Arrhythmia

Updated: Cardiologist in pacemaker insertion dispute


Update: Since the publication of this article the Supreme Court has ruled that the reprimand should be set aside and the conditions imposed on Dr Chatoor’s licence to practise should be removed.  See the full updated article here.

A cardiologist working in regional NSW has lost his appeal to overturn a reprimand for inappropriate insertion of a cardiac pacemaker.

The Civil and Administrative Tribunal of NSW has upheld a verdict that Dr Roger Chatoor was guilty of unsatisfactory professional conduct in 2014 when he inserted a dual-chamber pacemaker in a 92-year old woman when there was doubt about whether she had complete heart block.

It also found that Dr Chatoor had failed to ensure there was adequate medical review of the patient when she was discharged from hospital after undergoing the procedure.

Dr Chatoor had appealed against a reprimand delivered by the Professional Standards Committee of the NSW Medical Council in 2018 for his actions. He also sought to remove supervision conditions imposed by the Council, which he claimed were onerous and unnecessary.

The case centred on whether it was good professional practice to insert a pacemaker in an elderly female patient where there was uncertainty about whether she had symptomatic bradycardia and whether her condition may have been related to her use of the calcium channel blocker diltiazem.

After hearing evidence from several cardiologists, the tribunal concluded that diltiazem was a potential cause for the patient’s bradycardia and she should have been monitored following its withdrawal to see how the symptoms responded before going ahead with the pacemaker procedure.

“Dr Chatoor did not give enough attention to the possibility that diltiazem was a reversible cause contributing to her symptoms. Rather than insert a pacemaker, he should have contemplated a conservative strategy and discussed this with the patient and her family,” the tribunal stated.

It concluded that a pacemaker had been inserted without sufficient clinical indication in circumstances where ECGs and tracings were not consistent with complete heart block but with Second Degree Type I AV block, which is not in itself an indication for permanent pacing.

“Inserting a pacemaker in Patient A fell significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience,” the tribunal stated.

The patient’s discharge from Gosford Private Hospital without adequate medical review also constituted unsatisfactory professional conduct, according to the tribunal. It was told the patient was transferred back to Dubbo Private Hospital without any written arrangements being made for cardiologist review, conduct described by expert witness Professor Michael Jelinek as “unconscionable” and “appalling”.

The tribunal noted that Dr Chatoor still believed his decision to insert the pacemaker was a matter for professional judgment based on differences between US and European guidelines.

For this reason, it recommended he remain under regular monthly supervision by another cardiologist and be required to maintain logs of the second opinions, patient details and procedures.

“This apparent lack of understanding makes it necessary to continue with these conditions for another two years,” the tribunal ruled.

It noted that since the 2014 incident, Dr Chatoor had been suspended from Dubbo Base Hospital and is currently working at Dubbo Private Hospital, Lingard Private Hospital in Newcastle and for an Aboriginal Health Service.

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