly out of the plane here is where the
   12       true atrial septum is.  And you can see that if
   13       you -- this is towards the back, if the catheter
   14       goes -- in attempting to puncture the septum, if
   15       the catheter goes too far towards the back
   16       posteriorly, it exits the right atrium.  And you
   17       can get back into the left atrium there, but
   18       you're outside of the heart in the midst.
   19            And in that setting, I might say, your
   20       sheath or your catheter is plugging the hole for
   21       as long as it is over the left atrium.  When you
   22       pull it back is trouble.
   23            If the catheter is too far forward, it
   24       enters the aortic root, and way too far forward,
   25       it is out that way.  And way too far backwards,
                                                               0079
    1       these are not too relevant, but it has
    2       implications for being too high or low, as well.
    3   Q   Got it.  The area that is the true atrial septum
    4       in your description doesn't include any of the
    5       area that has a muscular layer between the two
    6       chambers?
    7   A   Well, this, as I say, is too low, too far down
    8       towards the valves to be able to show that.
    9   Q   Okay.  But there is an area that is not the
   10       fossa ovalis that has a layer of muscle?
   11   A   Yes, this limbus, this rim around it.
   12   Q   The limbus, okay.  And I think you said
   13       previously that you just don't know whether or
   14       not or how many times you have ever had your
   15       transseptal puncture go through that limbus?
   16   A   Yes.
   17   Q   Okay.  Exhibit 4, can you tell me what is
   18       represented by the one and two?
   19   A   Okay.  Number one is the proper course of a
   20       transseptal assembly, traversing the atrial
   21       septum and into the left atrium.  Number two is
   22       just ever so slightly forward of that, and it
   23       goes into the aortic root.  And this is my
   24       representation in this projection of the autopsy
   25       findings.
                                                               0080
    1   Q   Okay.  Do you have an opinion, within reasonable
    2       medical probability, what the distance is
    3       between the edge of the fossa ovalis and the
    4       number two puncture?
    5   A   The front edge of the fossa may be --
    6            MR. PERRY:  Can I just clarify, do you mean
    7       in this patient or generally?
    8            MS. PLANT:  I'm talking about for this
    9       patient.
   10            MR. PERRY:  Okay.
   11   A   That would be from the pathology, and I think
   12       that was four or five millimeters or so.  I
   13       could check that number for you.
   14   Q   That's okay.  Do you -- going with the
   15       presumption that it was four or five
   16       millimeters, what are -- structurally, what is
   17       before you get to the aorta, is there a
   18       thickness of muscle before you get to the aorta
   19       in that projection?
   20   A   Right atrium.  Right atrial free wall is here.
   21   Q   Okay.
   22   A   And there is, technically, a space between the
   23       right atrial free wall and the aorta, but it is
   24       like the space between a glove and a hand; it is
   25       not much.  Fluid can get in there, blood can get
                                                               0081
    1       in there, and a catheter traversing there
    2       situated, sitting right in the aortic root, a
    3       sheath, could stay there for an extended period
    4       of time and not do any leaking, any appreciable
    5       leaking.
    6   Q   Would you expect a catheter placed in the
    7       direction that your number two arrow goes, for
    8       that to feel different to the operator from
    9       passing a transseptal through the fossa ovalis?
   10   A   I would have no way of knowing that.
   11   Q   Okay.  Do you, when you do transseptal passes,
   12       rely on your sense of feel as one of your
   13       guides?
   14   A   It -- one can feel a so-called pop as the needle
   15       traverses the septum.  After that, I must say I
   16       don't recall any tactile sensation, even though
   17       a larger diameter structure, the dilator and
   18       sheath, are going through.  So I've not felt
   19       any -- the most resistance I've felt is with
   20       that initial puncture.
   21   Q   Okay.
   22   A   And I must plead ignorance as to what it feels
   23       like going through an aortic wall.
   24   Q   I guess my question was more geared towards what
   25       your expectation would be, rather than the
                                                               0082
    1       experience.
    2   A   I know what it feels like normally.  Sometimes
    3       there is no discernible pop, but that's the most
    4       to which I'm accustomed.
    5   Q   Is there something additional that you would do,
    6       if you have a case where you don't feel a
    7       discernible pop that gives you, you know, a
    8       concern that maybe you didn't make your pass in
    9       the place that you intended it?
   10   A   Left atrial pressure.
   11   Q   So you don't do anything different from what you
   12       would normally do?
   13   A   No.  I am monitoring that pressure.  And if it
   14       looks like a left atrial wave form, whether I
   15       felt a pop or not, I'm in the right location.
   16       And if it doesn't have a right wave form,
   17       whether I had a pop or not, I'm not happy with
   18       it unless I get some confirmation, some
   19       indisputable corroboration that I'm uniquely
   20       within the cavity of the left atrium.
   21   Q   Okay.  Have you ever used contrast dye?
   22   A   Yes, ma'am.
   23   Q   Okay.  Do you still use that?
   24   A   On occasion.
   25   Q   Okay.  What is the occasion that would prompt
                                                               0083
    1       you to use contrast dye?
    2   A   I was -- a couple of weeks ago, I used it in a
    3       situation in which I felt a pop, and the
    4       laboratory I was in was a relatively new
    5       configuration, and I was not entirely happy with
    6       the left atrial wave form I was seeing, pressure
    7       wave form.
    8            And I asked for some dye and injected it,
    9       and even though the fluoroscopic appearance
   10       looked good, I wanted additional confirmation,
   11       so I injected dye.  And I was in the left
   12       atrium.
   13   Q   What do you do -- or what did you see when you
   14       injected contrast dye?
   15   A   There is a puff that appears, contained within
   16       the space where I would identify the left
   17       atrium.  And it moves, kind of swirls around a
   18       little bit.  In this case, it went into the left
   19       atrial appendage a tiny bit and then was
   20       expelled from there, and went towards the
   21       ventricle.
   22   Q   Could you observe the direction that it moves?
   23   A   That the -- that it moves, the rapidity with
   24       which it moves, and the direction.
   25   Q   Would it be within the standard of care to use
                                                               0084
    1       contrast as the sole method of confirming
    2       presence in the left atrium?
    3   A   I think that's acceptable.
    4   Q   Okay.  Do you have an opinion, within reasonable
    5       medical probability, as to what would have been
    6       shown had Dr. Cockrell utilized contrast in this
    7       case?
    8   A   If he had the needle in the aorta and injected
    9       dye, it would have had a rapid rush towards the
   10       head, instead of towards the left hip, a slower
   11       progression towards the left hip.
   12   Q   I think previously, we were discussing that your
   13       view is that contrast can be used either before
   14       or after the advancement of the actual needle?
   15   A   I should clarify that then.  It can be used
   16       before to stain the atrial septum to show that
   17       you are there, but that is no substitute for
   18       assuring that you are uniquely in the left
   19       atrium with the needle before passing the rest
   20       of the system over it.
   21   Q   Has NASPE or ACCHE or any other body promulgated
   22       policies upon transseptal puncture technique?
   23   A   I don't believe so.  And NASPE is a past entity.
   24       It is now Heart Rhythm Society, HRS.
   25   Q   Oh, thank you.  It was NASPE as of 2004;
                                                               0085
    1       correct?
    2   A   The change occurred about then.
    3   Q   Okay.  So fair to say that as of 2004, there was
    4       not a protocol or policy issued by --
    5   A   Our society.
    6   Q   -- any of the societies that might be taken as
    7       authoritative on the transseptal puncture
    8       technique, and what is required?
    9            MR. PERRY:  Object to the foundation.
   10            MS. PLANT:  Okay.
   11            MR. PERRY:  Go ahead.
   12   A   Correct.
   13   Q   Obviously, you're familiar with many of the
   14       techniques that are utilized at your hospital;
   15       are there any other facilities where you know
   16       what their various techniques are that they use
   17       for transseptal puncture?
   18   A   Yes.
   19   Q   What are the institutions that you're familiar
   20       with?
   21   A   At the University of California, San Francisco,
   22       intra-cardiac echo is used extensively.  At
   23       Brigham, in the Women's Hospital, that is used
   24       plus angioplasty guidewire by some of the
   25       workers.  I don't know of anybody right off who
                                                               0086
    1       uses only dye.
    2   Q   I think you mentioned Dr. Pappone previously?
    3   A   Uses pressure monitoring.
    4   Q   Oh, he does pressure monitoring, in your
    5       recollection?
    6   A   Uh-huh.  Some will use a combination of
    7       techniques, pressure monitoring and
    8       intra-cardiac echo, or pressure monitoring plus
    9       dye injection or angioplasty guidewire.
   10   Q   You have produced a number of journal articles
   11       for me.  What were you looking for when you did
   12       your medical literature search?
   13   A   I was not really looking for anything.  I was
   14       providing some background material for
   15       Mr. Perry.
   16   Q   Okay.  So this was to educate Mr. Perry in the
   17       procedure?
   18   A   Types of procedures for treatment of atrial
   19       fibrillation, as well as the transseptal
   20       technique.
   21   Q   Are any of the articles or chapters that you
   22       provided, is it your position that any of these
   23       articulate a standard of care?
   24   A   I think, in that they are all, as they address
   25       the topic, are in agreement about the
                                                               0087
    1       transseptal technique, the importance of
    2       affirming left atrial location, that they do set
    3       that standard of care.  They don't speak to one
    4       unique method of affirming that.
    5   Q   Is the Journal of the American College of
    6       Cardiology a reliable and authoritative journal?
    7   A   It is reliable.
    8   Q   Okay.
    9            MR. PERRY:  Journal of the American College
   10       of Cardiology?
   11            MS. PLANT:  JACC.
   12            MR. PERRY:  Thanks.
   13   Q   Are you familiar with an article from JACC that
   14       discusses a survey that was done in Italy of
   15       transseptal catheterization techniques?
   16   A   No, I'm not.
   17   Q   Would that be something that would reasonably
   18       speak to what reasonably prudent
   19       electrophysiologists do in utilizing precautions
   20       for a transseptal technique?
   21            MR. PERRY:  I'm going to object, that's --
   22       I'm sorry, you said an article of a study in
   23       Italy?
   24            MS. PLANT:  Correct.
   25            MR. PERRY:  And you're asking if it is what
                                                               0088
    1       reasonably prudent physicians in the U.S. would
    2       do?
    3            MS. PLANT:  I  was asking if it was a --
    4       what -- would it speak to what a reasonably
    5       prudent physician would do.
    6            MR. PERRY:  I'll object to the fact that it
    7       is a --
    8   A   Without reading it, I can't speak to that.
    9   Q   Why don't I give you a second and let you look
   10       at it, and share it with Mr. Perry, as well.
   11            MR. PERRY:  Thanks.
   12            (A discussion was held off the record.)
   13   Q   Would the use of ICE alone be sufficient as a
   14       precaution for proper placement of a transseptal
   15       catheter?
   16   A   If one can clearly visualize where the needle is
   17       at, at all times, and confirm that it is in the
   18       left atrium, that should be adequate.
   19   Q   Would the use of a pigtail catheter in the aorta
   20       alone suffice, in addition to fluoroscopy, for
   21       placement of a transseptal catheter?
   22   A   No, it would not.
   23   Q   Does your interpretation of this article
   24       indicate that the individuals were using a --
   25       strike that question.
                                                               0089
    1            Do you take from this article that there
    2       are electrophysiologists who use only that
    3       approach?
    4   A   Yes.
    5   Q   Okay.
    6            MR. PERRY:  I'm sorry, "only that approach"
    7       being the pigtail?
    8            MS. PLANT:  Correct.
    9   Q   And is it your testimony that those
   10       electrophysiologists are practicing beneath the
   11       standards of care?
   12   A   Yes.  And I would note that those
   13       electrophysiologists do, on average, over a
   14       hundred procedures a year.  And it is noted that
   15       they are highly experienced centers.
   16            Now, I believe Dr. Cockrell stated that he
   17       was ranging up towards 12 to 15 procedures per
   18       year around this time.  And that is not the same
   19       level of experience, in my estimation.
   20   Q   Okay.  So my understanding was that you said,
   21       yes, that is beneath the standard of care?
   22   A   In a very practiced, experienced operator, to
   23       use the tools that they suggest in this article
   24       is I don't think outside of the standards of
   25       care.
                                                               0090
    1            Now, they note in this article, that if
    2       only the needle punctures a structure that it
    3       shouldn't, it can be withdrawn without adverse
    4       sequella.  One has no way of knowing if the
    5       needle is in -- if you have only gone through
    6       with a needle unless some other method is used.
    7            So for them to say that we didn't use any
    8       other method to confirm where we are, but we
    9       only went through into a wrong space with a
   10       needle, they had to have had some other method,
   11       in those cases.  Otherwise, they would have put
   12       the whole sheath where they shouldn't have been,
   13       and would have encountered a complication.  Am I
   14       being unclear?
   15   Q   To me, which only means that I'm not
   16       understanding.
   17   A   Okay.
   18   Q   You're talking about some of the complications
   19       described in the article?
   20   A   Uh-huh, yes.
   21   Q   And those don't necessarily correlate with the
   22       individuals who are using just a pigtail
   23       catheter in the aorta?
   24   A   Well, if you're using a pigtail catheter in the
   25       aorta, and your needle goes posterior to that,
                                                               0091
    1       such that it looks like you are not in the
    2       aorta, unless you have some other way of
    3       confirming that that needle is not in the aorta,
    4       you don't know that it is not.
    5            If the needle is outside of the heart, way
    6       behind the left atrium, a pigtail catheter in
    7       the aorta is of no avail.  You have to -- in
    8       order to recognize that only the needle is in a
    9       place where it shouldn't be before the entire
   10       sheath, dilator and sheath are passed over it,
   11       you have to have some other method of knowing
   12       where that needle is.
   13   Q   Okay.  So in your view, the individuals who are
   14       described in this paper as using only that
   15       precaution, only a pigtail catheter in the
   16       aorta, are practicing beneath the standard of
   17       care?
   18            MR. PERRY:  Objection, asked and answered.
   19   A   That is not what I said.  I said these highly
   20       experienced individuals, who average over a
   21       hundred procedures a year, and who, when they
   22       encounter a situation in which, hey, this
   23       doesn't seem right, are using some additional
   24       modalities.  They don't say that, but they have
   25       to have; otherwise, they wouldn't have pulled
                                                               0092
    1       the needle back and not entered into
    2       complications.
    3   Q   So you're assuming -- I think what you're
    4       assuming is that they have not identified being
    5       in the wrong place based on the location of the
    6       pigtail catheter?
    7   A   Correct.
    8   Q   Because you don't think that that is enough to
    9       tell someone where they are?
   10   A   Correct.
   11   Q   But that's just your supposition; correct?
   12   A   Well, I think it is a very good inference,
   13       because if they didn't use some other method of
   14       finding out where their needle was when it was
   15       in a wrong location, they would have gone ahead
   16       with the much larger-diameter dilator and
   17       sheath, and made a large hole and ended up
   18       leaking somewhere.
   19   Q   Wasn't the purpose of the survey that they did
   20       to ask what precautions are you using?
   21            MR. PERRY:  I'm going to object.  It is
   22       argumentative.  And this is a survey that the
   23       doctor had about five minutes to read, sitting
   24       at his deposition.  Go ahead.
   25   A   Well, it says it is an informal, voluntary
                                                               0093
    1       survey.  The data may be biased with reporting
    2       accuracy, one way or another.  So it is a
    3       survey, like any survey, as a -- it is not a
    4       rigorously controlled scientific study.
    5   Q   So even though on the face of the article, it
    6       describes people who are using only one
    7       precaution, and others who are using no
    8       precautions, your assessment is they actually
    9       are using more than what's been reported; is
   10       that correct?
   11            MR. PERRY:  Objection, argumentative,
   12       characterization, asked and answered.  Go ahead.
   13   A   My assessment is that if they were using no
   14       method whatsoever, they could not have figured
   15       out that the needle was in the wrong place.
   16       Because it can look good on fluoroscopy, which
   17       is the only method they would have been using,
   18       if no other corroboration, and yet be in the
   19       wrong place.  And fortunately, they were smart
   20       enough, experienced enough, having done it
   21       hundreds of times, to have suspected that
   22       this -- there's something wrong here.
   23            MS. PLANT:  May I have that for a second?
   24            MR. PERRY:  Sure.
   25   Q   You didn't mention, when we were talking about
                                                               0094
    1       precautions, transesophageal echocardiogram; is
    2       that another acceptable method of verifying
    3       location?
    4   A   It can be used, yes.  It is not very extensively
    5       used.
    6   Q   Okay.  I just wanted to make sure I have a
    7       completed list and understanding of the various
    8       ways.  It sounds like there are many ways, but I
    9       wanted to make sure I understand what are all of
   10       the different ways that one can comply with the
   11       standard of care in verifying the location, from
   12       your perspective.
   13   A   And of course, that's a transesophageal echo
   14       done at the time the needle is trying to pass
   15       through the atrial septum.
   16   Q   Right, okay.  So that contemporaneous TEE would
   17       be an appropriate precaution?
   18   A   It is an additional useful modality.
   19   Q   And if you used that, you wouldn't need to use
   20       anything else to comply with standards of care?
   21   A   If it told you that you were uniquely in the
   22       left atrium with your needle, before passing the
   23       dilator and the sheath, usually it should be
   24       able to.  But it can be difficult to get stable
   25       images of the atrial septum with the beating
                                                               0095
    1       heart with a transesophageal echo.
    2   Q   How does it tell you that you're uniquely in the
    3       left atrium, visually?
    4   A   On a screen, yes.
    5   Q   Okay.  And you have never tried that system?
    6   A   I have not.  No, I'm sorry, I have once, many,
    7       many years ago.
    8   Q   Okay.  And it sounds like it didn't stick; you
    9       didn't like it?  Why did you abandon it?
   10   A   Well, it is an additional piece of equipment
   11       that's difficult to fit in with all of our
   12       fluoroscopy stuff.  There is another person
   13       there that's looking at it.  Somebody has to be
   14       manipulating the transesophageal probe.  And
   15       they don't like radiation when you're doing
   16       fluoroscopy.  And the images, I -- end up being
   17       not quite suitable.
   18   Q   So in either using ICE or a contemporaneous TEE,
   19       those are two systems where what you're doing is
   20       visually plotting, seeing where you are with
   21       respect to the patient's anatomy?
   22   A   Correct.
   23   Q   And in a system where you use electrocatheters
   24       and take them as anatomical landmarks, that's
   25       also a system where you're visually confirming
                                                               0096
    1       where you are?
    2   A   It is a -- it doesn't tell you where your needle
    3       is.
    4   Q   You can't see the needle?
    5   A   It tells you where your needle is in relation to
    6       those structures, but it doesn't tell you,
    7       you're in the left atrium.  These other imaging
    8       modalities, the sonographic imaging modalities
    9       do say, yes, my needle is at the atrial septum,
   10       it is tinting it, it is pushing it, and then it
   11       pops into the left atrium.
   12   Q   Would you agree that the use of the electrodes
   13       and the bundle of His and the coronary sinus
   14       tell you, at a minimum, where you're not?  In
   15       other words, they tell you by landmarks, by
   16       anatomical landmarks, where you are not, as far
   17       as --
   18   A   Well --
   19   Q   Go ahead.
   20   A   Well, if you're adjacent to one of those
   21       electrocatheters, and they're truly at this
   22       bundle of His and the coronary sinus, you know
   23       that you're not where you should be, in relation
   24       to the atrial septum.  And they are a guide, but
   25       individual variations in anatomy, a so-called
                                                               0097
    1       vertically related heart or a horizontally
    2       related heart, a large heart, a small heart, and
    3       so forth, variations in someone has had a
    4       partial lung removed, so the heart has shifted
    5       in the chest.
    6            They are a guide, but they are not an
    7       infallible guide as to where the center of --
    8       where the atrial septum is.  And I have been
    9       surprised on occasion, that, oh, that's where
   10       the fossa ovalis really is.  I would not have
   11       thought it was there, but there it is.
   12   Q   Did Mr. Manoogian's heart have any anatomic
   13       variations or abnormalities to it, to your
   14       knowledge?
   15   A   I believe his left ventricle was slightly
   16       dilated, but I don't recall mention of
   17       significant substantial variations in the atrial
   18       anatomy.
   19   Q   Do you agree that a bad outcome for a patient
   20       does not necessarily demonstrate medical
   21       negligence?
   22            MR. PERRY:  Objection.  You can answer.
   23   A   That is correct.
   24   Q   In other words, patients can have bad outcomes,
   25       even with the very best of care?
                                                               0098
    1            MR. PERRY:  Same objection.
    2   A   That is correct.
    3   Q   And you have had patients suffer bad outcomes?
    4            MR. PERRY:  Objection as to what you mean
    5       by "bad outcomes."
    6   A   I would characterize some outcomes as bad.
    7   Q   Have you ever had a patient die --
    8   A   Yes.
    9   Q   -- consequent to care you rendered?
   10            MR. PERRY:  Objection.
   11   A   Yes.  Subsequent to care I rendered.
   12   Q   My question was:  Was it consequent to care you
   13       rendered?
   14            MR. PERRY:  Objection as to what that
   15       means.
   16   A   I would characterize it as in spite of care I
   17       rendered.
   18   Q   Did the slight dilation of Mr. Manoogian's left
   19       ventricle, is that something you would expect to
   20       have any role or impact on proper transseptal
   21       placement?
   22   A   No.
   23   Q   Can a puncture to the fossa ovalis bleed at all?
   24   A   Well, there is some bleeding from one atrium to
   25       another, but external to the heart, no.
                                                               0099
    1   Q   Okay.  In the cases where you have encountered
    2       tamponade, were you always able to locate the
    3       source of the bleeding?
    4   A   I would say almost never.
    5   Q   And why is that?
    6   A   Well, we have several catheters in the heart
    7       simultaneously, and tamponade develops.  Blood
    8       pressure drops where you make a diagnosis of
    9       tamponade with echocardiogram.  Which catheter
   10       may have done the damage is generally not
   11       appreciable.  In a substantial number of
   12       cases -- perhaps I should back up.
   13            Years ago, we did open heart surgery to
   14       cure certain rhythm disturbances.  These
   15       patients would have electrophysiology studies
   16       prior to the procedure, the open heart surgery.
   17       And in some cases, there would be some blood in
   18       the pericardial sac when the surgeon opened up
   19       the next day or two days after our procedure,
   20       and a little bruising, typically on the right
   21       ventricle.  Probably, that's the catheter that
   22       perforates most of the time.
   23            Mr. Manoogian did not have a catheter in
   24       his right ventricle, so that's not applicable in
   25       his case.  But in the times that we see this,
                                                               0100
    1       very often, it seems to be towards the end of a
    2       procedure or actually at the end of the
    3       procedure, and catheters are being withdrawn.
    4       Presumably, they were plugging their own holes.
    5   Q   The occurrence of tamponade in and of itself
    6       doesn't necessarily mean the physician
    7       performing the procedure was negligent; right?
    8            MR. PERRY:  Objection, asked and answered.
    9       You can go ahead.
   10   A   That is correct.
   11   Q   We talked a little bit about your experience
   12       with watching other individuals have a needle
   13       stick into the aorta.  The question I want to
   14       ask is:  Do you have an opinion on whether the
   15       needle stick alone can cause tamponade?
   16   A   My impression is that it should not.
   17   Q   Okay.
   18   A   And my very, very limited experience and hearsay
   19       from others suggests that is correct.
   20   Q   Is that an opinion that you hold within
   21       reasonable medical probability?
   22   A   Yes, ma'am.
   23   Q   Do you have an opinion as to the cause of
   24       Mr. Manoogian's blood pressure drop at 1520, at
   25       1615?
                                                               0101
    1   A   1520, a variety of things could have occurred.
    2       He has had an accumulation of several milligrams
    3       of sedation, Versed, V-E-R-S-E-D, by that time.
    4       There's a notation of Propofol, P-R-O-P-O-F-O-L,
    5       infusion beginning about then.  It can drop
    6       blood pressure.
    7            It could be that he had some leakage around
    8       this perforation at that time, but not so much
    9       that it caused tamponade.  That was the 1520.
   10       You asked also about --
   11   Q   1615.
   12   A   Well, it really didn't change dramatically from
   13       1520.  There is a bump upwards, but then it just
   14       restabilized back where it was at 1615.
   15   Q   Are either of those blood pressure drops events
   16       that would have caused you concern, or caused
   17       you to do something to investigate, had you been
   18       notified of those blood pressure drops?
   19   A   Going from his 140 or so that had been
   20       relatively stable for about an hour or so prior
   21       to the initial drop, down to the 1530, I would
   22       have paused the procedure to assess as to why
   23       this would be.  That doesn't mean I would get an
   24       echocardiogram.  I would say, has he had his
   25       sedation increased, is he bleeding from the
                                                               0102
    1       groin, is he uncomfortable.
    2   Q   You would inquire of the patient?
    3   A   Inquire of the patient, inquire of the nurse
    4       anesthetist, or whoever is monitoring and
    5       providing medication for him.
    6   Q   Can you estimate how many ablations for atrial
    7       fibrillation you have done?  I'm sorry.
    8   A   No, that's fine.  Several hundred.
    9   Q   Several hundred?
   10   A   (Nods head up and down.)
   11   Q   What other procedures require a transseptal
   12       puncture?
   13   A   Ablation of left atrial tachycardia, some forms
   14       of ventricular tachycardia, in which one cannot,
   15       for whatever reason, use the retrograde aortic
   16       approach.  And those are electrophysiology
   17       procedures.  Left atrial flutters, those are the
   18       ones.
   19   Q   Are there any non-electrophysiology procedures
   20       that you're aware of that utilize a transseptal?
   21   A   That's where it started, yeah.  And those would
   22       be measurement of left atrial pressure, and/or
   23       getting into the left ventricle to measure left
   24       ventricular pressure, when the aortic valve
   25       can't be crossed for whatever reason.  Aortic,
                                                               0103
    1       in the old days, or still mitral valvular
    2       plasty, pulmonary vein dilation, some
    3       hemodynamic assessments and oxymetric
    4       assessments prior to characterization of
    5       congenital heart disease, abnormalities.
    6   Q   What is Wolff-Parkinson-White syndrome -- is
    7       that correct?
    8   A   Correct.  There are two Fs in Wolff, three
    9       names, Wolff-Parkinson-White, hyphenated.
   10            That is a disorder in which a so-called
   11       accessory pathway, or residual bundle of heart
   12       muscle connects atrium and ventricle extrinsic
   13       to the normal atrial-ventricular conduction
   14       system.  And in particular, transmits impulses
   15       from atrium to ventricle such that an
   16       abnormality shows up on the resting
   17       electrocardiogram so-called delta wave,
   18       D-E-L-T-A.
   19            Wolff-Parkinson-White Syndrome is that
   20       abnormality in young individuals with episodes
   21       of palpitations, tachycardia.
   22   Q   Is there a procedure that is geared at
   23       addressing Wolff-Parkinson-White Syndrome that
   24       involves transseptal puncture?
   25   A   Yes, ma'am.  I neglected to mention that,
                                                               0104
    1       because it is -- I so rarely see those nowadays,
    2       but yes.
    3   Q   Is it seen more rarely now than it used to be?
    4   A   Yes.
    5   Q   Do you know why?
    6   A   The individuals who have it are undergoing
    7       ablation at a rate faster than the birth rate of
    8       this abnormality.
    9   Q   In the several hundred A-Fib ablations that you
   10       have done, is it accurate to say that you have
   11       never punctured the aortic root, even with a
   12       needle?
   13   A   That is correct.
   14   Q   Okay.  So the use of fluoroscopic guidance with
   15       anatomic landmarks has safely guided you to the
   16       left atrium in hundreds of cases?
   17            MR. PERRY:  Objection.
   18   A   No.
   19            MR. PERRY:  That is not what he said.
   20            MS. PLANT:  Okay.
   21   A   I use those, and I use left atrial pressure
   22       monitoring to confirm that my needle is where it
   23       should be.
   24   Q   Does the left -- does the pressure monitor do
   25       something prior to the needle stick?
                                                               0105
    1   A   Confirms that I'm in the right atrium, but I'm
    2       not looking for that information.
    3   Q   Okay.  So in other words, the pressure has
    4       confirmed for you what you have already done in
    5       those hundreds of cases, which is, effectively
    6       punctured into --
    7   A   The correct location.
    8   Q   -- the correct location?
    9   A   Or tells me that I have punctured into the
   10       incorrect location, not necessarily the aorta.
   11   Q   And has that ever happened?
   12   A   Yes, ma'am.
   13   Q   And where have you punctured that was the wrong
   14       location?
   15   A   The right atrial free wall.
   16   Q   Can you show me.
   17   A   I really can't on there.  It is out of the plane
   18       of -- it is above the septum.
   19   Q   Okay.
   20   A   The two atria arc, kind of like two spheres.
   21       And the atrial septum, the tops of the two
   22       atria, I don't know if you can see this too
   23       well.
   24            The tops of the two atria are like this,
   25       with the septum in between there.  And as the
                                                               0106
    1       catheter with this type of bend on it -- I'm
    2       running out of hands here -- but the catheter
    3       with this type of bend on it comes up to the
    4       atrial septum, if it doesn't engage there and go
    5       into the left atrium, and continues going up and
    6       eventually does meet a perpendicular surface,
    7       the right atrial free wall, and goes in an arc
    8       very similar to what one would see going into
    9       the left atrium, but it is over the top of the
   10       left atrium.  It won't give a left atrial
   11       pressure tracing, injection of dye will not
   12       swirl towards the left ventricle.  An
   13       angioplasty guidewire will not go up the left
   14       upper vein, and intra-cardiac echocardiography
   15       will tell you, you're not in the left atrium.
   16   Q   Have you had any other occasions, apart from the
   17       time that you punctured the right atrial free
   18       wall, when you punctured the wrong place?
   19   A   No.
   20   Q   Do you know why, in the case that you punctured
   21       the right atrial free wall, why that happened
   22       apart from, I mean, you've given an anatomic
   23       description, but was there something different
   24       about that patient?
   25   A   A very large right atrium, extremely large right
                                                               0107
    1       atrium.
    2   Q   So if your practice had been to use pressures,
    3       or to use contrast in cases where there was an
    4       indication, something that would make you think
    5       that there was going to be difficulty in the
    6       transseptal path, that would be a case where you
    7       would have utilized it?
    8   A   Well, I do every case.
    9   Q   I'm using a hypothetical, the hypothetical
   10       being, if you used the contrast, or -- if you
   11       used contrast or if you used pressures on an
   12       as-needed basis, as opposed to using it in every
   13       case, this would be a case that would tell you,
   14       I need to have an extra precaution because of
   15       the patient's anatomy?
   16   A   Well, certainly.  Now, I have been in locations
   17       that I did not recognize where I was.  I was
   18       probably buried in the atrial -- the needle was
   19       buried in the atrial septum, or it may have
   20       actually exited, and -- exited the right atrial
   21       free wall, and I pulled the needle back because
   22       I was not getting the pressure tracing I needed.
   23       And but in a handful, a couple of cases, I
   24       recognized that I was definitely outside.  In
   25       the rest of the cases, I simply pulled back.
                                                               0108
    1       But I knew to pull back because the monitoring I
    2       was looking for, the signal I was looking for to
    3       say, you're safely in the left atrium, was
    4       absent.
    5   Q   So there was more than one occasion where you
    6       have punctured a place that you didn't intend to
    7       puncture?
    8   A   Yes, where my first pass with a needle did not
    9       end me up in the left atrium.
   10   Q   How many times would you say that's happened?
   11   A   Probably 40 or 50.
   12   Q   Can you estimate a percentage of cases where you
   13       have the needle puncture into a place that is
   14       not the right place?  Forty or 50 times seems
   15       like it is a large portion of the several
   16       hundred procedures.
   17   A   Well, maybe we're talking semantics.  If I
   18       extend the needle, attempting my puncture
   19       through the septum, and I don't get the left
   20       atrial recordings, or I inject dye and I see not
   21       what I want to see, I don't really know --
   22       sometimes I don't know where I am, with that,
   23       whether it is stuck in the -- it is a very thick
   24       septum, and I'm just not through it all of the
   25       way, that's probably the majority of those
                                                               0109
    1       cases, or whether it is a little bit off angle
    2       in the right atrial free wall, or have exited
    3       the right atrial free wall.
    4   Q   You would not expect a transseptal catheter to
    5       make an 8-millimeter puncture; correct?
    6   A   An 8-millimeter diameter puncture, no.
    7   Q   I understand you do consulting work, or maybe
    8       you did in the past; you do consulting work with
    9       Medtronic, Inc.?
   10   A   I do.
   11   Q   And what's your relationship with them?  What do
   12       you do with them?
   13   A   I advise them, on a very sporadic nature, as to
   14       features of implantable cardiac rhythm
   15       management devices that would be nice, or that
   16       this feature is not very useful after all.
   17   Q   Do they fund research for you?
   18   A   Periodically.
   19   Q   Do they pay you a salary or a honorarium?
   20   A   Periodically.  Honorarium, not salary.
   21   Q   That's what I meant.
   22   A   I should not say periodically.  I should say
   23       sporadically.
   24   Q   Consistent with the sporadic times that you're
   25       giving them the advice?
                                                               0110
    1   A   Yes.
    2   Q   What is the significance of a person having
    3       regurgitation at three of their valves?
    4   A   Well, that's a rather open question.  It depends
    5       on the degree of regurgitation, more than the
    6       fact of it.  There is a so-called trivial or
    7       physiologic regurgitation, particularly in the
    8       tricuspid and pulmonic valves, and the mitral
    9       valve can have a little bit as well that is of
   10       no clinical significance.
   11   Q   I'm not going to be able to find a page of the
   12       medical records, but let me take a second and
   13       see if I can.
   14            Are you familiar with correlating a trivial
   15       amount or a trace amount and a moderate amount
   16       of regurgitation with numbers, like a number of
   17       one through four?
   18   A   Sure.
   19   Q   Okay.  Assume for me that Mr. Manoogian had
   20       regurgitation at three valves, and he had a two
   21       out of four at the tricuspid, a three out of
   22       four at the mitral, and two out of four at the
   23       aortic valve.  What, if anything, does that tell
   24       you about the condition of his heart?
   25   A   Doesn't really tell me a whole lot.  He had some
                                                               0111
    1       valvular regurgitation that could be clinically
    2       significant, although individuals with just
    3       those findings can run the gamut, from very
    4       symptomatic, very limited exercise capacity to
    5       none.
    6   Q   Are you going to be rendering any opinions with
    7       respect to Mr. Manoogian's life expectancy, had
    8       he not passed away?
    9   A   I don't have any reason to suspect it would have
   10       been dramatically limited.
   11   Q   Do you have any reasons to suspect that it would
   12       have been somewhat limited?
   13   A   Individuals with left ventricular systolic
   14       dysfunction can have a decrease in life
   15       expectancy, but if it was due to his atrial
   16       fibrillation and that was cured, that might
   17       vanish.  It is speculative, either way.
   18   Q   Would Mr. Manoogian's smoking habit have
   19       affected his life expectancy?
   20   A   More than likely.
   21   Q   In a negative way?
   22   A   In a negative way.
   23   Q   Okay.  Are you able to quantify at all what
   24       effect his however-many-years smoking habit
   25       would have had on his life expectancy?
                                                               0112
    1   A   I can't quantify that.
    2   Q   Okay.  Would a depressed ejection fraction have
    3       an impact on life expectancy expectations --
    4       life expectancy?
    5   A   As I stated previously, it can, but to the
    6       degree that that might have been reversible
    7       after definitive therapy of his atrial
    8       fibrillation, I can't say.
    9   Q   Do you agree that Mr. Manoogian had moderate
   10       non-ischemic cardiomyopathy?
   11   A   One might say mild.  One might say moderate.
   12   Q   Is there any reason why a prostate infection
   13       would precipitate atrial fibrillation?
   14   A   Well, not directly.  There are some nerve
   15       reflexes that can indirectly provoke episodes of
   16       atrial fibrillation.
   17            MS. PLANT:  I can take this chance to see
   18       if Susan has any questions, and I'll go through
   19       my notes to see if I have anything else to talk
   20       about.
   21            MR. PERRY:  Susan, do you have any
   22       questions for Dr. Miller?
   23            MS. BOYCE:  I have two questions.  Hold on
   24       one second.
   25   
                                                               0113
    1   DIRECT EXAMINATION,
    2      QUESTIONS BY MS. SUSAN BOYCE:
    3   Q   Dr. Miller, can you hear me okay?
    4   A   Perfectly.
    5   Q   Okay.  I just want to put on the record that you
    6       have no opinions that any hospital personnel
    7       deviated from the standards of care at any time;
    8       correct?
    9   A   Hospital personnel?
   10            MR. PERRY:  She is asking, are you offering
   11       an opinion.
   12   A   I'm -- no.
   13   Q   That's correct?
   14   A   Correct.
   15   Q   Okay.  And you're not acknowledging in this case
   16       or contending in this case or giving any opinion
   17       whatsoever that any hospital deficiency, such as
   18       lack of equipment, insufficient equipment caused
   19       or contributed to the injury?
   20   A   I can agree with that.
   21            MS. BOYCE:  That's all I have.
   22            MR. PERRY:  Did you want some time to go
   23       over your notes?
   24            MS. PLANT:  I think I can.
   25   
                                                               0114
    1   REDIRECT EXAMINATION,
    2      QUESTIONS BY MS. MARIANNE D. PLANT:
    3   Q   A little bit of background, so we're doing this
    4       in a little reverse order.
    5            Have you ever been sued in a medical
    6       malpractice suit?
    7   A   Yes, ma'am.
    8            MR. PERRY:  Just objection.  Go ahead.
    9   Q   How many times?
   10   A   I have been named four times.
   11   Q   Are all of the cases resolved?
   12   A   Yes, ma'am.
   13   Q   Okay.  What was the nature of the allegations in
   14       those cases?
   15   A   Completely divergent.  And in what detail would
   16       you like this?
   17   Q   If you can go through them, one through four?
   18   A   Sure.  The first was in about 1989, or '90.
   19       '89, I think.  It was a case in which a
   20       gentleman had a disorder called ventricular
   21       tachycardia, a life-threatening rhythm
   22       disturbance.  In those days, we did surgical
   23       therapy, as I alluded to previously.  I feel
   24       like an old man "in those days."
   25            I was in charge of the intraoperative
                                                               0115
    1       mapping, the electrophysiological mapping,
    2       telling the surgeon, this is the spot, or that's
    3       the spot.  And as such, I dealt with the
    4       patient's -- a lot of the patient's management
    5       before and after the procedure.  The gentleman
    6       came into the hospital with this disorder,
    7       multiple episodes requiring shock treatment.
    8            And he was scheduled for a surgical
    9       procedure on a Friday morning.  He came into the
   10       hospital on a Thursday.  We were all set to do
   11       it Friday.  Thursday night, he had recurrent
   12       episodes and severe hemodynamic decompensation.
   13            And at about 2:00 in the morning, after a
   14       couple of phone calls, I said, "We have got to
   15       go.  We have to not wait until 6:00 in the
   16       morning.  We have to go now."
   17            So we called in the anesthesiologist and
   18       the perfusionist and the surgeons.  And we were
   19       doing CPR on him going down to the operating
   20       room.  The procedure went very smoothly.
   21            When the surgeon removed, cut out the
   22       section of the heart that was responsible for
   23       the rhythm disturbance, it was a thinned out
   24       area.  And he ended up cutting too deeply.  This
   25       was in the septum, the partition between the two
                                                               0116
    1       ventricles.  You can't know how thick that is,
    2       you just cut.  And it ended up with a little
    3       leak between the two ventricles.  He patched
    4       that over, and the procedure continued.
    5            The man did phenomenally well.  And no
    6       rhythm disturbances thereafter.  Through the
    7       course of the next day and on Saturday, he was
    8       doing so well, his blood pressure was actually
    9       too high.  And he was in ICU.  And suddenly, he
   10       dropped his blood pressure severely.
   11            Could not figure out what was going on.  So
   12       the surgeons opened up his chest in the ICU.
   13       There was no blood around the outside of the
   14       heart.  He had blown this patch between the two
   15       ventricles.  And so they rushed him down to the
   16       operating room to try to repair this, but it was
   17       too late, and he expired in the operating room,
   18       and thence to the morgue on a Saturday.  And his
   19       records were lost somewhere.
   20            And his wife remembered my name, because I
   21       had dealt with her, trying to reassure her and
   22       so forth.  And I was served with a suit thereby.
   23       There being no records, it was a couple of years
   24       later that the suit was brought, there being no
   25       records, no one could say exactly what, it was
                                                               0117
    1       all recollection.  And that ended up being
    2       settled before deposition.  Any questions with
    3       that?
    4            Okay.  A second was in about 1997, or -8,
    5       '97, in which a woman came into the hospital
    6       over the July 4th holiday, and was having some
    7       chest pain, and was scheduled for a cardiac
    8       catheterization, I believe, the following
    9       Tuesday or so.
   10            Somehow, over the weekend, she had a
   11       cardiac arrest and expired in the hospital.  I
   12       had never taken care of her, had never seen her.
   13       I had never offered any opinions, but I had read
   14       two of her electrocardiograms in a stack of the
   15       electrocardiograms when she was hospitalized.
   16       And I was named in that proceeding.  I had to
   17       give a deposition as a defendant, of which I was
   18       dismissed.
   19            The third time I was sued by a woman who I
   20       did see.  She was not represented.  She
   21       cross-sued herself.  And she had come into the
   22       emergency room one evening with a headache, and
   23       was found to have an extremely high blood
   24       pressure, was given some medication for that,
   25       and had some shortness of breath or chest pain.
                                                               0118
    1       And that's when they called in our team.
    2            I was not in the hospital at that time, but
    3       my interns and residents saw her, gave her some
    4       medication.  Because of her risk factors, the
    5       next morning when I saw her, we recommended a
    6       stress test.  She declined and wanted to go
    7       home.  We let her go home.
    8            A year or two later, she brought suit,
    9       again on her own behalf, alleging that I had
   10       seen her in the emergency, and all she wanted
   11       was something for her headache, and I refused to
   12       give something for her headache, instead ramming
   13       two syringe-fulls of a medication called Lotrel,
   14       L-O-T-R-E-L, into her veins, at which point she
   15       had a cardiac arrest, saw God, flopped off the
   16       stretcher, and somehow managed to get back on
   17       the stretcher, after which she was left with a
   18       rash.
   19            And I had not seen her in the emergency
   20       room.  She did not get this medication by vein,
   21       which doesn't even come by a vein.  She didn't
   22       get the medication at all.  She didn't have the
   23       cardiac arrest.  She didn't flop on the floor,
   24       but I couldn't dispute that she might have had a
   25       rash afterwards.  That case was dismissed.
                                                               0119
    1            And the last one was a gentleman who
    2       underwent atrial fibrillation ablation that was
    3       successful.  And I do not know what the nature
    4       of his complaint was.  He again represented
    5       himself, without legal counsel, and the case was
    6       dismissed.
    7   Q   And what was the year, approximate time of the
    8       third and fourth cases?
    9   A   The third one was brought 2004, early 2005.  The
   10       last one was earlier this year, February or
   11       March, sometime like that.
   12   Q   Okay.  Have you ever worked with Mr. Perry's
   13       office before?
   14            MR. PERRY:  Objection, you can answer.
   15   A   I don't believe so.
   16   Q   How did you first become involved in the
   17       Manoogian case?
   18   A   I was contacted -- trying to remember how and
   19       when.  I don't -- I don't believe -- I believe
   20       it was a different attorney, Mr. Duncan
   21       or Dobson or some such, Duncan, I think.
   22   Q   Were you told who the electrophysiologists
   23       involved were?
   24            MR. PERRY:  Objection.  You can answer.
   25   A   Not, I don't think at the first blurb, I was.
                                                               0120
    1   Q   Do you know or know of Dr. Cockrell or Dr. Lee,
    2       separate from having reviewed this case?
    3   A   No, ma'am, I don't.
    4   Q   Do you know Dr. Hugh Calkins, and is he someone
    5       who is considered one of the national experts in
    6       atrial fibrillation ablation?
    7   A   I would say --
    8            MR. PERRY:  Objection.
    9   A   -- I would agree with that.
   10   Q   How often in your career have you reviewed
   11       medical malpractice cases as an expert?
   12            MR. PERRY:  Just so I don't keep
   13       interrupting, I just object to these lines of
   14       questions.
   15   A   How often or how many?
   16   Q   How many, either way, whatever way you think of
   17       it.
   18   A   Oh, over the years, probably a dozen, maybe
   19       slightly more, but not dramatically more.
   20   Q   And do you know, of the approximately dozen, how
   21       many are for the plaintiff and how many are for
   22       the defendant?
   23   A   I would have to say it is pretty evenly
   24       balanced.
   25   Q   Have you ever testified in Maryland before?
                                                               0121
    1   A   I don't think so.
    2   Q   Or I should say ever?
    3   A   Have I testified in court?
    4   Q   Have you testified in court, in any court?
    5   A   Yes.
    6   Q   Okay.  Where have you testified?
    7   A   Pennsylvania and Connecticut and Florida.
    8   Q   Have you ever testified in either depositions or
    9       trial in a case involving an allegation of
   10       improper transseptal placement?
   11   A   I don't believe so.
   12   Q   What do you charge for review of medical
   13       records, and what do you charge for testimony as
   14       an expert?
   15   A   For medical records it is $500 an hour, that's
   16       whatever, review, conversations, so on.  For a
   17       day like today, it is $2,000 for three hours and
   18       I think $750 an hour thereafter.  And for trial
   19       testimony, I believe it is 3,500 per day and
   20       travel expenses.
   21   Q   Do you know how much time you have spent on this
   22       case, up until the time of your deposition
   23       today?
   24   A   I keep track of that, but I don't know.  I don't
   25       know what the tally is right off.
                                                               0122
    1   Q   Have you sent a bill to Mr. Klores' office?
    2   A   Huh-uh.
    3   Q   Huh-uh?
    4   A   I don't believe so.  Nothing recent, anyway.
    5   Q   How do you keep track of your time, is it in the
    6       computer?
    7   A   Yes.
    8   Q   So is that something that you would be able to
    9       access if you had access to your computer?
   10   A   Yes.
   11   Q   Can you provide that to Mr. Perry --
   12   A   Gladly.
   13   Q   -- afterwards?
   14            MR. PERRY:  Does that mean I have to pay it
   15       then?
   16            MS. PLANT:  And if you would provide it to
   17       me, Mr. Perry, I would be appreciative.
   18            MR. PERRY:  Sure.
   19   Q   We've talked a little bit about what materials
   20       you have reviewed.  I see you have a pile over
   21       there, medical records and deposition
   22       transcripts?
   23   A   Dr. Lee, my CV, this scratch, Dr. Cockrell, and
   24       this stuff.  Oh, here's a couple of cover
   25       letters for transmittal of these items here,
                                                               0123
    1       which is photomicrographs of Mr. Manoogian's
    2       histopathology.  I think this is some --
    3   Q   That is not something I have seen before.  May
    4       I?
    5            MR. PERRY:  May I see it before you?
    6   A   I have an event log from the electrophysiologist
    7       study ablation, both the Purcka system -- it is
    8       not called as such, but that is what it is, and
    9       Carto, C-A-R-T-O.  Purcka is P-U-R-C-K-A.  And
   10       autopsy findings.  And much of this is
   11       redundant, similar to what is in here.
   12            MR. PERRY:  I can represent to you that
   13       these, I believe, were prepared by Dr. Hutchins.
   14       I'd be happy to give you copies.
   15            MS. PLANT:  Off the record.
   16            (A discussion was held off the record.)
   17            MR. PERRY:  I'll give copies if you agree
   18       to give me a copy of your article.
   19            MS. PLANT:  You can have it.
   20            MR. PERRY:  Thanks.  We will have to make
   21       copies of those.  That may be the doctor's only
   22       copy.
   23   Q   Okay.  I may have already asked you this, so I
   24       apologize.
   25            Do any of the journals or chapters that you
                                                               0124
    1       have provided, do you assert that any of these
    2       articulate the standard of care?
    3            MS. PLANT:  We did.
    4            MR. PERRY:  I object.  Asked and answered.
    5            MS. PLANT:  We don't need to go through it
    6       again.
    7   Q   Have you consulted any other healthcare
    8       providers in reaching your opinions in this
    9       case, for example, have you spoken with any
   10       other electrophysiologists about what is
   11       required by the standard of care?
   12   A   No.
   13   Q   I understand Mr. Perry gave you information
   14       about what Dr. Militano said in deposition.
   15            Were there any other communications from
   16       Mr. Perry that formed the basis of your opinions
   17       in this case?
   18   A   I don't think so.
   19   Q   Okay.  I shouldn't limit it.  Any information
   20       that you were provided by any of plaintiff's
   21       counsel that resulted in your rendering any
   22       of -- certain of your opinions in this case?
   23   A   I can't think of any.
   24   Q   Okay.  Is there any other literature that you
   25       found when you did your literature search, apart
                                                               0125
    1       from what you have provided today?
    2   A   Well, as I say, I was not doing it for
    3       information for me.  I was doing it for
    4       information for Mr. Perry.
    5   Q   Okay.
    6   A   So the short answer is no.
    7   Q   Okay.
    8   A   I'm sorry.
    9   Q   That's okay.  Did you know Mr. Manoogian?
   10   A   I did not.
   11   Q   Do you know any of the experts who have been
   12       designated in this case?  Are you aware of who
   13       the experts who have been designated in this
   14       case are?
   15   A   I've been told of some.
   16   Q   And who are you aware of, and who do you know?
   17   A   Dr. Fred Morady, M-O-R-A-D-Y.
   18   Q   How do you know him?
   19   A   Oh, we've been friends for umpteen years.  He's
   20       a very well-regarded electrophysiologist.  And
   21       Dr. Calkins, who you mentioned, Hugh,
   22       C-A-L-K-I-N-S.  And Dr. Laurence -- I believe, a
   23       U, Laurence, starts with an L -- Epstein,
   24       E-P-S-T-E-I-N, whom I've known since he was one
   25       of our trainees.
                                                               0126
    1   Q   Do you know Dr. Platia?
    2   A   Yes, I'm sorry.  Ed Platia, P-L-A-T-I-A.
    3   Q   And how do you know him?
    4   A   Well, we all kind of ran in the same circles for
    5       years.  Well, that doesn't sound right, does it?
    6   Q   Is it your opinion that needle of -- let me
    7       strike that and start over.
    8            Do you have an opinion that you hold within
    9       reasonable medical probability that a puncture
   10       with a needle only and not the catheter or
   11       dilator, that that is essentially something that
   12       can happen with relative impugnity?
   13            MR. PERRY:  Objection.
   14   A   I believe experience, and a limited experience,
   15       and what limited data there are, suggests that
   16       that is the case.
   17   Q   Have you ever done a literature search to
   18       investigate whether complications arising from a
   19       needle puncture have been reported?
   20   A   I was given a literature search just today.
   21       That's my only experiences in the literature
   22       that addresses that point specifically.
   23            MS. PLANT:  Thanks for your patience.  I
   24       think we're just about finished.
   25   By Ms. Plant:
                                                               0127
    1   Q   Going back to that article just for a moment, do
    2       you have any knowledge, one way or the other, as
    3       to whether the breakdown that's shown in that
    4       survey, or that article, of the techniques and
    5       tools used, whether that would also be the same
    6       if a survey was done in the United States?  Do
    7       you have any basis for saying it would be
    8       different?
    9   A   Well, I think our tools are the same as theirs.
   10       I can't -- I can't say what proportion might be
   11       used overall.
   12            MS. PLANT:  Okay.  I have no further
   13       questions.
   14            MR. PERRY:  Susan, any other questions?
   15            MS. BOYCE:  No, I don't have any questions.
   16            MR. PERRY:  Okay.  I think we're done then.
   17       We would read it.
   18          AND FURTHER DEPONENT SAITH NOT.
   19   
   20   
                                ___________________________
   21                            JOHN M. MILLER, M.D.
   22   
   23   
   24   
   25   
                                                               0128
    1   STATE OF INDIANA           )
                                   )  SS:
    2   COUNTY OF MARION           )
    3   
    4         I, Victoria S. Stuart, RPR, a Notary Public in
    5    and for the County of Marion, State of Indiana, at
    6    large, do hereby certify that JOHN M. MILLER, M.D.,
    7    the deponent herein, was by me first duly sworn to
    8    tell the truth, the whole truth, and nothing but
    9    the truth in the aforementioned matter;
   10         That the foregoing deposition was taken on
   11    behalf of the Defendants at the offices of Indiana
   12    University School of Medicine, Krannert Institute
   13    of Cardiology, 1801 North Senate Avenue,,
   14    Indianapolis, Marion County, Indiana, on the 19th
   15    day of July, 2006, at 2:00 p.m., pursuant to the
   16    applicable Maryland rules;
   17         That said deposition was taken down in
   18    stenograph notes and afterwards reduced to
   19    typewriting under my direction, and that the
   20    typewritten transcript is a true record of the
   21    testimony given by the said deponent;
   22         And that signature was requested by the
   23    deponent and all parties present;
   24         That the parties were represented by their
   25    counsel as aforementioned.
                                                               0129
    1         I do further certify that I am a disinterested
    2    person in this cause of action, that I am not a
    3    relative or attorney of either party or otherwise
    4    interested in the event of this action, and that I
    5    am not in the employ of the attorneys for any
    6    party.
    7         IN WITNESS WHEREOF, I have hereunto set my
    8    hand and affixed my notarial seal on this _______
    9    day of July, 2006.
   10   
   11   
   12                                 N O T A R Y   P U B L I C
   13   
   14   My Commission Expires:
   15   June 2, 2008
   16   County of Residence:
   17   Marion County
   18   
   19   
   20   
   21   
   22   
   23   
   24   
   25