0001 1 IN THE COURT OF COMMON PLEAS CUYAHOGA COUNTY, OHIO 2 3 AMNE ORRA, INDIVIDUALLY 4 VS. CASE NO. CV-07-645828 JUDGE BRIDGET MCCAFFERTY 5 CLEVELAND CLINIC FOUNDATION, ET AL. 6 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 7 VIDEOTAPED DEPOSITION OF 8 ROOSEVELT BRYANT, III, MD 9 June 6, 2008 10 9:04 a.m. 11 Houston Marriott Medical Center Hotel 6580 Fannin Street 12 Houston, Texas 13 Judy H. Gallo, CSR 14 15 16 17 18 19 20 21 22 23 24 25 0002 1 APPEARANCES 2 . 3 FOR THE PLAINTIFF(S): 4 JESSICA A. PERSE (0078823) 5 AND RONALD MARGOLIS, ESQUIRES 6 BECKER & MISHKIND CO., L.P.A. 7 Skylight Office Tower 8 1660 West 2nd Street, Suite 660 9 Cleveland, Ohio 44113 10 . 11 FOR THE DEFENDANT(S): 12 INGRID KINKOPF-ZAJAC, ESQUIRE 13 ROETZEL & ANDRESS 14 1375 East Ninth Street 15 One Cleveland Center, 9th Floor 16 Cleveland, Ohio 44114 17 . 18 ALSO PRESENT: 19 ROY LANGLEY, VIDEOGRAPHER 20 . 21 . 22 . 23 . 24 . 25 . 0003 1 Videotaped Deposition of 2 Roosevelt Bryant, III, M.D. 3 June 6, 2008 4 THE VIDEOGRAPHER: This is the 5 video-taped deposition of Dr. Roosevelt Bryant 6 being taken on June 6, 2008. The time is 7 approximately 9:04 a.m. We are now on the 8 record. 9 ROOSEVELT BRYANT, III, MD, having 10 been first duly sworn, testified as follows: 11 DIRECT EXAMINATION 12 BY-MS.PERSE 13 Q. Good morning, Doctor? 14 A. Good morning. 15 Q. We had a brief opportunity to 16 introduce ourselves before the deposition, but 17 I wanted to let you know that I'm -- my name 18 is Jessica Perse, and I'm the attorney 19 representing the Orra family in this matter. 20 A. Pleasure to meet you. 21 Q. Likewise. I think that it's 22 important to emphasize since we're not having 23 a face-to-face meeting and we're forced to 24 deal with the confines of telephonic 25 communication, I wanted to make sure that if 0004 1 you don't hear me well or understand what I'm 2 asking, please ask me to clarify. 3 A. Sure. 4 Q. And, likewise, it's important that 5 you do your best to answer the question as 6 clearly, and I may be occasionally asking you 7 to speak up, so that I can be sure that I 8 understand your answer. 9 A. Okay. 10 Q. Is that okay with you? 11 A. Absolutely. 12 Q. Okay. Have you ever had your 13 deposition taken before? 14 A. Once before. 15 Q. Okay. And even though you had 16 your deposition taken before, I just want to 17 make sure that you and I are communicating 18 with each other. 19 A. Okay. 20 Q. And it's important that we do 21 answer and have an exchange with complete 22 questions and answers, so the court reporter 23 can accurately record our exchange. Is that 24 okay? 25 A. Sure, it is. 0005 1 Q. It's important that I ask my 2 question full -- ask my question fully and 3 before you answer. Is that all right? 4 A. Absolutely. 5 Q. And I will do my best not to jump 6 ahead, and I want to make sure that you have 7 an opportunity to fully answer my question. 8 So it's important that we don't talk over 9 each other. All right? 10 A. Great. Will do. 11 Q. It's important that you understand 12 that I'm going to rely on your answers that 13 you give today in -- in this deposition when 14 this case goes to trial. Do you understand 15 that? 16 A. I understand. 17 Q. Okay. Since I'm not able to be 18 present at your location. Did you bring 19 anything to today's deposition? 20 A. My briefcase for work. 21 Q. Okay. Did you bring any materials 22 for today's deposition? Specifically for 23 today's deposition? 24 A. I did not. 25 Q. Did not. 0006 1 I had sent a request to your 2 attorney or to Ms. Kinkopf, requesting that 3 you bring a CV with you. Did you bring 4 that? Did -- 5 MS. KINKOPF-ZAJAC: I have -- I 6 brought a copy of had his CV. 7 MS. PERSE: I'm sorry. 8 MS. KINKOPF-ZAJAC: I brought a copy 9 of his CV. 10 MS. PERSE: Okay. So you -- you 11 brought that along with you? 12 MS. KINKOPF-ZAJAC: Yes. 13 MS. PERSE: Okay. I'm going to 14 want -- unfortunately, since we're working 15 long-distance, I do want that marked as 16 exhibit for today's deposition. 17 MS. KINKOPF-ZAJAC: Okay. 18 MS. PERSE: Is that agreeable with 19 you? 20 MS. KINKOPF-ZAJAC: Yes. 21 MS. PERSE: Ingrid, I'm going to 22 ask you to hand the CV to Dr. Bryant, and I 23 would like him to take a moment to review 24 it. 25 A. Okay. I've looked at it. 0007 1 Q. (By Ms. Perse) Have you had a 2 chance to review the CV? 3 A. Yes. 4 Q. Okay. 5 MS. PERSE: And, court reporter, 6 can I ask you to mark that as the first 7 exhibit or Exhibit A? 8 THE REPORTER: Yes. 9 (Exhibit-A was marked.) 10 THE REPORTER: Okay. 11 MS. PERSE: Okay? 12 THE REPORTER: Yes. 13 Q. (By Ms. Perse) Doctor, how -- how 14 many pages is that CV? 15 A. Four. 16 Q. Okay. And is that your most 17 current edition, if you will, of your CV? 18 A. Actually, it -- no. It is not. 19 I've reformatted it recently. 20 Q. Okay. And when did you re -- 21 reformat or -- or revise your deposition? At 22 what time? 23 A. I haven't revised my deposition. 24 Q. I'm sorry. 25 A. I revised the CV probably three or 0008 1 four days ago. 2 Q. Would you be able to provide that 3 more current copy to your attorney, so that 4 she could forward that to me following this 5 deposition? 6 A. Yes. 7 MS. PERSE: And Ingrid, I'm going 8 to make a request on the record that I have 9 an updated CV from Dr. Bryant. 10 MS. KINKOPF-ZAJAC: That's fine. 11 But I -- I would ask that you also just 12 follow-up with a letter. 13 MS. PERSE: Sure. 14 MS. KINKOPF-ZAJAC: Okay. 15 Q. (By Ms. Perse) And, Dr. Bryant, 16 can you tell me what is -- what revisions 17 you may have made on this CV? 18 A. I basically changed the format of 19 the CV. Meaning the -- the sort of type 20 setting of the page and some of the status 21 of some of the publications on there have 22 changed. So I updated that. 23 Q. Okay. I'm going to ask you to do 24 what you can to speak up. We may -- we may 25 feel like we're yelling at each other, but 0009 1 you sound a little bit distant. 2 A. No. The format -- I changed the 3 format of the CV, the page layout of the CV, 4 and the status of some of the publications 5 has changed. 6 Q. Okay. And as far as the substance 7 of the CV. I guess I need you to clarify 8 what the status of some of the publications 9 is? 10 A. So one paper that I -- I had 11 listed under the section "Submitted 12 Manuscripts" has been accepted to a journal. 13 So that was changed. 14 Q. Okay. Are -- is there any new 15 -- are there any new publications that are 16 not recorded in the CV that we're working off 17 today? 18 A. No. No. There are not. 19 Q. Okay. And as far as anything else 20 that you may have brought to today's 21 deposition. Do you -- did you bring any 22 research that you or anyone else may have 23 conducted on your behalf relative to this 24 matter? 25 A. Well, no -- 0010 1 MS. KINKOPF-ZAJAC: Well, I'm just 2 going to make a statement there that I -- 3 that would obviously exclude anything that I 4 have done even though I'm his representative. 5 But he can tell you, you know, himself that 6 he hasn't done anything. But just so -- and 7 that would exclude anything that I have done. 8 MS. PERSE: Are you objecting? 9 MS. KINKOPF-ZAJAC: Yes. 10 MS. PERSE: Okay. That's -- I just 11 wanted to clarify that. 12 Q. (By Ms. Perse) So, Dr. Bryant, did 13 you bring anything, other -- anything else -- 14 any medical records to this deposition? 15 A. I didn't bring anything. 16 Q. Okay. So -- 17 A. Related to the case. 18 Q. Okay. Now, in terms of your CV. 19 How about let's start with just getting some 20 background information. 21 Can you state your full name, for 22 the record? 23 A. Roosevelt Bryant, III. 24 Q. And what is your current location? 25 Your current address? 0011 1 A. My home address? 2 Q. Yes. 3 A. 13005 Meadow Springs Drive, 4 Pearland, Texas. And the zip is 77584. 5 Q. And are you currently employed in 6 Texas? 7 A. I am. 8 Q. And where is it that you are 9 working? 10 A. Texas Children's Hospital. 11 Q. I'm sorry. That was Texas -- 12 A. Texas Children's Hospital. 13 Q. Okay. And how long have you been 14 working at that institution? 15 A. 11 months. 16 Q. So that brings us -- what month 17 and year did you start working there? 18 A. July of last year. 19 Q. And in what capacity are you 20 working there? 21 A. I'm a fellow in congenital heart 22 surgery. 23 Q. And is this the first year in your 24 fellowship? 25 A. It is. 0012 1 Q. And tell me, how long is a 2 fellowship in congenital heart surgery? 3 A. Well, it varies. My fellowship is 4 two years. They range from one to two 5 years. 6 Q. Okay. Prior to July of 2007, 7 let's review a little bit of your training up 8 until that point. 9 Tell me when -- about your college 10 education, undergrad and med school. Can you 11 review those for me? 12 A. Sure. 13 I went to Dillard University for 14 undergraduate school. That's in New Orleans, 15 Louisiana. I went to medical school at 16 Boston University in Boston, Massachusetts. 17 Q. And when did you graduate from 18 undergrad? 19 A. 1990. I'm sorry. Yeah. Yeah. 20 1990. 21 Q. Okay. And then at Boston 22 University. When did you graduate from 23 Boston University? 24 A. 1999. 25 Q. Okay. And between your graduation 0013 1 from undergrad to your graduation -- 2 A. Uh-huh. 3 Q. -- from medical school, did you do 4 anything, other than course work? 5 A. Sure. 6 Q. And tell me about what you did in 7 that time frame. What -- were you employed? 8 A. I was. Between college and 9 medical school, I spent two years doing 10 research. One year was at Howard Hughes 11 Medical Institute at Vanderbilt University. 12 Q. Okay. Again, I'm sorry. You said 13 Syracuse. Can you repeat that? I can't 14 hear. 15 A. So between college and medical 16 school, I was employed for two years. My 17 first year was as a research assistant at 18 Howard Hughes Medical Institute at Vanderbilt 19 University in Nashville, Tennessee. 20 Q. Okay. And what year was that? 21 A. 1990, '91. 22 Q. Okay. And what was the purpose of 23 that research? 24 A. Research. It was basic science 25 laboratory research. 0014 1 Q. Was there any focus involved in 2 that? Any special -- you know, special 3 interest involved in that? 4 A. Well, the -- the lab's focus was 5 on G protein analysis. 6 Q. And then the year following that, 7 you did some additional research. Tell me 8 about that. 9 A. Yes. I was a research assistant 10 at Boston Children's Hospital in the cardiac 11 surgery research labs. 12 Q. And for how long did you do that? 13 A. Just under a year. 14 Q. And when did you complete that 15 research? 16 A. I -- well, I was a research 17 assistant. So during the time that I was 18 there, I was accepted to medical school. 19 So -- 20 Q. And when were you accepted to 21 medical school? 22 A. In 1990. I finished that research 23 in 1991 at Boston Children's. 24 Q. I guess I am somewhat confused, 25 and I apologize. You finished your grad 0015 1 school in 1990, and you did two years of 2 research. 3 And when did you start your 4 medical school education? 5 A. 1992. 6 Q. All right. And that was at Boston 7 University? 8 A. Correct. 9 Q. Okay. When were you accepted into 10 Boston University? 11 A. I don't remember the exact date, 12 but it was during my time when I was at -- 13 doing research at Boston Children's. 14 Q. Okay. 15 A. So it would have been the year 16 before I started -- 17 Q. Okay. 18 A. -- medical school. 19 Q. And then from '92 to '99, if I 20 understood you correctly, you were attending 21 medical school at Boston University? 22 A. Yes. But two of those years were 23 spent doing research. 24 Q. Okay. And what was the focus of 25 your research during those two years? 0016 1 A. Well, I was looking at cardiac 2 development. I was at the NIH in Bethesda, 3 Maryland. And I was studying transcriptional 4 regulation of a cardiac gene that was 5 responsible for development of the heart in a 6 mouse species. 7 Q. I'm sorry. You broke up there. 8 I -- 9 A. So I was doing research at the NIH 10 in -- in -- in Bethesda, Maryland, and I was 11 studying cardiac development. 12 Q. Is a medical school education 13 typically seven years? 14 MS. KINKOPF-ZAJAC: Objection. 15 A. It can -- 16 MS. KINKOPF-ZAJAC" go ahead. 17 A. It can be if you spend time doing 18 research. 19 Q. (By Ms. Perse) Okay. Did you take 20 any other time off during that seven-year 21 period? 22 A. No. 23 Q. Any other employment during that 24 seven-year period? 25 A. No. 0017 1 Q. When you graduated in '99, what 2 did you do following your graduation? 3 A. I went to general surgery 4 residency. 5 Q. And where did you do your 6 residency? 7 A. The University of Kansas Medical 8 Center in Kansas City. 9 Q. And was that for the duration of 10 your general surgery residency? 11 A. That is correct. 12 Q. Okay. So tell me what years you 13 were at Kansas Medical Center for general 14 surgery residency? 15 A. 1999 through 2004. 16 Q. And so your internship year was in 17 1999, is that correct? 18 A. Correct. 19 Q. And then your chief residency year 20 was in 2004, correct? 21 A. Yes. 22 Q. Okay. 23 A. I really spent two years as a 24 chief resident. 25 Q. Two years? 0018 1 A. Yes. 2 Q. I guess my math -- how -- how 3 many years, total, general surgery did you 4 do? 5 A. Five. But two of those were as a 6 chief resident rather than one. 7 Q. And did you do any -- and 8 typically a general surgery residency is five 9 years, correct? 10 A. That is true. Mine was five 11 years. 12 Q. And I -- I guess you have me a 13 little stumped there on the two-year chief 14 residency. Does that mean you abbreviated 15 years two through four? 16 A. No. That just means that my last 17 two year of general surgery residency were as 18 a chief resident rather than just my last 19 year. 20 Q. Okay. And so as a PD 4, you 21 were considered a chief resident? 22 A. Yes, ma'am. 23 Q. Are you board certified in general 24 surgery? 25 A. No. 0019 1 Q. Okay. Have you taken your boards 2 in general surgery? 3 A. No. 4 Q. Have you taken any part of the 5 boards on surgery, general surgery? 6 A. No. 7 Q. From 2004 to 2007, what was the 8 substance and what were you doing during that 9 period of time? 10 A. I was a resident in cardiothoracic 11 surgery at Cleveland Clinic. 12 Q. And help me out here. Is -- is 13 that to be distinguished from a fellow in 14 cardiothoracic surgery? 15 A. At Cleveland Clinic, it is 16 distinguished. 17 Q. Tell me how they distinguish it or 18 how you understand it to be distinguished? 19 A. Well, the residency program at 20 Cleveland Clinic is for residents that are 21 pursuing certification in thoracic surgery. 22 So that is distinguished from a fellow who is 23 coming for additional training after already 24 completing a thoracic surgery residency. 25 Q. Okay. And is a thoracic -- so 0020 1 your -- to be specific, your residency at the 2 Cleveland Clinic was in thoracic surgery, 3 correct? 4 A. Yes. Or you could call it 5 cardiothoracic surgery. There are several 6 acronyms, but thoracic surgery is accurate. 7 Q. Was there any kind of certification 8 required for you to enter the thoracic 9 surgery program at the Cleveland Clinic? 10 A. Not certification, per se. The 11 requirement for all thoracic surgery residency 12 programs is to complete a five-year general 13 surgery residency program. 14 Q. Okay. And is there any 15 requirement to be certified in general surgery 16 before you undertake the thoracic surgery 17 residency? 18 A. That has changed. So at the 19 moment, it is not. 20 Q. Tell me when it has changed. 21 A. Within the last two years. 22 Q. Okay. And prior two years, be -- 23 two years ago, that would be 2006? 24 A. Yes. Well, the requirement for 25 completing general surgery certification to get 0021 1 thoracic surgery boards is something that 2 happened while I was a general surgery 3 resident, which is the reason that I didn't 4 sit for the general surgery boards because it 5 wasn't required to complete the thoracic 6 surgery residency. 7 Q. And -- and, again, you're telling 8 me that that change happened in 2006? 9 A. Well, that change happened while I 10 was a general surgery resident. 11 Q. Okay. Following your thoracic 12 surgery training or residency at the Cleveland 13 Clinic, have -- did you take -- have you 14 taken any boards? 15 A. I am sit -- no. I have not. 16 But I am sitting for the thoracic surgery 17 boards in December. 18 Q. December of 2008? 19 A. Yes. 20 Q. Tell me a little bit about those 21 boards. Is that a two-part series? 22 A. It is a two-part series. 23 Q. So the boards that you're sitting 24 for in December, are they written or oral? 25 A. That will be the written boards. 0022 1 Q. And when do you anticipate sitting 2 or taking the oral board or part two? 3 A. Whenever the date is. I think the 4 date is some time in June of 2009. 5 Q. In terms of your -- 6 A. Or 2010, it would be. Well, 2009. 7 Correct. 8 Q. I'm sorry. I'm -- I -- 9 A. I -- I don't know the exact date 10 of the -- of the orals. But usually it's in 11 June after the written. The following June 12 after the written exam. 13 Q. Now, as far as your thoracic 14 surgery boards. Do you -- are you required 15 to do a certain number of cases before you 16 can sit for the thoracic surgery boards? 17 A. Yes. 18 Q. And do you maintain a log of those 19 cases? 20 A. Yes. Well, yes. I maintained a 21 log when I was doing my adult cardiac 22 training. 23 Q. And that adult cardiac training was 24 done at the Cleveland Clinic, correct? 25 A. Yes. 0023 1 Q. And did you -- you said you 2 maintained that log while you were a 3 resident, correct? 4 A. Correct. 5 Q. And who do you provide that log 6 to, to obtain the -- or to be permitted to 7 sit for the thoracic surgery boards? 8 A. The American Board of Thoracic 9 Surgery. 10 Q. Okay. So that was something that 11 was required of you. And what, specifically, 12 do you have -- do you or did you have to 13 log for that American Board of Thoracic 14 Surgery? 15 A. In cases you -- you performed as a 16 resident. 17 Q. And what, in particular, about 18 those cases were they -- did you have to 19 format the specific type of cases that you 20 participated in? 21 A. Yes. There are categories of 22 cases. 23 Q. And did you have to also discern 24 or explain in what capacity you acted in 25 those or acted or participated in those 0024 1 specific cases? 2 A. Correct. 3 Q. And by that I mean, you would have 4 to tell the board in your log when you acted 5 as the primary surgeon? 6 A. Correct. 7 Q. As well as the first assistant? 8 A. Correct. 9 Q. And even as the second assistant? 10 A. I don't recall there being a 11 category for second assistant, but there may 12 have been. It's been a while since I looked 13 at it. 14 Q. Okay. Tell me what other 15 categories you would have available to you to 16 report to the thoracic boards as to what 17 capacity you acted in those particular cases? 18 A. Primary surgeon or first assistant. 19 I'm certain that those are two categories. 20 Q. In order to sit for the thoracic 21 surgery boards, do you have to have a certain 22 number of cases and certain types of cases? 23 A. Yes. 24 Q. And tell me what those types of 25 cases include. 0025 1 A. Well, the broad categories are 2 thorac -- adult thoracic, adult cardiac, and 3 congenital. 4 Q. And how many cases are you 5 required to do for the thoracic? 6 MS. KINKOPF-ZAJAC: I'm just going 7 to note an objection because this -- we are 8 so far afield already. And it is not 9 relevant to anything with this case. But if 10 you want to keep on going, given the time 11 constraints and the fact that we started 12 late, go on. 13 Q. (By Ms. Perse) Doctor, how many 14 thoracic surgery cases do you need to -- in 15 order to sit for the thoracic boards? 16 A. You know, I don't remember the 17 specific number, but I think it was around 18 75. I would have to go back and look to 19 really be accurate about that. 20 Q. And that would be in a -- the 21 primary -- capacity as a primary surgeon or 22 would that include primary surgeon, first 23 assistant? 24 A. Well, I think that the number is 25 for primary surgeon. 0026 1 Q. And then in terms of the 2 congenital procedures that you would have to 3 do? 4 A. My recollection of that is 10 as 5 primary surgeon. 10 as first assistant. 6 Q. And you would get those 10 as 7 primary surgeon and 10 as first assistant in 8 your capacity as a resident at -- in your 9 thoracic surgery residency at the clinic 10 ,correct? 11 A. Yes. These are minimum case 12 requirements. So, yes. I would get them as 13 a resident in thoracic surgery. 14 Q. And, generally speaking, how many 15 congenital heart cases did you log for the 16 purposes of the thoracic surgery board? How 17 many did you log as primary surgeon and first 18 assistant? Just give me -- 19 A. Well, I -- you know, I don't have 20 the numbers in front of me. I didn't 21 realize we were going to be asking these 22 questions. I don't have the numbers in front 23 of me. I don't really remember the numbers 24 off the top of my head. But I certainly met 25 the minimum requirement. I'm sure I exceeded 0027 1 the minimum requirement. 2 Q. And do we have -- do you have any 3 way to access that log to provide me that 4 information? 5 A. Not right now, I don't. 6 Q. Would you be able to? 7 MS. KINKOPF-ZAJAC: Well, I -- I'm 8 going to suggest that you write me a letter 9 to this because I don't know that this is 10 necessarily relevant to anything to do with 11 this case. So if you want to formulate a 12 request for production for this, and then I 13 can address that situation and look at 14 whatever documents he's able -- he's been 15 able to come up with and just go from that. 16 Q. (By Ms. Perse) Well, Doctor, I'm 17 just asking you as far as your -- your 18 training and experience. I want to know if 19 you would be able to provide me with the log 20 that you provided the American Thoracic Board 21 as far as your credentials for sitting for 22 that board? 23 A. Sure. I can provide you with 24 that. 25 Q. Thank you. 0028 1 Tell -- tell me a little bit -- 2 when you talk about the congenital heart 3 procedures versus the cardiac procedures. You 4 distinguished that a little bit. 5 As far as the congenital heart 6 procedures. Does that refer to adults that 7 have congenital heart surgery, or does that 8 include a pediatric population? 9 A. Well, that's a broad category of 10 congenital heart disease, but whether pediatric 11 or adult. 12 Q. So it would include -- the 13 congenital heart disease includes pediatric 14 cases, true? 15 A. True. 16 Q. Okay. And where did you do your 17 -- the surgical training for the pediatric 18 congenital heart disease? 19 A. At Cleveland Clinic. 20 Q. Okay. Is -- was there a 21 certain -- 22 A. My -- my -- during my thoracic 23 training, the requirements to -- to meet that 24 was done at Cleveland Clinic. 25 Q. And your pediatric congenital heart 0029 1 surgery rotation, if you will, at the clinic, 2 from when to when did you do that if at all? 3 A. Well, I did it. And it was under 4 the direction of the then chairman of 5 congenital heart surgery, and it was during 6 the first rotation of my second year. So, 7 that would have been 2005 to 2006. The 8 first, you know, July, August, September of 9 2006. 10 Q. I'm sorry. Can you give me those 11 years again? I -- 12 A. 2006. July through August of 13 2006, I think is -- is the correct date. 14 Q. Okay. So that was a one-month 15 rotation? 16 A. July, August, and September. 17 Excuse me. It was a three-month rotation. 18 Q. Okay. And then as far as the 19 congenital heart surgery that you would do on 20 adults. Was there a specific rotation that 21 you would have done for that? 22 A. No. 23 Q. Okay. Now, the purpose of your 24 thoracic surgical training or residency was to 25 get more training in thoracic procedures, is 0030 1 that correct? 2 MS. KINKOPF-ZAJAC: Objection. Go 3 ahead. 4 A. The purpose of my residency program 5 in thoracic surgery? 6 Q. (By Ms. Perse) Yes. 7 A. Was to become a thoracic surgeon. 8 Q. And in order to become a thoracic 9 surgeon, you needed more training -- 10 A. Yes. 11 Q. -- in thoracic procedures? 12 A. You have to train specifically in 13 thoracic surgery to become a thoracic surgeon. 14 Q. Okay. Doctor, I'm going to remind 15 you that because of the diffi -- because we 16 are taking this long-distance and we're not 17 face to face, there are times that I'm 18 completing an answer and you're answering -- 19 A. Okay. 20 Q. -- question, and you're answering 21 and vice versa. So I didn't quite get that 22 answer. 23 A. To -- 24 Q. I wanted to -- I was asking that 25 the purpose of your thoracic surgery training 0031 1 -- resi -- I'm sorry. That the purpose of 2 your thoracic surgery residency was to get 3 more training in thoracic surgery, is that 4 correct? 5 A. That's correct. 6 Q. The three months that you did your 7 pediatric rotation in your thoracic surgery 8 residency, were those done at the Cleveland 9 Clinic? 10 A. They were. 11 Q. Was there any portion of time or 12 portion of your thoracic surgery residency 13 that you did not -- were not at the 14 Cleveland Clinic proper? 15 A. No, ma'am. 16 Q. Now tell me, during -- it -- let 17 me ask first. Am I correct in assuming that 18 your residency in thoracic surgery started in 19 July of 2004? 20 A. That is correct. 21 Q. And it ended in July of 2007, 22 correct? 23 A. Correct. Well, June of 2007. 24 Q. Okay. So from July of '04 to 25 July of '05 -- 0032 1 A. From July of '07 through June of 2 '07. 3 Q. Okay. I am going year by year. 4 I'm curious what -- 5 A. I'm -- I'm just -- 6 Q. -- from July of '04 to -- to June 7 of '05. Would you have been considered a 8 first year thoracic surgery resident? 9 A. Correct. 10 Q. And then from July of '05 to June 11 of '06, you would have been considered a 12 second year thoracic surgery resident? 13 A. Correct. 14 Q. And then, obviously, the third year 15 was from July of '06 to June of '06, 16 correct? 17 A. Correct. 18 Q. Help me out. Is thoracic surgery 19 -- is there any mandatory number of years for 20 thoracic surgery residency? 21 A. I -- I wouldn't -- 22 MS. KINKOPF-ZAJAC: Objection. Go 23 ahead. 24 A. I -- I don't know if there is a 25 mandatory number. The -- the -- the length of 0033 1 time for the residency training varies from 2 one program to the next. 3 Q. (By Ms. Perse) Is there any 4 requirement from the American Board of 5 Thoracic Surgery as to a certain number of 6 years or months in training? 7 A. Well, I don't know that there is a 8 requirement in terms of number of years. 9 There is a requirement in terms of cases. 10 Q. So is it fair to say that if -- 11 if -- once -- once you complete the certain 12 number of cases, then you have completed your 13 residency? 14 MS. KINKOPF-ZAJAC: Objection. 15 A. I -- I -- I guess that's up to 16 the American Board of Thoracic Surgery. 17 Q. (By Ms. Perse) And would you agree 18 that your duties as a thoracic surgery 19 resident would -- would change from year to 20 year? 21 A. True. 22 Q. And how do they change? 23 A. You are given more responsibility 24 in terms of patient care, the types of cases 25 change, the volume of cases may change. 0034 1 Q. And could we agree that your 2 participation in a surgery as either the 3 primary surgeon or the first assistant would 4 change, based on the number of years you had 5 in your training? 6 A. That's -- that's fair. I think 7 that's probably true. 8 Q. At the clinic, is there -- is it 9 specifically three years long, or does that 10 -- do they alter the length of your 11 residency, based on the number of cases you 12 do? 13 MS. KINKOPF-ZAJAC: Objection. Go 14 ahead. Are we talking about back during his 15 residency? 16 MS. PERSE: Yes, I am. 17 MS. KINKOPF-ZAJAC: Okay. Go on. 18 A. It's in general a three-year 19 residency program. 20 Q. (By Ms. Perse) At the Cleveland 21 Clinic? 22 A. Yes. 23 Q. So a PG Level 1 would have less 24 responsibility or should have less 25 responsibility than a PG-3 thoracic surgery 0035 1 resident, correct? 2 A. In -- in -- in general. 3 Q. Now, during those three years, did 4 you work, in addition to your residency 5 training, any moonlighting, if you will? 6 A. No, ma'am. 7 Q. And in terms of your medical 8 training, did you take the national boards? 9 A. Yes. 10 Q. And when did you take the final 11 part of your national board exam? 12 A. Several months ago. 13 Q. Was that at the completion of your 14 thoracic surgery residency? 15 A. Correct. 16 Q. Now, I understand the N -- 17 national board exam is a -- I think it was a 18 three-part exam? 19 A. Correct. 20 Q. When did you take part one? 21 A. I took part one when I was in 22 medical school. 23 Q. Did you pass that on the first 24 attempt? 25 MS. KINKOPF-ZAJAC: Objection. Go 0036 1 ahead. 2 A. No. 3 Q. (By Ms. Perse) And how many 4 attempts did it take you to pass national 5 boards part one? 6 MS. KINKOPF-ZAJAC: Objection. Go 7 ahead. 8 A. Two. 9 Q. (By Ms. Perse) Do you know the 10 year that you completed, successfully completed 11 national boards part one? 12 A. No. I don't have -- I don't 13 remember that year. 14 Q. Moving onto part two of the 15 national board exam. When did you take that? 16 A. When I was in medical school. 17 Q. And how many -- did you pass on 18 the first attempt? 19 MS. KINKOPF-ZAJAC: Objection. 20 A. No. I did not. 21 Q. (By Ms. Perse) And how many 22 attempts did it take you to pass the second 23 part of national boards? 24 MS. KINKOPF-ZAJAC: Objection. 25 A. Also two. 0037 1 Q. (By Ms. Perse) And do you know 2 what year you successfully completed national 3 boards part two? 4 A. Prior to graduation from medical 5 school. 6 Q. Is it true that you have to pass 7 and be the national boards, parts one and 8 two, before you can graduate from medical 9 school? 10 A. That is correct. 11 Q. Now, as far as national boards 12 part three. When is the first time you took 13 that part three of the national board exam? 14 A. I was a resident in general 15 surgery. 16 Q. And did you take it any other 17 time? 18 MS. KINKOPF-ZAJAC" objection. 19 A. Yes. 20 Q. (By Ms. Perse) And how many other 21 times did you take it? 22 MS. KINKOPF-ZAJAC: Objection. 23 A. Three times. 24 Q. (By Ms. Perse) And did you -- when 25 can we say that you -- did you not pass on 0038 1 times one, two -- one and two? 2 MS. KINKOPF-ZAJAC: Objection. 3 A. Correct. 4 Q. (By Ms. Perse) And when did you 5 successfully complete part three of your 6 national board exam? 7 A. About several months ago. 8 Q. Was that in 2007 or 2008? 9 A. 2008. 10 Q. Is it true that you have to -- in 11 order to be board certified in general 12 surgery, you have to pass national -- your 13 national boards part one, two, and three? 14 A. Correct. 15 Q. In terms of sitting for your 16 thoracic surgery boards. I would assume that 17 you would have to pass national boards part 18 one, two, and three? 19 A. Correct. 20 Q. And why -- and tell me why it is 21 that you did not sit for the general surgery 22 board? 23 MS. KINKOPF-ZAJAC: Objection. We 24 have been down -- over this already. 25 MS. PERSE: I believe he told you 0039 1 -- 2 MS. KINKOPF-ZAJAC: Go ahead. 3 MS. PERSE: -- that he did not 4 sit for the general surgery boards. I'm 5 asking him why he did not sit. 6 MS. KINKOPF-ZAJAC: Right. And I 7 believe that we've already been down this 8 road before. But go ahead and tell her, 9 again. 10 A. I did not sit for the general 11 surgery boards because it was not a 12 requirement for obtaining thoracic surgery 13 board certification. 14 Q. (By Ms. Perse) Do you intend to 15 be, or are you a fellow of the American 16 College of Surgeons? 17 A. I'm a fellow in thoracic surgery. 18 If that falls under the category of being a 19 fellow of the American College of Surgeons. 20 Q. Are you familiar with the American 21 College of Surgeons? 22 A. Yes. 23 Q. And are you a member of the 24 American College of Surgery? 25 A. Not -- not at this point. 0040 1 Q. And why is that? 2 MS. KINKOPF-ZAJAC: Objection. 3 A. I don't -- I -- I haven't applied 4 for a membership. I don't -- I'm -- I'm not 5 sure I -- I -- I really understand your 6 question. 7 Q. (By Ms. Perse) During -- at any 8 point in your training from '99 to 2007, 9 after you had graduated from medical school, 10 were you ever a member of the American 11 College of Surgery? 12 A. I'm -- I'm not a member of the 13 American College of Surgeons. 14 Q. And my question was -- is between 15 1999 through 2007, were you ever a member of 16 the American College of Surgery? 17 A. Well, I -- I don't -- I'm not 18 aware that that is something that is possible 19 while you're -- while you're a resident. 20 Q. Again, you didn't have a resident 21 status with the American College at any 22 point? 23 A. Well, I assume that being a 24 resident for -- in a -- in a -- in a board 25 certified American Surgery -- Board of Surgery 0041 1 residency program, you're -- you're a resident 2 in one of those -- in one of those residency 3 programs. 4 Q. But, again, in terms of the 5 American College of Surgery. Were you, 6 during your residency, ever a member at -- on 7 -- as a resident a member of the American 8 College of Surgery? 9 A. No. 10 Q. Did you ever apply to be a member 11 of the American College of Surgery during 12 that time frame? 13 A. Not to my recollection. 14 Q. And you are familiar with the 15 American College of Surgery, right? 16 MS. KINKOPF-ZAJAC: Objection. 17 Asked and answered. 18 A. Yes. 19 Q. (By Ms. Perse) Can you tell me a 20 little bit about what your understanding of 21 the American College of Surgery is? 22 MS. KINKOPF-ZAJAC: I'm going to 23 object to this. This is irrelevant. But go 24 ahead, Doctor. 25 A. Well, it's clearly -- clearly an 0042 1 organization designed for individuals that are 2 engaged in the field of general surgery. 3 Q. (By Ms. Perse) Is the American 4 College of Surgery a respected organization 5 among surgical specialties? 6 MS. KINKOPF-ZAJAC: Objection. 7 A. Yes. 8 Q. (By Ms. Perse) In terms of your 9 CV. Tell me where you have been licensed to 10 practice medicine. 11 A. Well, I have been -- I have had 12 training licenses in Kansas, where I did 13 general surgery; in Ohio, where I trained for 14 cardio thoracic; and here in Texas. 15 Q. Okay. Were those all under 16 training certificates? 17 A. That is correct. 18 Q. Has your license in Ohio, Kansas, 19 or Texas been restricted in any way? 20 MS. KINKOPF-ZAJAC: Objection. 21 Q. (By Ms. Perse) Other than the 22 teaching certificate? 23 A. Well, I have -- as I said, I had 24 training certificates. I am not aware of any 25 restrictions on my training licenses in those 0043 1 states. 2 Q. Did you -- are you still licensed 3 in Ohio? 4 A. My training certificate is no 5 longer valid in Ohio. It ended when I ended 6 my residency program. 7 Q. And what about your training 8 certificate in Kansas? 9 A. That, too, ended when I finished 10 my residency program in general surgery in 11 Kansas. 12 Q. Okay. And in Texas, your license 13 is current? 14 A. My training license is actually 15 current. 16 Q. Did you successfully complete your 17 CT residency or thoracic surgery residency at 18 the Cleveland Clinic? 19 A. I did. 20 Q. Now, your -- your present capacity. 21 You are a fellow at the -- do you rep -- 22 tell me, again, what the hospital is you're 23 working at? 24 A. Texas Children's Hospital. 25 Q. And you have no private practice 0044 1 at the present time, is that correct? 2 A. No, ma'am. 3 Q. Now, you -- you told me when we 4 started this deposition that you have provided 5 a deposition previously in another case. Is 6 that true? 7 A. That's correct. 8 Q. Can you tell me when you gave that 9 deposition? 10 MS. KINKOPF-ZAJAC: I am going to 11 just request a continuing objection to this, 12 but you can go ahead and answer. 13 A. It was approximately three years 14 ago. 15 Q. (By Ms. Perse) And so that was -- 16 where was that deposition given? 17 A. The deposition was actually given 18 in Ohio, but it was from a case that 19 occurred when I was a general surgery 20 resident. 21 Q. Okay. And that case, when you 22 were a general surgery resident, that was 23 during your time when you were in Kansas, is 24 that correct? 25 A. That's correct. 0045 1 Q. And can you tell me a little bit 2 about the facts of the case that you were 3 involved in? 4 A. I -- I don't remember all the 5 details. But the case involved a -- a -- a 6 patient that did not survive after operation 7 for morbid obesity. 8 Q. Were you a named defendant in that 9 case? 10 A. Initially. But my name was 11 dropped because I was a resident, at the 12 time, and I didn't do the operation. 13 Q. And what year resident were you 14 when you participated in the surgery? 15 A. I think I was a fourth-year 16 resident. 17 Q. I think we've reviewed the fact 18 that when you were a fourth-year resident, 19 you were also considered a chief resident? 20 A. True. 21 Q. And were you the primary surgeon 22 on that case? 23 A. No, ma'am. I was not. 24 Q. And who was the primary surgeon? 25 A. The surgeon's name? 0046 1 Q. Well, first, tell me what capacity 2 he acted in or she acted in? 3 A. He was the surgeon for the 4 patient. I was his assistant. 5 Q. Would it be correct to characterize 6 him as the attending on the case? 7 A. Yes. That would be correct. 8 Q. And so you were the first 9 assistant in that case? 10 A. That is correct. 11 Q. And did the patient die during the 12 surgery? 13 A. No, ma'am. 14 Q. And how soon after the surgery did 15 the patient die? 16 A. I -- I don't remember the details 17 to that degree. 18 Q. And what did the patient -- what 19 complications did the patient die of? 20 A. The patient -- I think it was 21 sepsis. But, again, I have to go back and 22 look at the record. I don't remember the 23 details surrounding all the circumstances. 24 Q. And the lawyers came to Ohio to 25 take your deposition? 0047 1 A. They did. 2 Q. And do you -- do you know when -- 3 I guess I could do the math, but what year 4 the -- you took care of the patient or the 5 case -- the time frame when the patient was 6 being treated? 7 A. I don't know, specifically. Again, 8 I -- I have to go back and look at the 9 record, but -- because I don't remember 10 specifically the time I was working with that 11 surgeon. It's -- it's been awhile. 12 Q. But it was when you were a PG-4, 13 correct? 14 A. Yes. It was -- it was when I 15 was a PG Y-4. 16 Q. Have you ever testified in trial? 17 A. No. 18 Q. Have you -- were you -- have you 19 been involved in any other lawsuits? 20 A. No. 21 Q. And that would include whether you 22 were as a named defendant or as a -- an 23 employee of any defendant? 24 A. I haven't been involved in any 25 other lawsuits in any capacity. 0048 1 Q. What was the outcome of the case 2 involving the gastric bypass? 3 A. I have no idea. 4 Q. So do you have any idea whether 5 the case is still open or if there was a -- 6 A. I have absolutely no idea. My 7 name was dropped from the lawsuit, and I -- 8 I don't know what the results were after 9 that. 10 Q. Have you had any disciplinary 11 actions against you relative to your state 12 license? 13 MS. KINKOPF-ZAJAC: Objection. 14 Q. (By Ms. Perse) And I guess that 15 would include Kansas, Texas, and Ohio? 16 MS. KINKOPF-ZAJAC: Objection. Go 17 ahead. 18 A. No. 19 Q. (By Ms. Perse) Are you a member of 20 any other professional associations? 21 A. Not at the moment. 22 Q. Okay. I guess I said "Other." 23 But are you a member of any professional 24 associations? 25 A. Not at the moment. 0049 1 Q. Were you at any time? Since I 2 don't have your CV, I guess I was just 3 looking to see if you are a member of any 4 other professional associations? Were or are? 5 A. Well, I used to be a member of 6 the American Association for the Advancement 7 of Science when I was doing research, basic 8 science research, but that had -- I haven't 9 really maintained it. 10 Q. Are you a member of the American 11 Board of Thoracic Surgery in the resident or 12 fellow capacity? 13 A. Not right now. 14 Q. Now, have you reviewed any material 15 in preparation for today's deposition? 16 A. Only as it relates to my 17 involvement in the case. 18 Q. And what have you reviewed? 19 A. Notes that I have written and some 20 nursing records regarding my involvement in 21 the case. 22 Q. Can you provide me with the notes 23 that you have written? 24 MS. KINKOPF-ZAJAC: Well, he is 25 looking at my copies. So, no. I mean, we 0050 1 can tell you what he looked at, but these 2 are my copies. 3 Q. (By Ms. Perse) Doctor, have you 4 prepared any independent notes, independent of 5 what you may have prepared at the direction 6 of your attorney in this case? 7 A. I haven't written any notes in -- 8 regarding the case, at all. 9 Q. And you discussed that you reviewed 10 some notes. 11 A. The medical record. 12 MS. KINKOPF-ZAJAC: We're talking 13 -- I am sorry. 14 Q. (By Ms. Perse) What medical records 15 have you specifically reviewed? 16 MS. KINKOPF-ZAJAC: Jessica, I'm 17 sorry. Just so -- I -- if you -- the 18 records -- the notes that he reviewed are 19 copies of his notes that are contained within 20 my copy of the records. That's what -- I'm 21 sorry. I was trying to clarify that, but 22 apparently I didn't. 23 So, hopefully that clarifies it. 24 Q. (By Ms. Perse) Have you reviewed 25 any literature in advance of today's 0051 1 deposition? 2 A. No. Lit -- literature regarding 3 the -- regarding what? 4 Q. Any -- any medical literature 5 regarding the substance or subject matter of 6 this case? 7 A. No. Not specifically. 8 Q. And you say not specifically. 9 That always leads me to believe that you 10 generally reviewed something. Is that true? 11 A. Well, I -- I just meant that I -- 12 I do look at the literature, but I haven't 13 reviewed anything for this case. 14 Q. And tell me what literature you've 15 looked at. 16 A. Well, I review literature. I'm 17 writing paper right now, so I re -- reviewed 18 literature regarding that paper. 19 Q. And, again, can you tell me what 20 literature you're -- you've reviewed recently? 21 A. Literature on Fontan conversion. 22 Q. I'm sorry. What? 23 A. Fontan conversion. 24 Q. Okay. 25 A. Literature on Fontan conversion. 0052 1 Q. And that's a procedure that's done 2 on a congenital heart patient, a pediatric 3 congenital heart patient. True? 4 A. True. 5 Q. And where is -- 6 A. Well, the conversion is actually 7 done on some adult patients. But, yes. 8 Q. Okay. And where do you look to, to 9 get the information for this Fontan procedure? 10 A. Medical textbooks, medical journals. 11 Q. And tell me as far as the texts 12 go. Tell me what journal -- text -- I'm 13 sorry. What journ -- what texts you may 14 refer to? 15 A. Well, there are several texts on 16 congenital heart surgery, and there are also 17 numerous different journals. 18 Q. And the numerous, congenital heart 19 surgery texts -- texts. Can you tell me 20 what those texts are that you are referring 21 to? 22 A. Well, sure. There are texts 23 written by Mavroudis and Backer on the 24 surgery for congenital heart disease. There 25 are texts written by Stark and de Leval on 0053 1 congenital heart disease. There are texts 2 written by Nicholas Kouchoukos called Cardiac 3 Surgery. It also has a fairly extensive 4 section on congenital heart disease. There 5 are several different resources. 6 Q. And those texts that you 7 specifically named, do those include congenital 8 heart surgery on the adult patient? 9 A. It covers a broad spectrum of -- 10 of congenital heart disease. 11 Q. And do you find those texts to be 12 reasonably reliable? 13 A. Yes. 14 Q. Now, moving on. You mentioned 15 that are several journals. Can you tell me 16 what journals that you would resource in your 17 experience and training? 18 A. For congenital heart disease. The 19 Journal of Thoracic and Cardiovascular Surgery. 20 The Annals of Thoracic Surgery. Those are 21 probably the two primary journals, I think 22 that most people look to for information. 23 Q. Any others? 24 A. There are a whole host of others. 25 The Journal of Cardiac Surgery. The Journal 0054 1 of Thoracic and Cardiovascular Surgery. There 2 are numerous, numerous journals. 3 Q. And do you find that those 4 journals are reasonably reliable? 5 A. I think that the most reliable 6 journals from my perspective are the Journal 7 of Thoracic and Cardiovascular Surgery and the 8 Annals of Thoracic Surgery. 9 Q. And do you consider those journals 10 to be good sources of information on current 11 topics in the area of CT surgery or thoracic 12 surgery? 13 A. Yes. 14 Q. Do you use those texts in the 15 management of your patients? 16 A. Yes. I -- I -- I use those 17 texts to increase my knowledge about the 18 disease processes affecting the patients that 19 I'm involved in. 20 Q. And would that also hold true for 21 the journals -- 22 A. Sure. 23 Q. -- that you referenced? 24 A. Sure. 25 Q. And did you utilize or research 0055 1 those texts and journals during your residency 2 at the Cleveland Clinic? 3 A. Yes. 4 Q. Do you consider those journals or 5 books or any book chapters to be reasonably 6 reliable on the topics that are relevant to 7 the lawsuit as you understand it or the care 8 of Mr. -- or Dr. Orra? 9 MS. KINKOPF-ZAJAC: Objection. Go 10 ahead. 11 A. Well, I'm -- I'm not sure which 12 chapter you're referring to. 13 Q. Do you consider any of the 14 journals that we discussed or the books to be 15 reasonably reliable on the topics that are 16 relevant to this lawsuit? 17 A. Well, I -- I -- 18 MS. KINKOPF-ZAJAC: I'm just going 19 to note an objection. Go ahead. 20 A. I didn't review any journals or 21 textbooks specifically regarding this case for 22 this -- for this deposition. 23 Q. (By Ms. Perse) But, in general, in 24 the care of a patient with an open atrial 25 septic -- septal defect repair. Would you 0056 1 consider the journals -- any of the journals 2 or books that we discussed to be reasonably 3 reliable on that topic? 4 MS. KINKOPF-ZAJAC: Objection. 5 A. For general information. 6 MS. KINKOPF-ZAJAC: Go ahead. 7 Q. (By Ms. Perse) Yes. For general 8 information on ASD repair? 9 A. Yes. 10 THE VIDEOGRAPHER: Counsel, we have 11 about two minutes left on the tape. 12 MS. PERSE: Okay. 13 Q. (By Ms. Perse) I'm just going to 14 ask that if you -- want to note on the 15 record that if you come to determine that 16 there is any specific literature that you 17 will be using to support any opinions that 18 you may hold in the case, that you provide 19 that information to Mrs. Kinkopf, so that I 20 may be made aware of those articles or books 21 -- books or book chapters. Especially -- 22 again, this is more of a legal thing. But 23 in light of the changes in Ohio law, I want 24 to be provided that information in advance of 25 trial, so that I can ask you specific 0057 1 questions on the literature that you may come 2 to be aware of or learn of or -- and may 3 use at trial in this matter. 4 THE VIDEOGRAPHER: Going off the 5 record. The time is approximately 10:02 a.m. 6 (Recess taken at 10:02 a.m. until 7 10:04 a.m.) 8 THE VIDEOGRAPHER: This is the 9 beginning of Tape Number 2. The time is 10 approximately 10:04 a.m. We are now back on 11 the record. 12 MS. PERSE: Hello. 13 THE WITNESS: Hi. 14 MS. PERSE: All right. So we're 15 ready to get back on the record? 16 MS. KINKOPF-ZAJAC: We are back 17 on. 18 MS. PERSE: I am sorry. I wanted 19 to make sure of that. 20 Q. (By Ms. Perse) Dr. Bryant, what is 21 -- was the extent of your involvement with 22 Dr. Orra's care or treatment at the Cleveland 23 Clinic? 24 A. I assisted Dr. Sabik with the 25 repair of the ASD, and I took care of him 0058 1 the first post-operative night. 2 Q. Did you -- were you at all 3 involved in the pre-op evaluation? 4 A. I was not. 5 Q. When is the first time that you 6 met Dr. Orra? 7 A. In the operating room. 8 Q. Did you ever have an opportunity 9 to see Dr. Michael Orra before his -- he 10 went to sleep or was under anesthesia? 11 A. I don't remember if he actually 12 had gotten any drugs. I -- I don't remember 13 if he was awake or not when I walked in the 14 operating room. 15 Q. Did you have any verbal exchange 16 with Michael Orra before you participated in 17 his surgery? 18 A. Not that I recall. 19 Q. In general, Doctor, before you 20 participate in a surgery, in your capacity as 21 a resident, -- 22 A. Uh-huh. 23 Q. -- what kind of preparation would 24 you undertake before you participate in that 25 surgery? 0059 1 MS. KINKOPF-ZAJAC: Let's note an 2 objection to the general nature of the 3 question. Go ahead if you can answer it. 4 A. Well, that -- that depends on what 5 the operation is. But, in general, you want 6 to know what the patient's diagnosis is and 7 what we're planning on doing for the patient. 8 Q. And would you do any literature 9 review in preparation for a surgery before 10 you participated in it as a resident? 11 A. Sure. 12 Q. Do you recall reviewing any 13 material before you participated in Dr. -- or 14 Michael Orra's surgery that day? 15 A. Not specifically. 16 Q. In general, what book would you 17 reference? 18 A. Well, it depends on what I was 19 trying to -- to look at, but you could 20 reference textbooks or journals. 21 Q. And before you participated in 22 Michael Orra's surgery, had you done any open 23 ASD repairs before? 24 A. I -- I'm -- I'm -- that I recall, 25 I'm -- I'm sure that I scrubbed some ASD 0060 1 closures prior to Dr. Orra's. 2 Q. And how many ASD closures had you 3 scrubbed in on before you participated in Dr. 4 Orra's? 5 A. I don't -- I don't remember the 6 exact number prior to doing that one. 7 Q. You don't recall? I'm sorry. I 8 -- I missed -- 9 A. I don't -- I don't remember the 10 exact number, prior to scrubbing in on Dr. 11 Orra's operation. 12 Q. Well, can you give me just a 13 ballpark range? Was it less than 10? 14 MS. KINKOPF-ZAJAC: Just note an 15 objection. Don't guess, Doctor. If you 16 know, you can tell her. 17 A. I -- I -- well, I'm sure that it 18 wasn't less than 10. I don't remember the 19 exact number. 20 Q. (By Ms. Perse) What -- so was it 21 between 10 to 15? 22 A. Well, I -- I -- I just can't tell 23 you for sure. But I'm -- I'm -- I don't 24 think it was less than 10, but I can't give 25 you an exact number. 0061 1 Q. When you say don't think it was 2 less than ten. That leads me to believe you 3 think it -- you believe it was greater than 4 10? 5 A. Yes. 6 Q. And in what capacity did you 7 participate in those ASD repairs, prior to 8 Michael Orra's surgery? 9 MS. KINKOPF-ZAJAC: Objection. Go 10 ahead. 11 A. Well, I don't -- you mean whether 12 I was -- what -- what -- what capacity do 13 you mean, specifically? 14 Q. (By Ms. Perse) Were you first 15 assistant or as primary surgeon? 16 A. I -- I honestly don't -- don't 17 remember. 18 Q. Had you ever performed an ASD 19 repair as a primary surgeon before you 20 participated in Michael Orra's surgery? 21 A. Yes. 22 Q. And how many open ASD repairs had 23 you participated in as a primary surgeon 24 before Michael Orra's surgery? 25 A. Well, as the primary surgeon or as 0062 1 the first assistant, like I said, I can't -- 2 I can't give you the exact number of cases. 3 Q. And your log that you prepared for 4 the thoracic board of surgery would include 5 the numbers of cases that you participated 6 in, that entailed open atrial septic defect 7 closures, correct? 8 A. Yes, ma'am. 9 Q. And that would be during the -- 10 your training before Dr. Orra's surgery, 11 correct? 12 A. Correct. 13 Q. And that would also -- you would 14 have to be required -- 15 A. Well, it would have the dates. 16 Q. -- to know what role you acted in, 17 in those surgeries, before Michael Orra's 18 surgery, correct? 19 A. Correct. 20 Q. Now, prior to participating in -- 21 when -- when did you get assigned to scrub 22 in on Michael Orra's surgery? 23 A. I -- I don't remember when I got 24 assigned. I was involved in the case, but I 25 don't -- I don't remember when the decision 0063 1 was made that I would be the person assisting 2 on the case. 3 Q. Tell me, when you're -- you are on 4 -- during November of 2005, -- 5 A. Yes. 6 Q. -- what rotation were you on? 7 A. You know, I really -- I -- I 8 don't remember whose service I was on. I 9 don't -- I'm -- I'm certain that I wasn't on 10 Dr. Sabik's service. 11 Q. I'm sorry. What was that? 12 A. I -- I don't remember being on Dr. 13 Sabik's service, but I don't remember whose 14 service I was on, primarily. 15 Q. And then beginning on December 1, 16 2005, were -- did -- were you -- did you 17 switch rotations? 18 A. Um, you know, to -- to really 19 answer that accurately, I would have to have 20 my rotation schedule in front of me, which I 21 don't. 22 Q. In general, when you were on 23 somebody's service and you did a surgery, 24 would it be accurate to say that you would 25 have followed that patient, post-operatively, 0064 1 unless you were on a new service? 2 MS. KINKOPF-ZAJAC: Objection. 3 A. That's correct. 4 Q. (By Ms. Perse) And in Michael 5 Orra's case, you parti -- you scrubbed in on 6 the surgery, correct? 7 A. Correct. 8 Q. And for how long did you treat or 9 participate in Michael Orra's care? 10 A. Just the first post-operative 11 night. 12 Q. And when you say the first 13 post-operative night? 14 A. The night of his operation. 15 Q. So that was the night of November 16 30th, 2005? 17 A. Yes. And I saw him the next 18 morning. 19 Q. Did you see Michael Orra at all on 20 December 1st after the morning? 21 A. No. I don't recall that I did. 22 I -- I -- we're -- I'm looking at the 23 record. I am trying to -- I -- I know I 24 wrote a note on him the following morning, 25 and I -- I wasn't involved at -- after that 0065 1 point. 2 Q. Did you -- were you on call that 3 first night post-operatively? 4 A. I think I was because I was -- 5 yes. 6 Q. Can you tell me, was that around 7 Thanksgiving? 8 MS. KINKOPF-ZAJAC: Objection. If 9 you know, Doctor. 10 A. I -- I don't remember. 11 Q. (By Ms. Perse) When you -- how 12 many general thoracic surgery residents were 13 on a service? 14 A. General thoracic surgery? 15 Q. Yeah. I'm looking for just kind 16 of the structure of your rotation just to get 17 a better sense of your responsibilities. 18 MS. KINKOPF-ZAJAC: This is just 19 back in 2005, correct? 20 MS. PERSE: Five. 21 MS. KINKOPF-ZAJAC: Back in 2005? 22 MS. PERSE: In 2005. 23 MS. KINKOPF-ZAJAC: Okay. 24 A. Well, the -- the structure of the 25 rotation, just in -- in general terms, is 0066 1 that there is usually a chief resident, and 2 then there's a junior resident for each -- 3 Q. (By Ms. Perse) In November, 4 2005 -- 5 MS. KINKOPF-ZAJAC: He -- he wasn't 6 done with his answer. 7 MS. PERSE: Oh, I'm sorry. 8 MS. KINKOPF-ZAJAC: Go ahead. 9 Q. (By Ms. Perse) I apologize. 10 That's the -- the difficulty with the 11 telephone communication. I -- please, I 12 thank you for correcting me, and I want to 13 make sure you have every opportunity to 14 answer. I apologize. 15 A. Yes. So, in general, there is a 16 -- there is a chief resident, and then 17 there's a -- a more junior resident, if you 18 will. 19 But there are fewer residents for 20 the general thoracic surgery service because 21 it's not as big of a service as the adult 22 cardiac surgery service. 23 Q. Finished your answer? 24 A. Yes. 25 Q. So there would be two thoracic 0067 1 surgery residents on a service, is that 2 accurate? 3 A. That's accurate. 4 Q. And in November, 2005 would you 5 have been considered a junior cardiothoracic 6 or a thoracic resident? 7 A. In November of 2005? 8 Q. Yes. 9 A. That would have been my second 10 year. So, yes. 11 Q. And who was your senior thoracic 12 resident in -- 13 A. Hum. 14 Q. -- November of 2005? 15 A. You know, I -- I really -- I 16 really don't remember. 17 Q. Well, it was a small thoracic 18 residency, correct? 19 A. Well, there is 25 residents. 20 Q. 25 residents? 21 A. Yes. 22 Q. And how many services were there 23 on the cardiothoracic? 24 A. For adult cardiac, there were six 25 services. 0068 1 Q. And how many -- in total, how many 2 services did those 25 residents cover? 3 A. Well, we covered this -- the 4 cardiac services, and then the thoracic 5 service. So you usually had -- 6 Q. And how many services was that? 7 A. Well, the -- pardon? 8 Q. How many -- I'm just -- I'm 9 looking for how many services that those 25 10 residents covered? 11 A. Five -- five or six services 12 total. The -- the general structure of the 13 service is that there is two to three staff 14 surgeons per service. 15 Q. And how many residents per service? 16 A. At least two, sometimes three, 17 depending on how many people we have for a 18 particular year. 19 Q. Is there a schedule that was 20 maintained -- and, again, you may not know -- 21 but did you guys follow a schedule that said, 22 these residents were on this service during 23 this month? 24 A. Yes. 25 Q. And that is how you knew who you 0069 1 were responsible for, correct? 2 A. Correct. 3 Q. Do you understand, Doctor? 4 A. Yes. I said correct. 5 Q. Oh, I had missed that. I 6 apologize. Again, one of those difficulties. 7 So where would that schedule be 8 originated from? 9 A. It is usually developed by the 10 program director. 11 Q. And during your residency, would 12 you be able to look back at those schedules 13 to see who was covering what service when? 14 A. If -- if they are maintained. I'm 15 not sure that the schedule is kept, you know, 16 in some -- in any way. Certainly at the 17 time -- 18 MS. PERSE: For your attorney. 19 Ingrid, I'm going to make a request on the 20 record that I be provided with the schedule 21 for the CT or the thoracic surgery residency 22 for that November, 2005 through January, 2006 23 time period. The Doctor can't recall who was 24 on that service. 25 MS. KINKOPF-ZAJAC: Again, I would 0070 1 just say put -- 2 MS. PERSE: I will -- I will -- 3 MS. KINKOPF-ZAJAC: -- put it in a 4 Request For Production of Documents, and I 5 will investigate if this even maintained. 6 MS. PERSE: Thank you. 7 MS. KINKOPF-ZAJAC: Uh-huh. 8 Q. (By Ms. Perse) And, Doctor, can 9 you tell me the number of open ASD surgeries 10 that you performed with Dr. Sabik before 11 Michael Orra's surgery? 12 A. I can't tell you the number I 13 performed with Dr. Sabik. 14 Q. And would that be something that 15 you would have included in your logs that you 16 provided for the thoracic boards? 17 A. No. 18 Q. So did you have to identify the 19 attending surgeons that you worked under? 20 A. No. 21 Q. Do you have a sense of whether or 22 not -- or can you tell me whether you 23 participated in more then 10 open ASD 24 surgeries with Dr. Sabik before Michael Orra's 25 surgery? 0071 1 A. I can't -- 2 MS. KINKOPF-ZAJAC: Objection. 3 A. I can't tell you that. 4 Q. (By Ms. Perse) And can you tell me 5 the number of cases that -- number of ASD, 6 open ASD cases that you did after Michael 7 Orra's surgery? 8 MS. KINKOPF-ZAJAC: Just note an 9 objection as to the relevancy. But if you 10 know, go ahead. 11 A. Well -- 12 MS. KINKOPF-ZAJAC: At the 13 Cleveland Clinic? 14 MS. PERSE: At the Cleveland Clinic. 15 MS. KINKOPF-ZAJAC: Okay. 16 Q. (By Ms. Perse) And that would be 17 those that you did with Dr. Sabik? 18 MS. KINKOPF-ZAJAC: Objection. Go 19 ahead. 20 A. Well, I -- again, I'm -- I'm not 21 going to have those records with -- based on 22 the staff surgeon I did it with. In fact, 23 right now, I don't even have the total 24 numbers in front of me. I can't tell you the 25 total numbers at Cleveland Clinic, but it's 0072 1 -- I did more than 20 congenital cases, 2 total, which was the number that -- minimum 3 number required by The American Board. But I 4 don't have my log in front of me. So I 5 can't tell you the exact number of congenital 6 cases, and I would have to look at the break 7 down and see exactly how many ASD's there 8 were. 9 Q. In terms of A -- open ASD repairs, 10 is that a relatively common congenital defect? 11 A. Yes. Open repairs? 12 Q. Open ASD repairs? But my first -- 13 A. Well, ASD is a common congenital 14 lesion. 15 Q. My first question was -- just to 16 be clear -- is the ASD -- or atrial septal 17 defects in adults, is that a relatively 18 common congenital disorder in adults? 19 MS. KINKOPF-ZAJAC I'm just going to 20 note an objection as to what you mean by the 21 word "Common." But go ahead. If you -- if 22 you know what she means by the word "Common." 23 A. Well, it is -- it is a common 24 congenital lesion in general. 25 Q. (By Ms. Perse) Are they commonly, 0073 1 the a -- atrial septal defects, are they 2 commonly recognized in children or adults? 3 MS. KINKOPF-ZAJAC: Objection. 4 A. In general, they are more commonly 5 seen in children. 6 Q. (By Ms. Perse) Can we agree that 7 an atrial septal defect can be unrecognized 8 until the patient becomes an adult? 9 A. Yes. 10 Q. And that would perhaps be more 11 often the case for an atrial septal defect as 12 opposed to other congenital abnormalities of 13 the heart. True? 14 MS. KINKOPF-ZAJAC: Objection. 15 A. It would depend on the congenital 16 abnormality. 17 Q. (By Ms. Perse) The open ASD 18 repair. An open -- I am sorry. An atrial 19 septal defect would be one of those defects 20 that would be more often or better tolerated. 21 And, therefore, clinically silent than many 22 other congenital heart defects. True? 23 MS. KINKOPF-ZAJAC: Objection. 24 A. I -- I wouldn't -- well -- 25 MS. KINKOPF-ZAJAC: Go ahead. 0074 1 A. I wouldn't say that's necessarily 2 the case. 3 Q. (By Ms. Perse) Do you have any 4 memory of doing an -- an open ASD re -- 5 surgery with Dr. Sabik before Michael Orra? 6 MS. KINKOPF-ZAJAC: Objection. 7 Asked and answered. 8 MS. PERSE: No. I -- I -- 9 Q. (By Ms. Perse) Again, I'm just 10 trying to get a sense of it. If he has any 11 memory of doing an open ASD surgery with Dr. 12 Sabik before Michael Orra's surgery? 13 MS. KINKOPF-ZAJAC: Objection. Go 14 ahead. 15 A. No. I don't have any -- any -- 16 any memory of that. 17 MS. KINKOPF-ZAJAC: I am sorry. 18 Q. (By Ms. Perse) Any -- do you have 19 any memory of doing an open ASD surgery with 20 Dr. Sabik after Michael Orra's surgery? 21 MS. KINKOPF-ZAJAC: Objection. 22 Asked and answered. Go ahead. 23 A. No. 24 Q. (By Ms. Perse) In terms of -- in 25 general, as a resi -- thoracic surgery 0075 1 resident, would you receive case assignments 2 in advance of the surgery, so that you could 3 use some preparation? Is that a fair 4 statement? 5 MS. KINKOPF-ZAJAC: Objection as to 6 the general nature of the question. Go 7 ahead. 8 A. I would say that, in general, 9 that's a true statement, but not always the 10 case. 11 Q. (By Ms. Perse) And, again, in Dr. 12 -- or in Michael Orra's case, you -- do you 13 recall receiving any forewarning, if you will, 14 about your assignment to his case, so that 15 you could do some preoperative -- 16 A. I don't remember that being the 17 case specifically. 18 Q. Did you review any of Michael 19 Orra's pre-operative testing before you 20 scrubbed in on his surgery? 21 A. I believe that we looked at the 22 echo report in the operating room. I didn't 23 look at any of his studies, per se, prior to 24 going into the operating room with the 25 exception of looking -- 0076 1 Q. What echo reports are you referring 2 to? 3 A. The pre-operative echo. 4 Q. Were those -- was there one, or 5 were there more than one? 6 A. I -- I don't remember how many 7 there were. I remember looking at -- at an 8 echo report in the operating room. 9 Q. And, again, you looked at the 10 report. Did you look at the actual studies? 11 A. No. I don't -- I don't recall 12 looking at the actual study. 13 Q. Now, did you look at the report 14 with anyone? 15 A. Not that I remember. 16 Q. When did you look at the report? 17 A. Well, I think that I looked at it 18 in the operating room. I don't remember 19 looking at it prior to that. 20 Q. And -- 21 A. I didn't meet the patient until he 22 -- he got in the operating room. 23 Q. And why would you have looked at 24 the echocardiogram report, prior to Michael 25 Orra's surgery? 0077 1 A. Well, I didn't look at it prior to 2 his surgery. 3 Q. When did you look at it? 4 A. In the operating room. 5 Q. So you looked at it after you had 6 completed Dr. -- Michael Orra's surgery? 7 A. No. In the operating room before 8 the patient went to sleep. 9 Q. Okay. I'm sorry. You're breaking 10 up a little bit. 11 A. I looked at it in the operating 12 room, prior to starting the operation. 13 Q. And why did you look at the report 14 before starting Michael Orra's surgery? 15 A. To confirm the reason that we were 16 doing the operation. 17 Q. And what was your understanding of 18 why you were doing Michael Orra's surgery? 19 A. It was that he had an atrial 20 septal defect. 21 Q. What about the echocardiogram was 22 important for you to know before undertaking 23 Michael Orra's surgery? 24 MS. KINKOPF-ZAJAC: Objection. Go 25 ahead. 0078 1 A. Well, in general, the things you 2 look for are type of defect, and whether or 3 not there are any additional lesions that 4 need to be addressed. 5 Q. (By Ms. Perse) Is there anything 6 else that you look at when you review the 7 echocardiogram? 8 MS. KINKOPF-ZAJAC: Objection. Go 9 ahead. 10 A. In terms of? In terms of what? 11 Q. (By Ms. Perse) Again, in 12 preparation for an open ASD repair. You've 13 already told me that you're looking for the 14 size of the defect and if -- 15 A. Well-- 16 Q. -- there is any other defects, 17 correct? 18 A. Well, I actually didn't say that. 19 What I said was you look to see what -- what 20 -- the reason that you're there. What the 21 patient's anatomy is, for example, and to 22 make sure there aren't any other lesions that 23 need to be addressed at the time of the 24 operation. 25 Q. And what kind of lesions would you 0079 1 be worried about in a patient, such as 2 Michael Orra? 3 A. Well, for an ASD, for example, you 4 want to make sure he doesn't have any 5 pulmonary venous anomalies, for example. 6 Q. Anything else? 7 A. Number of defects. Size of 8 defect, in general. 9 Q. Did Michael Orra have any 10 abnormalities with his pulmonary venous return? 11 A. Not that I'm aware of. 12 Q. When you reviewed the 13 echocardiogram, was there anything -- 14 A. I do -- I do not -- 15 Q. -- on that, that led you to 16 believe there was a pulmonary venous return 17 abnormality? 18 A. No. There wasn't. 19 Q. And when you reviewed Michael 20 Orra's echocardiogram, was -- were there any 21 additional defects that you recognized? 22 A. I -- I -- no. I do not remember 23 there being any additional defects. 24 Q. Is there any other characteristics 25 of the echocardiogram or things that you 0080 1 would take from the echocardiogram that would 2 be necessary for you to know before 3 undertaking an ASD repair, in general? 4 MS. KINKOPF-ZAJAC: Let's note an 5 objection. Go on. 6 A. Besides what I've mentioned? No. 7 He had good function. In general, his LV 8 functioned well. He had some degree of RV 9 dysfunction, but that's not uncommon. 10 Q. And when you say some degree of RV 11 dysfunction. Was that quantified on the 12 echocardiogram that you relied on before 13 Michael Orra's surgery? 14 A. I think it said mild to moderate. 15 Q. And what does that -- what does 16 that information convey to you as the 17 cardiothoracic surgeon performing an open ASD 18 repair? 19 A. That he's had a longstanding shunt. 20 Q. Does it tell you -- is it of any 21 other importance? 22 MS. KINKOPF-ZAJAC: Objection. Go 23 ahead. 24 A. Well, that he's had a longstanding 25 shunt, and he has some degree of RV 0081 1 dysfunction, which may be based on the de -- 2 degree of shunting that he's had. 3 Q. (By Ms. Perse) In terms of his -- 4 you mentioned LV. 5 A. Uh-huh. 6 Q. What are you referring to when you 7 say -- 8 A. Left ventricle. 9 Q. -- LV? 10 A. Left ventricle. 11 Q. And what are you referring to when 12 you say RV? 13 A. Right ventricle. 14 Q. So his left ventricular function, 15 how was that on the pre-operative 16 echocardiogram? 17 A. Normal. 18 Q. And can you quantify for me what 19 your understanding as a cardiothoracic surgeon 20 -- what your understanding of mild to 21 moderate RV or right ventricular dysfunction 22 is? 23 A. Well, less than normal. 24 Q. And what is normal right 25 ventricular function? 0082 1 A. Well, what -- what specifically -- 2 you want a -- a number or -- 3 Q. I just -- 4 A. The -- the function was less than 5 it normally is. 6 Q. -- was going to get into a 7 cardiothoracic surgeon's head and try to 8 understand the terminology. 9 What is normal cardi -- what is 10 normal right ventricular function? 11 A. Well, when you're looking at the 12 echo, if the contractility isn't what it 13 normally would be, then it's depressed, and 14 there are various different grades for that. 15 Q. So when somebody describes 16 something as moderate or mild to moderate RV 17 dysfunction. How depressed is that function? 18 A. Mildly to moderately depressed. 19 Q. And can you give me a percentage 20 on what that function -- 21 A. Not unless one was given at the 22 time of the -- of the -- of the study. 23 Q. Would there be a difference in 24 terminology when someone describes mild to 25 moderate dysfunction as opposed to moderate to 0083 1 severe dysfunction? 2 A. I -- 3 MS. KINKOPF-ZAJAC: Objection. 4 A. I -- 5 MS. KINKOPF-ZAJAC: When he uses 6 those terms or when someone else uses those 7 terms? 8 Q. (By Ms. Perse) What I'm -- what 9 his understanding as a cardiothoracic surgeon 10 that is interpreting a report. 11 I want to know what his 12 understanding of the difference between mild 13 to moderate dysfunction versus the description 14 of moderate to severe dysfunction? 15 A. Well, I think that's very 16 subjective, and it really depends on the 17 person that's reading the study. 18 Q. But we started this by you 19 explaining to me that you -- you read the 20 report in rely -- and relied on that report 21 in par -- in participating in Michael Orra's 22 surgery. True? 23 MS. KINKOPF-ZAJAC: Objection. I 24 don't think that was his testimony. Go 25 ahead. 0084 1 Q. (By Mr. Perse) Doctor? 2 A. Can you -- can you restate the 3 question? 4 MS. PERSE: Court reporter, can you 5 read back that question for me, or for the 6 Doctor?Hello? 7 THE REPORTER: Yes. I'm -- I'm 8 getting it. 9 (Question was read by the 10 reporter.) 11 A. Well, I read the report prior to 12 participating in the operation. True. 13 Q. (By Ms. Perse) And why did you 14 read that report? 15 A. To look at the patient's diagnosis 16 and to look at his anatomy, prior to 17 participating in the operation. 18 Q. And we talked a little bit about 19 -- are -- is it -- in general, are there 20 any other parameters that you look at that 21 are provided to you as a cardiothoracic 22 surgeon -- 23 A. Right. 24 Q. -- when reading the echocardiogram 25 report? 0085 1 A. Correct. 2 Q. And we discussed that -- the two 3 additional parameters we were discussing was 4 right ventricular function and left ventricular 5 function. Is that true? 6 A. That is correct. I also said that 7 we look at the anatomy of the defect, itself, 8 and were there any other additional lesions. 9 Q. Correct. 10 A. And the usually the 11 echocardiographer will give some indication of 12 what the patient's function is. 13 Q. And when you are looking at that 14 echocardiogram report and you see the 15 description as to the ventricular function, 16 does the cardiothoracic surgeon rely on that 17 information in performing the surgery to 18 repair the defect? 19 MS. KINKOPF-ZAJAC: Objection. Go 20 ahead. 21 A. I think, in part, yes. But also 22 there is a -- an echocardiogram that is done 23 in the operating room for -- for almost every 24 case. 25 Q. (By Ms. Perse) When you look at -- 0086 1 in pre-operative preparation for a patient, 2 such as Michael Orra, and you look at the 3 description as to the ventricular function. 4 What does -- how does mild to moderate right 5 ventricular dysfunction differ from a 6 description of moderate to severe right 7 ventricular dysfunction? 8 MS. KINKOPF-ZAJAC: Objection. 9 It's been asked and answered. Go ahead. 10 Tell her again. 11 A. Well, again, I wasn't involved in 12 the pre-operative preparation of the patient. 13 I read the report when the patient arrived in 14 the operating room, prior to -- prior to 15 performing the operation with Dr. Sabik. 16 Q. (By Ms. Perse) So when you read 17 the report, were you relying on the report, 18 at all? 19 MS. KINKOPF-ZAJAC: Objection. 20 Asked and answered. Go ahead. 21 A. Yes. 22 Q. (By Ms. Perse) And what about that 23 report were you relying on in Michael Orra's 24 case? 25 A. I was looking at the patient's 0087 1 anatomy. Whether or not he had any other 2 associated lesions, and -- and what the 3 patient's function was. 4 Q. And what I'm trying to understand 5 is, what your understanding of a description 6 of mild to moderate dysfunction of the right 7 ventricle meant to you as a cardiothoracic 8 surgeon, prior to participating in Michael 9 Orra's case? 10 MS. KINKOPF-ZAJAC: Objection. 11 Asked and answered. 12 MS. PERSE: I don't believe I've 13 gotten an answer, and I find it distracting 14 that you say that. 15 MS. KINKOPF-ZAJAC: I believe you 16 have. Go ahead. 17 A. Well, mild -- mild to moderate 18 dysfunction means that the patient did not 19 have normal RV function at the time of the 20 operation. 21 Q. (By Ms. Perse) And can you tell me 22 what the -- by percentage, how depressed the 23 right ventricular function would be in a 24 patient that has mild to moderate dysfunction? 25 A. Well, -- 0088 1 MS. KINKOPF-ZAJAC: Objection. 2 Asked and answered. Go ahead. 3 A. -- as I stated before, it wasn't 4 quantitated. So I -- I can't tell you what 5 percentage dysfunction the patient had. It's 6 a general term that is very subjective 7 depending on who the echocardiographer is. 8 Q. (By Ms. Perse) But if you were 9 relying on that as a thoracic surgeon before 10 undertaking a procedure, you have an 11 understanding of what mild to moderate 12 dysfunction means to you, correct? 13 A. Yes. 14 Q. And so prior to undertaking Michael 15 Orra's surgery, the description of mild to 16 moderate dysfunction on an echocardiogram 17 report what -- meant what to you? 18 A. Meaning that he had RV dysfunction 19 that wasn't normal. It had mildly depressed 20 right ventricular dysfunction. 21 Q. And that is not as severe as 22 moderately depressed, correct? 23 A. Correct. 24 Q. And that is not as severe as 25 severely depressed -- 0089 1 A. Correct. 2 Q. -- ventricular dysfunction, correct? 3 A. Correct. 4 Q. And that description of right 5 ventricular dysfunction was sufficient for you 6 to find -- to feel that undertaking the 7 repair was appropriate in a patient such as 8 Michael Orra, correct? 9 A. I didn't -- 10 MS. KINKOPF-ZAJAC: Objection. Go 11 ahead. 12 A. I didn't make that decision. 13 Q. (By Ms. Perse) Who did? 14 A. Well, I assumed that it was the 15 attending surgeon, who is operating on the 16 patient. 17 Q. So explain for me why you reviewed 18 the echocardiogram before scrubbing in on 19 Michael Orra's surgery? 20 MS. KINKOPF-ZAJAC: Objection. 21 Asked and answered about three times already. 22 A. Because I was assisting on the 23 operation, and I wanted to look at the 24 anatomy of the patient, confirm his diagnosis 25 before scrubbing into the operation. 0090 1 Q. (By Ms. Perse) Today and when you 2 undertake an open ASD repair, the description 3 of mildly deficient, right ventricular 4 function, does that impact your decision-making 5 regarding undertaking a repair? 6 MS. KINKOPF-ZAJAC: Did you say 7 mildly sufficient? 8 Q. (By Ms. Perse) Mildly -- what -- 9 mildly depressed or deficient, yes. 10 MS. KINKOPF-ZAJAC: Oh, deficient. 11 Okay. Objection. You can answer it. Go 12 ahead. 13 A. Well, again, I -- I didn't make 14 any -- any decisions about this particular 15 case and whether or not this patient was 16 going to surgery to have the ASD closed. 17 Q. (By Ms. Perse) Is there anything 18 else on the echocardiogram that a 19 cardiothoracic surgeon looks at before 20 performing an open ASD repair? We've already 21 talked about the abnormal venous return and 22 the multiple defects, the right ventricular 23 dysfunction and the left ventricular 24 dysfunction. 25 A. Sure. 0091 1 Q. Anything else -- 2 A. I do -- 3 Q. -- that is provided to you in the 4 echocardiogram report that is necessary for 5 the cardiothoracic surgeon to know before 6 undertaking the procedure? 7 MS. KINKOPF-ZAJAC: Objection. Go 8 ahead, again. 9 A. Well, the -- the echo -- this 10 depends on what the -- what the lesion is 11 that is being fixed on the amount of 12 information that you get and what the purpose 13 of the echo is. Echos can look at all 14 different aspects of cardiac anatomy, so. 15 Q. (By Ms. Perse) Is it important to 16 know the pulmonary arterial pressures before 17 performing an open ASD repair? 18 A. Sure. 19 Q. And were the pulmonary artery 20 pressures reported on Michael Orra's 21 pre-operative echocardiogram? 22 A. Do you mind if I look at the echo 23 report again? 24 Q. Sure. 25 MS. KINKOPF-ZAJAC: Which one? 0092 1 THE WITNESS: The pre-op echo. 2 MS. KINKOPF-ZAJAC: Which one? 3 That's it. 4 Q. (By Ms. Perse) Have you found it 5 yet, Doctor? 6 A. Yes. But I'm not seeing any -- 7 any specific PA pressures. 8 Q. And can you tell me what you're 9 looking at? 10 A. I'm looking at the echo report. 11 I'm sorry. This is dated November 23rd of 12 2005. You know, they do the normal 13 description of each one of the chambers. I 14 don't -- I don't see any mention specifically 15 of pulmonary artery pressures in this echo 16 report. It talks abut the LV function, which 17 was -- had an EF of 60 percent. 18 Q. I am sorry. The LV function what? 19 A. 60 percent, which is normal, as I 20 -- as I stated. But I don't see any PA 21 pressures in this echo report. 22 Q. And tell me how the -- the right 23 ventricular function is described? 24 A. Well, in the conclusions, it says, 25 severely dilated right atrium and severely di 0093 1 -- dilated RV with moderate dysfunction. 2 Q. Is there any percentage in terms of 3 that description? 4 A. There is not. 5 Q. And who performed that study? 6 MS. KINKOPF-ZAJAC: Note an 7 objection as to him interpreting someone 8 else's report. But go ahead, if you know. 9 A. Well -- 10 Q. (By Ms. Perse) Well, actually, 11 number one, we're looking -- he's re -- he's 12 telling me about a study that he's looking 13 at. I'm trying to identify it. So I want 14 to make sure I know who -- since we're 15 working long-distance as to -- 16 A. The -- 17 Q. -- what he is referring to just -- 18 A. I'm trying to -- I'm trying to see 19 if it -- 20 Q. -- on the record. And, number 21 two, he indicated that he looked at the echo 22 report before he undertook Michael Orra's 23 surgery. 24 A. Well, the re -- at the top, it 25 says, the report was signed by Ellen Mayer 0094 1 Sabik. 2 Q. And who is that? Do you -- do 3 you recognize that signature? 4 A. She's a cardiologist at Cleveland 5 Clinic, I assume. 6 Q. And what is her name? 7 A. Ellen Mayer Sabik. 8 Q. And can tell -- spell the last 9 name for me? 10 A. S-A-B-I-K. 11 Q. Okay. Is she any relation to the 12 -- Dr. Sabik that you were working with on 13 -- on Michael Orra's case on November 30th? 14 A. Yes. 15 Q. And what relationship? 16 A. It's his wife. 17 MS. PERSE: I would like that 18 report to be marked for exhibit. 19 MS. KINKOPF-ZAJAC: This is in my 20 copy of the records. I will provide someone 21 with a copy subsequent to this. Do you not 22 have this copy of the record? 23 MS. PERSE: Well, I just want to 24 make sure that the court reporter has the 25 document that the doctor is referring to. 0095 1 MS. KINKOPF-ZAJAC: This is in my 2 bound copy of the records. 3 MR. MARGOLIS: All right. Well, 4 you can give it to the court when you get 5 home. 6 MS. KINKOPF-ZAJAC: Oh, that's 7 fine. I can do that. I'm not -- okay. 8 But do you not have this? 9 MS. PERSE: I have plenty of Dr. 10 Gar -- or Dr. Garcia and the pre-operative 11 work-up. I have not located the exact record 12 that he is referring to. I'm just not sure 13 because I can't see what he's looking at. 14 MS. KINKOPF-ZAJAC: It is a 15 transesophageal echo report from November 23rd 16 of 2005. 17 MS. PERSE: And, again, I would 18 just like you to make sure that that -- 19 MS. KINKOPF-ZAJAC: I -- no 20 problem. 21 MS. PERSE: -- gets marked as an 22 exhibit for it to be attached to this 23 deposition, so I know that we're speaking 24 about the same report. 25 Q. (By Ms. Perse) Doctor, did you 0096 1 review anything else prior to undertaking 2 Michael Orra's surgery? 3 A. I don't remember seeing any other 4 study besides this one. 5 Q. And we had discussed earlier that 6 -- forget that. 7 Were you aware of Michael Orra 8 having a cardiac catheterization? 9 A. Yes. 10 Q. And how did you become -- how did 11 you learn that Michael Orra had a cardiac 12 catheterization before? 13 A. Well, I think that that was part 14 of his record when he came to the operating 15 room. 16 Q. So is it fair to say that you 17 would have looked at that catheterization 18 before participating in Michael Orra's surgery? 19 MS. KINKOPF-ZAJAC: Objection. 20 A. No. I -- I'm -- no. I didn't 21 look at the -- at the study, itself. 22 Q. (By Ms. Perse) And did you -- so 23 you -- just because you broke up a little 24 bit. 25 A. I did not look at the study. 0097 1 Q. Did you look at the report before 2 Michael Orra's surgery? 3 A. I actually don't remember if I 4 actually looked at the report. I was aware 5 that -- that they had attempted to close a 6 device; that he was initially evaluated for a 7 device closure. 8 Q. And how did you become aware of 9 that? 10 A. By looking at the record, prior to 11 scrub in to the operation. 12 Q. And what record told you that? 13 A. Well, I don't remember 14 specifically. 15 Q. Other than the catheterization 16 report, would there be any other record that 17 would tell you that? 18 A. Yes, notes. But, like I said, I 19 don't remember specifically where I looked and 20 found that information. 21 Q. Did you have any conversation with 22 Dr. Sabik before the surgery about Michael 23 Orra's pre-op cardiac catheterization? 24 A. Not that I remember. No. 25 Q. Do you recall seeing Dr. Sabik 0098 1 before Michael Orra's surgery? 2 A. The morning of the surgery? I 3 don't remember seeing him before we actually 4 started the operation. I don't remember 5 talking to him about it specifically prior to 6 -- prior to meeting the patient in the 7 operating room. 8 Q. When do you recall seeing Dr. 9 Sabik in the operation room? 10 A. When he came in to do the case. 11 Q. And at what point in time -- or 12 what were you doing at that time? 13 A. At the time that he came in? 14 Q. Yes. 15 A. Well, usually what happens is, my 16 responsibility is to open the patient. 17 Obviously, he's under anesthesia. We've 18 prepped. We've draped. And I open the -- 19 the patient. And I -- I -- usually, I 20 cannulate the patient for bypass. I don't 21 remember specifically if I did that in this 22 case. But that would be the -- that would 23 be the norm for us is to -- to have the 24 resident cannulate the patient for bypass, and 25 then attending actually comes in at that 0099 1 point and does the operation. 2 Q. So the practice, the cardiothoracic 3 practice at the Cleveland Clinic was that the 4 resident would prep and drape the patient, 5 correct? 6 A. Correct. 7 Q. And then they would make the skin 8 incision, correct? 9 A. Correct. 10 Q. And they would do -- in this -- 11 in a case such as Michael Orra, they would 12 take the sternal saw and open the -- the 13 sternum, correct? 14 A. Correct. Now, that is -- you 15 know, that is depending on what the operation 16 is. 17 Q. Understood. And that's why I'm 18 saying -- I kind of said it generally. 19 A. Right. That's -- that's correct. 20 Q. In the thoracic service, it was 21 the resident's responsibility to be in 22 attendance to the patient when the patient 23 went to sleep and the patient was prepped and 24 draped and the skin incision was made. The 25 chest was opened with the sternal saw. A 0100 1 dissection was undertaken to prepare for 2 cannulation. All those things were done 3 before the cardiothoracic attending walks into 4 the room, correct? 5 MS. KINKOPF-ZAJAC: Objection. Go 6 ahead. 7 A. In general, that is correct. 8 Q. (By Ms. Perse) Any reason that 9 wouldn't have been the case in Michael Orra's 10 surgery? 11 A. Not that I can remember. 12 Q. And then, just moving on in terms 13 of the procedure. The -- you mentioned that 14 you -- typically, the resident would cannulate 15 the patient before the attending would arrive. 16 Is that true? 17 A. True. 18 Q. Tell me what's involved with -- 19 when you describe cannulation? 20 A. In general, one has to place purse 21 strings in the various cardiac structures. 22 The aorta, superior and inferior vena cava, 23 and then place the cannulas into those 24 structures. 25 Q. And when you place the cannula -- 0101 1 tell me how big is that cannula that you 2 described? 3 A. It -- it really varies, depending 4 on size of the patient, for example. I -- I 5 -- there -- there are multiple different 6 cannula sizes. 7 Q. And an adult male patient who is 8 being cannulated -- what's the purpose of 9 cannulation? 10 A. To put the patient on 11 cardiopulmonary bypass. 12 Q. And when you are cannulating an 13 adult male patient in preparation for a 14 cardiothoracic procedure, what size tube would 15 you typically use? Just give me a range? 16 MS. KINKOPF-ZAJAC: Just note an 17 objection. Go ahead. 18 A. It -- it -- it just depends. It 19 depends on the patient's size. It -- it 20 depends on what you need to achieve a 21 full-flow cardiopulmonary bypass. 22 Q. And an adult male patient, that is 23 the typical -- let's say 170 kilograms 24 patient, what size cannula would you use? 25 A. Again, it depends on -- 0102 1 MS. KINKOPF-ZAJAC: Objection. 2 Asked and answered. 3 A. -- the size of the patient. 4 Q. (By Ms. Perse) Well, I'm giving 5 you the size of the patient. 6 MS. KINKOPF-ZAJAC: Objection. 7 Asked -- 8 Q. (By Ms. Perse) In that it is a 9 male patient, and he is 170 kilograms. 10 MS. KINKOPF-ZAJAC: Objection. 11 Asked and answered. Go ahead. Can you answer 12 that any more than what you did? 13 THE WITNESS: No more than what I 14 did. 15 A. I -- i don't know what -- I don't 16 remember what size cannula we put in Dr. 17 Orra. 18 Q. (By Ms. Perse) I'm not asking 19 that. I'm again asking what's the typical 20 size for a patient that is 170 kilos, what 21 other information do you need to know the 22 size of the patient? 23 A. We have multiple different cannulas 24 that we use for cardiopulmonary bypass. So I 25 -- I can't give you any more specific answer 0103 1 than that. 2 Q. How do you decide what size to use 3 then? 4 A. Well, size of the patient and 5 whatever the requirements are for a full-flow 6 cardiopulmonary bypass. 7 Q. And what's the range of sizes in 8 an adult patient? I want to exclude the 9 pediatric population. Hopefully, making that 10 a little easier for you. 11 MS. KINKOPF-ZAJAC: Objection. 12 Q. (By Ms. Perse) What's the range of 13 cannulas? 14 A. A range of multiple different 15 sizes. 16 Q. And that's what I'm asking. What 17 range -- 18 A. 16 French, 18 French. 19 Q. How big is -- 20 MS. KINKOPF-ZAJAC: Wait. Wait. 21 One person needs to talk at a time. We're 22 both -- everybody is -- 23 MS. PERSE: I apologize. I didn't 24 hear him. So -- 25 MS. KINKOPF-ZAJAC: Okay. So he's 0104 1 giving you a range of different sizes that 2 could potentially be used for -- 3 A. 16 French, 18 French. There is a 4 multiple of different ranges for both arterial 5 cannula and for the venous cannula. 6 Q. (By Ms. Perse) So what's the -- 7 what is the caliber of an 18 French cannula? 8 A. What -- what do -- what do you 9 mean specifically? 10 Q. Is it the size of a pen, or is 11 it the size of a drinking straw? I'm trying 12 to get a sense of how big these cannulas 13 are? 14 A. Well, I can't -- 15 MS. KINKOPF-ZAJAC: I'm just going 16 to note an objection. Go ahead. 17 A. I can't -- I -- I don't have a 18 -- a good reference for that. It -- it 19 really depends on the patient's size. How big 20 the aorta is. There is a multiple of 21 different variables that going into making 22 that decision. 23 Q. (By Ms. Perse) As the 24 cardiothoracic or the thoracic resident, you 25 make that decision before the attending comes 0105 1 the room -- in the room -- 2 A. Well, I -- I -- 3 Q. -- as to what size cannula to put 4 in a patient, is that correct? 5 A. Yes and no. In general, for a 6 particular attending, they have an arterial 7 cannula that they tend to prefer to use. 8 So -- 9 Q. Dr. Sabik's preference -- 10 MS. KINKOPF-ZAJAC: Let him finish 11 the -- 12 Q. (By Ms. Perse) -- in terms of the 13 size of the arterial cannula? 14 MS. KINKOPF-ZAJAC: I just want to 15 -- Jessica, he was still working on his 16 answer. Please let him finish. 17 MR. MARGOLIS: I couldn't hear you. 18 Say that again. 19 MS. KINKOPF-ZAJAC: He was still 20 working on his answer. Please let him 21 finish. 22 MR. MARGOLIS: I apologize. Let me 23 turn the volume up again. Okay. 24 MS. KINKOPF-ZAJAC: Go ahead. 25 A. Yes. I was saying for a 0106 1 particular attending, there may be a 2 particular cannula that they prefer to use to 3 do their -- to do their operation. 4 Q. (By Ms. Perse) Are you done? 5 A. Yes. 6 Q. And then my follow-up question was, 7 what was Dr. Sabik's particular cannula that 8 he was -- wanted you to use, arterial 9 cannulation? 10 A. Well, I know -- I know that he 11 had one. The name of it and the particular, 12 you know, brand of it, I don't remember. 13 But we put his cannula in that he usually 14 uses. 15 Q. And you would do that before he 16 gave you that direction because that would be 17 his practice, is that correct? 18 A. Well, the general -- the general 19 sequence is that we would call the attending 20 to let them know that we were about to 21 cannulate. 22 Q. And then what would happen? 23 A. Well, he would say whether or not 24 we could go ahead, and I would cannulate. 25 Q. Do you recall that conversation 0107 1 with Dr. Sabik in Michael Orra's case? 2 A. I don't recall that specific 3 conversation. I can tell you that's the 4 usual routine. 5 Q. Do you put the arterial cannula 6 before you put the venous cannula in? 7 A. In general, yes. 8 Q. Why? 9 A. Well, that's the way that we 10 usually do it. It gives you access, for 11 one, in case you have bleeding when you -- 12 when you put in the venous cannulas. 13 Q. Which is more likely to cause 14 bleeding, the arterial or the venous cannula 15 insertion? 16 A. Well, they both bleed when you put 17 the cannulas in because you are entering a 18 structure that has blood in it. 19 Q. And the artery -- or the artery -- 20 the arterial cannula goes in the aorta, 21 correct? 22 A. Correct. 23 Q. That's a high-pressure system? 24 A. Yes. 25 Q. And would it be more likely that 0108 1 the arterial cannula would bleed if there was 2 a problem with cannulation as opposed to the 3 venous cannula insertion? 4 A. I wouldn't say that's necessarily 5 the case. 6 MS. KINKOPF-ZAJAC: Objection. 7 A. I think if there is a problem with 8 cannulation, either the aorta or vein or 9 superior or inferior vena cava would bleed. 10 Q. So we're at the point in the 11 operation where the arterial cannula is in 12 and the venous cannula is in. 13 It would have been -- do you 14 recall those cannulations in Michael Orra's 15 situation for surgery? 16 A. The actual act of cannulation, I 17 don't remember it, specifically, but I would 18 say it was uncomplicated. 19 Q. And do you recall if Dr. Sabik was 20 present during the cannulation? 21 A. I don't remember that he was. 22 MS. KINKOPF-ZAJAC: I just need to 23 interject. It is -- we need to decide how 24 long we are going to go here. Do you have 25 any sense as to how long you are going to 0109 1 be, so he can make some phone calls as he 2 needs to -- 3 MS. PERSE: It is probably going to 4 be at least an hour, hour and a half. 5 MS. KINKOPF-ZAJAC Oh, God. Well, 6 I -- I don't even have this room that long. 7 MR. MARGOLIS: Get a late 8 check-out. We'll pay the difference. 9 MS. KINKOPF-ZAJAC: Can -- can you 10 -- let's go off the record. 11 THE VIDEOGRAPHER: Going off the 12 record. The time is approximately 10:59 a.m. 13 (Recess taken at 10:59 a.m. until 14 11:02 a.m.) 15 THE VIDEOGRAPHER: This is the 16 beginning of Tape Number 3. The time is 17 approximately 11:02 a.m. We are now back on 18 the record. 19 Q. (By Ms. Perse) Okay, Doctor. 20 We're back on the record. 21 A. Hi. 22 Q. And I think we were discussing the 23 cannulation. 24 A. Yes. 25 Q. What is your recollection of when 0110 1 Dr. Sabik arrived to -- into Michael Orra's 2 operation -- to the operating room? 3 A. My -- my recollection would be 4 that he came after we had cannulated. 5 Q. Prior to cannulation, did Dr. -- 6 Michael Orra have any hemodynamic --namic 7 difficulties that you can recall? 8 A. Not that I recall. 9 Q. On your review of the record, were 10 there any hemodynamic changes?Any difficulties? 11 A. Well, what I reviewed was the 12 operative note, and I did not see evidence of 13 any hemodynamic compromise, prior to -- prior 14 to -- prior to cannulation. 15 Q. When you open the chest, do you 16 make an assessment as a cardiothoracic 17 surgeon, being the surgeon in the room at the 18 time, as to the left ventricular function by 19 observation? 20 A. Yes. Of -- of -- of what of it 21 you can see. 22 Q. And in Michael Orra's case, what 23 was your observation of his left ventricular 24 function? 25 A. Well, as I was about to say. Of 0111 1 what -- of the -- of what you can see of 2 the left ventricle. I don't remember 3 specifically, but I -- his function was 4 normal based on the -- based on the echo. 5 Q. Are there -- can -- and you 6 corrected me. When you open the chest and 7 are looking at the heart contracting in the 8 chest, what is the anatomic structure that 9 you observe? Is it the right ventricle? Left 10 ventricle? 11 A. When you immediately open the 12 chest, you see the right ventricle because 13 it's most anterior structure. 14 Q. And so the operating cardiothoracic 15 surgeon in attendance at that point of the 16 operation before cannulation makes an 17 assessment as to the right ventricular 18 function. Is that true? 19 MS. KINKOPF-ZAJAC: Objection. 20 A. True. 21 Q. (By Ms. Perse) And in Michael 22 Orra's case, what was your observation as to 23 his right ventricular function? 24 A. Well, you know, I don't remember 25 what his heart looked like specifically. 0112 1 Q. Did you make any notation 2 post-operatively as to his right ventricular 3 function? 4 A. I didn't personally make any 5 notation about what it looked like when we 6 opened his chest. 7 Q. Is it fair to say that if you do 8 not recall, and you didn't make any notation, 9 that his right ventricular function was 10 unremarkable? 11 MS. KINKOPF-ZAJAC: Objection. 12 A. No. I don't think that's fair. 13 I think it just means I didn't make a 14 notation of it, and I don't remember 15 specifically what it was like. 16 Q. (By Ms. Perse) And can you make an 17 assessment as to whether his right ventricle 18 -- ventricle was enlarged? 19 A. Well, again, I -- I don't remember 20 specifically what his heart looked like at 21 the time of the operation. 22 Q. In general, as a cardiothoracic 23 surgeon before cannulation, is there any need 24 to make an assessment as to the right and 25 left ventricular contractility and size before 0113 1 cannulation? 2 MS. KINKOPF-ZAJAC: Objection. Go 3 ahead. 4 A. Well, we look at the heart when we 5 open the chest for every patient. 6 Q. (By Ms. Perse) And if you were to 7 observe an abnormality, is that important in 8 terms of the progress of the operation and 9 your surgical planning at that time? 10 A. It -- it -- 11 MS. KINKOPF-ZAJAC: Objection. Go 12 ahead. 13 A. It depends on -- on why you're 14 there. If the patient is there with known 15 decreased function, then -- then that's an 16 observation. 17 Q. (By Ms. Perse) And in Michael 18 Orra's case, his pre-operative echo that you 19 reviewed before you opened his chest, there 20 was moderate dysfunction of his right 21 ventricle. True? 22 A. True. 23 Q. And wouldn't it be important to 24 assess his right ventricular function upon 25 opening the chest before cannulation? 0114 1 MS. KINKOPF-ZAJAC: Objection. 2 A. If you're referring to looking at 3 the heart and make an assessment of his 4 function, yes. But what I said was I don't 5 remember specifically what it looked like. 6 Q. (By Ms. Perse) Were there any 7 difficulties in what you did to Michael Orra, 8 during his operation, before Dr. Sabik 9 arrived? 10 A. Not that I remember. 11 Q. And that -- when you say not that 12 you remember, that's based on your independent 13 recollection of the operation? 14 A. That's based on my recollection of 15 the operative notes. 16 Q. Well, there is kind of two things. 17 One is what you recall independent of the 18 records. Maybe many things. But what you 19 recall independent of the records, and then 20 what you may or may not have made note of or 21 there may or may not have been notations in 22 the record about. 23 A. I don't remember there being 24 anything unusual. 25 Q. Specifically asking about your 0115 1 recollection of Michael Orra's surgery? 2 A. Correct. 3 Q. Do you recall any difficulties with 4 the procedure before Dr. Sabik arrived? 5 A. I -- I don't recall there being 6 any difficulty, prior to Dr. Sabik's arrival. 7 Q. And were there any difficulties 8 after Dr. Sabik arrived? 9 MS. KINKOPF-ZAJAC: Objection. 10 A. In terms of? 11 MS. KINKOPF-ZAJAC: He's asking you 12 in terms of what difficulties. 13 Q. (By Ms. Perse) Well, were there 14 any problems with Michael Orra's surgery? 15 MS. KINKOPF-ZAJAC: Objection. Go 16 ahead. 17 A. That I recall, the operation went 18 well. 19 Q. (By Ms. Perse) And, Doctor, I 20 want to just -- as an aside, just want to 21 make sure that we are communicating and that 22 I am doing the best that, you know, I can, 23 that you are able to understand my questions, 24 and -- and you've been doing a good job so 25 far. But I want to make sure that I give 0116 1 you every opportunity to answer the questions 2 as fully and completely as possible. Your 3 attorney is doing a good job reminding me, 4 but just keep me on track. Okay? 5 A. Okay. Okay. 6 Q. Now, following the cannulation, 7 what happens in an open ASD repair? Do you 8 use the cannulation to go onto bypass? Is 9 that true? 10 A. Do you just want a general 11 description of what happens to close an ASD, 12 or are you referring specifically to this 13 case? 14 Q. Let's talk about in general first. 15 I just want to get a sense of what happens 16 after you cannulate. 17 MS. KINKOPF-ZAJAC: Objection as to 18 the general nature. But go ahead. 19 Q. (By Ms. Perse) And, again, just to 20 narrow the frame of reference. I want to 21 know on AS -- an open ASD repair, what 22 happens after you cannulate? 23 A. You go on bypass. 24 Q. And how is that procedure 25 performed? Do you pass off the cannulas or 0117 1 the other end of the cannula after you have 2 inserted them in the respective vessels? 3 A. That's already done prior to 4 cannulation. 5 Q. So those cannulas are handed to 6 you from somebody -- somebody else, and it's 7 a portion that's off the field, is that 8 correct? 9 A. Yes. But we are beyond that 10 point. If you are -- if you have gone on 11 bypass, everything is already where it needs 12 to be to -- to go on bypass. 13 Q. But you can't go on bypass until 14 the cannulas are in their right place, 15 correct? 16 A. Yes. But I thought -- I thought 17 you said we had already cannulated. 18 Q. Yeah. You cannulated. I guess 19 that's just a matter of my difficulty with 20 the semantics here. 21 But you put the cannulas in the 22 respective vessels, correct? 23 A. Correct. 24 Q. And you would put the cannula -- 25 the arterial cannula in the aorta, correct? 0118 1 A. Correct. 2 Q. Where do the venous cannulas go? 3 A. Well, they go in the -- in the 4 right side of the heart. Either in the 5 superior vena cava, inferior vena cava, or in 6 the right atrium as a single cannula. 7 Q. And in Michael Orra's case, where 8 did they go? 9 A. In the superior vena cava and 10 inferior vena cava. Two separate cannulas. 11 Q. So you put those cannulas in. And 12 then is blood circulated through those 13 cannulas? 14 A. Sure. To go to the bypass 15 machine. 16 Q. Do they -- do you open one cannula 17 before you open the other? 18 A. There is a sequence that all the 19 cannulas have to be unclamped to go on the 20 cardiopulmonary bypass machine. 21 Q. And what's that sequence? 22 A. What is the sequence of -- of 23 opening the cannulas? 24 Q. Correct. Or unclamping them? Is 25 that the same thing? 0119 1 A. Yes. 2 Q. And what's the sequence? 3 A. Well, it's somewhat surgeon 4 dependent. 5 Q. And as a thoracic surgery resident 6 performing the cannulation at the Cleveland 7 Clinic under doctor -- on a patient of Dr. 8 Sabik's, you would have followed Dr. Sabik's 9 routine? 10 A. I didn't put the patient on 11 cardiopulmonary bypass. 12 Q. Okay. And whose -- who put the 13 patient on cardiopulmonary bypass? 14 A. Dr. Sabik. 15 Q. So once you were cannulated, -- 16 A. Yes. 17 Q. -- then it -- Dr. Sa -- Sabik 18 would come in? 19 A. Dr. Sabik would come in. 20 Q. And do you recall Dr. Sabik 21 arriving to Michael Orra's surgery? 22 A. Yes, after we cannulated, which is 23 the usual time that he would arrive. 24 Q. Can you tell me what it means to 25 vent the left heart during a procedure like 0120 1 Michael Orra's? 2 A. Sure. 3 Q. What does that mean? 4 A. It means to put a -- a separate 5 type of drain to get blood from the left 6 side of the heart. 7 Q. From the left side of the heart. 8 Did you finish? 9 A. Yes. 10 Q. Does that blood go anywhere? 11 A. It goes back into the 12 cardiopulmonary bypass machine. 13 Q. Do you recall venting Michael 14 Orra's left heart? 15 A. I do not recall that specifically. 16 Q. Did anybody vent Michael Orra's 17 heart? 18 A. I do not recall a vent being used, 19 but this -- this patient has an atrial septal 20 defect. So you wouldn't -- the left heart 21 is already vented because he has an ASD. So 22 the left heart is communicating with the 23 right heart through the atrial septal. 24 Q. So is it -- am I understanding 25 correctly that his -- an open ASD repair does 0121 1 not need to have the left heart vented during 2 bypass? 3 MS. KINKOPF-ZAJAC: Just note an 4 objection. I don't think that's what he 5 said. 6 MS. PERSE: Well, that is what I am 7 trying to figure out, what he is said. 8 MS. KINKOPF-ZAJAC: Is there is a 9 specific record that you are referring to 10 that you want -- 11 Q. (By Ms. Perse) I am just asking 12 him -- 13 MS. KINKOPF-ZAJAC: Okay. So -- 14 Q. (By Ms. Perse) -- with an open 15 ASD, -- 16 MS. KINKOPF-ZAJAC: Okay. 17 A. I -- 18 Q. (By Ms. Perse) -- is it necessary 19 to have the left heart vented? 20 A. Well, I think that's depend -- 21 MS. KINKOPF-ZAJAC: Objection. Go 22 ahead. 23 A. -- that's dependent on the surgeon 24 performing the operation. 25 Q. (By Ms. Perse) And is that -- is 0122 1 the left heart venting -- venting part of the 2 preparation in -- for preparing the patient 3 for bypass? 4 A. No. Not -- not for our particular 5 institution. 6 Q. And when you are referring to our 7 particular institution, are you referring to 8 the Cleveland Clinic, or where your at now? 9 A. I am referring to when I was at 10 the Cleveland Clinic. 11 Q. Okay. So the practice at the 12 Cleveland Clinic in terms of open ASD repairs 13 and preparing the patient for can -- for 14 bypass would not include venting the left 15 heart? 16 A. It would not. I wouldn't do it. 17 The decision to vent -- to vent the patient 18 was made by the attending. And if it was 19 done, it was done by the attending. 20 Q. Okay. Was the left heart vented 21 in Michael Orra's case? 22 A. I don't remember that it was 23 vented, or whether it was not vented. I -- 24 Q. When you take a -- you take a 25 look at the operative note. Does -- is 0123 1 there a description of whether or not Michael 2 Orra's left heart was vented? 3 A. I do not see any indication in the 4 operative note that the left heart was 5 vented. 6 Q. Thank you. 7 So can you conclude that the heart 8 was -- the left heart was not vented? 9 MS. KINKOPF-ZAJAC: Objection. 10 A. No. I cannot conclude that. 11 Q. (By Ms. Perse) Why? 12 MS. KINKOPF-ZAJAC: Objection. 13 A. I can't conclude that because the 14 left heart was essentially open because he 15 had a communication between his right and 16 left side, which was the ASD. 17 Q. I understand that. 18 But just by virtue of the fact 19 that he had that open communication, I think 20 we have already established does not tell us 21 whether or not the left heart should be 22 vented, correct? 23 A. I am sorry. Can you state that 24 again? 25 Q. I -- earlier you described that 0124 1 the left heart venting in an ASD repair is a 2 -- is based on the cardiothoracic surgeon's 3 preference, correct? 4 A. Correct. 5 Q. And when you read -- read the 6 operative report, you indicated that there is 7 no mention of whether or not -- there is no 8 mention of the left heart being vented, 9 correct? 10 A. Correct. 11 Q. And my question to you is, based 12 on that, can we conclude that Michael Orra's 13 left heart was not vented during his ASD 14 repair? 15 MS. KINKOPF-ZAJAC: Objection. 16 Asked and answered. Go ahead. 17 A. Can I clarify what you mean by 18 left heart vent? 19 Q. (By Ms. Perse) Well, that's why I 20 asked you what left heart venting was. 21 A. Well, my -- when -- when referring 22 to a left heart vent, we -- we mean 23 placement of a separate cannula in the left 24 side of the heart to decompress the left side 25 of the heart in somebody that has a septated 0125 1 heart, meaning that the right and left sides 2 don't communicate. 3 Q. Understood. 4 So is it your -- 5 A. Which isn't the case with Dr. 6 Orra. 7 Q. -- the left heart vent was 8 necessary or unnecessary in Michael Orra's 9 case? 10 MS. KINKOPF-ZAJAC: Objection. Go 11 ahead. 12 A. Well, I would say a left heart 13 vent would be unnecessary for an ASD closure. 14 Q. (By Ms. Perse) In general? 15 A. In general. Unaware -- I am not 16 aware of any surgeon that puts in a left 17 heart vent for an ASD closure. 18 Q. And on review of the record, was 19 Michael Orra's left heart vented? 20 A. I did not see any evidence of a 21 left heart vent in the operative note. 22 Q. And do you recall, independent of 23 the operative note, whether or not Michael 24 Orra's left heart was vented? 25 A. I do not recall his left heart 0126 1 being vented. 2 Q. And the venting of the left heart, 3 that is done to remove any air bubbles that 4 may be in the left heart, is that correct? 5 A. Well, it depends on what you mean 6 by left heart vent. There are a lot of ways 7 to get air out of the heart. The left heart 8 vent in my training has been to decompress 9 the volume from the left side of the heart 10 when it is -- when it is overly distended or 11 when you suspect that you are going to have 12 a lot of blood coming back to the left side 13 of the heart, and you need a way to get -- 14 to get it out, basically. 15 Q. So it is only to vent the excess 16 blood? It has nothing to do with air? 17 A. Well, yes. Because you can vent 18 air from the heart through the aorta, which 19 is usually what we would do to -- to get air 20 out. You don't necessarily have to do it by 21 putting a separate cannula in, per se. 22 Q. And the cannula that's placed in 23 the aorta to remove any ex -- air that may 24 be in the left side of a circulation. Is 25 that cannula placed before or after the 0127 1 coronary artery circulation? 2 A. What -- what do you mean before or 3 after the coronary artery circulation? 4 Q. Is a cannula placed before or 5 after the coronary artery blood vessels come 6 off of the aorta? Proximal or distal to the 7 take-off of the coronary vessels? 8 A. The cannula is placed in the 9 aortic root. 10 Q. And is that distal or proximal to 11 the coronary vessels? 12 A. It is usually distal. 13 Q. So if there were air in the left 14 heart, that air would travel through -- out 15 the left heart into the aorta and could exit 16 the cannula in the aortic root, correct? 17 MS. KINKOPF-ZAJAC: Objection. 18 A. Correct. 19 Q. (By Ms. Perse) The vent -- if the 20 vent is placed in the left ventricle, and if 21 there were air in the left ventricle, that 22 would remove or prevent the air from 23 traveling through the ventricle into the 24 aortic root, is that correct? 25 A. Well, I can't say with certainty 0128 1 that an LV vent would prevent all the air 2 from escaping the LV and going into the 3 aortic root. That's -- the purpose of it is 4 to try and get the air out. But to be able 5 to say that all of the air would go out 6 through the -- through the cannula placed in 7 the -- in the LV apex site, I can't say that 8 with certainty. 9 Q. But if that is the first line of 10 defense of removing the air from the 11 ventricle that may be introduced during an 12 open cardiac procedure, correct? 13 A. I am sorry. What -- what -- what 14 is the first line of defense? 15 Q. The cannula in the left ventricle? 16 A. I would not say that to be the 17 case. 18 Q. Let's talk a little bit about the 19 -- following the cannulation and placing the 20 patient on bypass. Dr. Sabik would come in 21 for placing the pa -- patient on bypass, 22 correct? 23 A. Correct. 24 Q. And do you recall Dr. Sabik being 25 specifically present for going on bypass in 0129 1 Michael Orra's case? 2 A. Yes. 3 Q. And why do you have that 4 recollection? 5 A. Because that's the way -- 6 MS. KINKOPF-ZAJAC: Objection. Go 7 ahead. 8 A. Because that's the way that we 9 usually do it. 10 Q. (By Ms. Perse) So that's the 11 practice? 12 A. That's the practice that -- 13 Q. Dr. Sabik's practice, correct? 14 A. And -- yes. And the practice -- 15 Q. You have an independent 16 recollection of Dr. Sabik being present for 17 going on bypass in Michael Orra's case? 18 A. Well, my recollection is that he 19 was -- he was there prior to going on 20 bypass. 21 Q. And you remember that by virtue of 22 Dr. Sabik's habit, not because you actually 23 recall that happening, is that correct? 24 A. I -- from my recollection of the 25 case, Dr. Sabik was there prior to us going 0130 1 on bypass. 2 Q. Prior to doctor -- or Michael 3 Orra's surgery, had you ever placed a patient 4 on bypass as the primary surgeon? 5 A. No. 6 Q. After Michael Orra's surgery, had 7 you ever placed a patient on bypass as the 8 primary surgeon? 9 MS. KINKOPF-ZAJAC: Objection. 10 A. No. Our -- our practice is to 11 cannulate the patient and the attending 12 surgeon initiates cardiopulmonary bypass. 13 Q. (By Ms. Perse) And why is that? 14 MS. KINKOPF-ZAJAC: Objection. 15 A. That would be a question that I -- 16 I can't necessarily answer. That is just the 17 practice at -- at the institution. 18 Q. (By Ms. Perse) So in order to sit 19 for your thoracic surgery boards, do you have 20 to have any log of acting as the primary 21 surgeon, putting a patient on cardiothoracic 22 bypass? 23 A. Sure. 24 Q. So since Dr. Orra's procedure, did 25 you put any patients on bypass as the primary 0131 1 surgeon? 2 MS. KINKOPF-ZAJAC: Objection. 3 A. Again, the answer is no. 4 Q. (By Ms. Perse) And I guess where 5 my disconnect is, is how are you planning on 6 sitting for the boards if you haven't put any 7 patients on bypass? 8 MS. KINKOPF-ZAJAC: Objection. 9 A. Well, the requirements for -- for 10 the thoracic surgery boards are to be 11 involved in various different cases of the 12 categories that they indicate, and I have 13 done so. So I am pretty sure there won't be 14 any complications to my sitting for the 15 thoracic surgery boards. 16 Q. (By Ms. Perse) Does the board 17 require you to act as the primary surgeon 18 putting the patient on bypass? 19 A. The board requires us to do a 20 certain number of cases of various different 21 categories, and there is a minimum re -- 22 requirement for each one of those cases. And 23 I have met all of those requirements. 24 Q. And where do you get those 25 requirements? How are you informed of those 0132 1 requirements? 2 A. They are established by the 3 American Board of Thoracic Surgery. 4 Q. And you have -- you know those 5 requirements? 6 A. Do I know the specific numbers of 7 each category? Is that -- is that the 8 question? 9 Q. Yes. 10 A. Not -- I can't give you the 11 numbers from memory right now, but they are 12 available on the American Board of Thoracic 13 Surgery web site, which is open to the 14 public. 15 Q. Now, following placing the patient 16 on bypass, what happened? 17 MS. KINKOPF-ZAJAC: Objection. 18 That's -- it's a pretty broad question. Are 19 you talking about intra-operatively? 20 Q. (By Ms. Perse) Yes. I'm ask -- 21 asking very -- the very specific points of 22 the procedure. So, again, I apologize. Just 23 to be clear, we have established in a 24 patient, such as Michael Orra, who had an 25 open ASD repair, that he would have been 0133 1 cannulated and Dr. Sabik would place the 2 patient on cardiothoracic bypass. Is that a 3 fair characterization, Dr. Bryant? 4 A. That's correct. 5 Q. And then what would be the next 6 step in an open ASD repair? 7 MS. KINKOPF-ZAJAC: Objection. In 8 this open ASD repair, or any open ASD repair? 9 Q. (By Ms. Perse) Let's start with in 10 any ASD repair? 11 MS. KINKOPF-ZAJAC: Objection as to 12 the general nature of the question. Go 13 ahead. 14 A. Well, in general, the next step 15 would be to arrest the heart. Open the 16 heart. Examine the cardiac anatomy of the 17 defect, and then close the defect. 18 Q. (By Ms. Perse) I'm sorry. You're 19 kind of fading in and out. Can you speak a 20 little louder? 21 A. Sure. So, in general, you have to 22 arrest the heart, which requires cross-clamping 23 of the aorta. Once the heart is arrested, 24 you open the heart. You examine the defect. 25 You close the defect. You close the heart, 0134 1 and you then separate from bypass. 2 Q. And how is the heart arrested? 3 A. With cardioplegic solution. 4 Q. And how is that administered? 5 A. By the perfusionist. 6 Q. And the per -- how does the 7 perfusionist administer the cardioplegia? 8 MS. KINKOPF-ZAJAC: Just note an 9 objection. Go ahead. 10 A. Well, they have a separate line 11 that -- that they run the cardioplegia 12 through, and that comes up to the patient, 13 and it's injected into the aortic root. 14 Q. (By Ms. Perse) And how is that 15 injected? Is there something that's placed 16 in the aorta? 17 A. Yes. There is a separate cannula 18 placed in the aortic root. 19 Q. And in Michael Orra's case, do you 20 recall placing that cannula? 21 A. I did not place that cannula. 22 Q. And if you didn't place the 23 cannula, who placed that cannula? 24 A. The attending surgeon. 25 MS. KINKOPF-ZAJAC: You have got 0135 1 to speak up. 2 A. The attending surgeon. 3 Q. (By Ms. Perse) Now is that 4 cardioplegia antegrade or retrograde 5 cardioplegia? 6 A. Well, from -- let me look at the 7 -- at the operative note just to say for 8 sure. It was -- it was antegrade 9 cardioplegia needle, which he says in his 10 operative note, he also used to vent the 11 aorta. He describes it as an antegrade 12 cardioplegia cannula aortic event was placed 13 in the ascending aorta. 14 Q. Can you tell me what the 15 difference between antegrade cardioplegia and 16 retrograde cardioplegia is? 17 A. Sure. Antegrade cardioplegia is 18 given down the coronary ostia. And 19 retrograde cardioplegia is given through the 20 coronary sites, which is the venous structure. 21 Q. How does the surgeon know that the 22 cannula is at the coronary ostia? 23 A. Because they are placed at the 24 coronary ostia. It is placed in the aortic 25 root. And when you cross-clamp the aorta, 0136 1 then you inject the cardioplegia through the 2 cannula. It goes into the coronary ostia 3 based on the fact that the aorta is 4 cross-clamped. 5 Q. So in my primitive way of 6 thinking, it has no other place to go but 7 into the coronary ostia because the aorta is 8 cross-clamped, correct? 9 A. Exactly. 10 Q. Is there a certain interval of 11 time that that medication is administered or 12 is it a continuous infusion? 13 A. It isn't continuous. And the 14 interval of time is -- I would say highly 15 variable at best. 16 Q. And I am sorry. When you first 17 spoke, your answer was that it is not a 18 continuous infusion? 19 A. No, ma'am. 20 Q. And how is the interval of time 21 between medications determined? 22 A. I think it is depending on -- some 23 of it is depending on surgeon preference. 24 Q. And is that directed -- you said 25 some of that. Who else or what else -- what 0137 1 other variable may be included in that 2 determination? 3 A. The -- the maybe routine of the 4 institution. It just -- it's -- it's -- I 5 found it to be variable from institution to 6 institution. I think if you look at the 7 literature, you will see that it is variable 8 from institution to institution. 9 Q. And what was the standard at CCF 10 or the Cleveland Clinic? I am sorry. 11 A. In general, I would say every 20 12 or 30 minutes depending on what type of 13 operation was being done. 14 Q. Or in open ASD repair, how frequent 15 would the cardioplegia be administered? 16 A. That's really difficult for me to 17 say for the entire institution. I don't -- 18 I can't give you a number of practice. I 19 haven't looked at the mean times for ASD 20 closure. In general, you know, I -- I think 21 that because this is short cross-clamp time, 22 mostly you get one shot -- one dose of -- of 23 antegrade cardioplegia. 24 Q. And, as far as the other variable. 25 You mentioned, what, surgeon's preference? Is 0138 1 there anything else? 2 A. No. 3 Q. And what was Dr. Sabik's 4 preference? 5 A. Well, I can't speak to all of Dr. 6 Sabik's cases. I -- I -- for this case, he 7 gave one dose of antegrade cardioplegia, based 8 on the operative record. 9 Q. Do you know how much cardioplegia 10 he gave? 11 A. No. You mean the volume or -- or 12 what specifically? 13 Q. Volume and dose? And/or dose? 14 A. I don't. Just that it was given 15 and -- 16 Q. And is that a communication that 17 takes place between the operating surgeon and 18 the people that are running the bypass? 19 A. Communication in terms of -- 20 Q. The order, if you will, for the 21 cardioplegia dose? 22 MS. KINKOPF-ZAJAC: Objection. If 23 you can answer that. 24 A. You mean -- I -- I -- I'm not 25 understanding. You mean the amount that -- 0139 1 Q. (By Ms. Perse) Both. Tell me, 2 again, the dose is volume dependent or how -- 3 how is that determined? When you're -- you 4 as a cardiothoracic surgeon are communicating 5 to the office person or the operating room 6 personnel about the dosing of cardioplegia, 7 does the cardiothoracic surgeon direct that, 8 or is that a determination that is made by 9 somebody else? 10 A. Well, I -- for this case, I didn't 11 give any -- any orders about when to give 12 cardioplegia. 13 Q. And I can understand that. I am 14 just trying to -- I pick your brain, if you 15 will, as a cardiothoracic surgeon. Whose 16 responsibility, the dosing -- and if that 17 entails volume or potency, whose determination 18 in the operating room is it as to the 19 cardioplegia dose? 20 MS. KINKOPF-ZAJAC: Objection. Go 21 ahead. 22 A. Well, again, for this -- for this 23 particular case, I wasn't -- I didn't give 24 any -- any orders or -- to anyone regarding 25 when to give cardioplegia. 0140 1 Q. (By Ms. Perse) And I'm not -- I 2 am going in terms of generalities right now. 3 I am just trying to figure out whose 4 responsibility is it as the thoracic surgeon, 5 as a thoracic surgeon in training -- 6 A. Uh-huh. 7 Q. -- what is it -- your 8 understanding of whose responsibility it is to 9 make a determination about the cardioplegia 10 dosing in the operating room? 11 MS. KINKOPF-ZAJAC: Objection. Go 12 ahead. 13 A. By dosing, what -- what do you 14 mean specifically? 15 Q. (By Ms. Perse) When cardioplegia is 16 given, the cardiothoracic surgeon directs the 17 person who is handling the bypass to give -- 18 to begin the cardioplegia, correct? 19 A. Correct. 20 Q. And that person is -- that is 21 running the bypass, is that person known as 22 the perfusionist? 23 A. Correct. 24 Q. In terms of the dose of 25 cardioplegia, who makes the determination as 0141 1 to what dose is given to the patient? 2 A. I am sorry, but what do you mean 3 by dose? 4 Q. When a medication is given, you 5 have to given some parameters, is that 6 correct? 7 A. Sure. 8 Q. And that parameter would be the 9 route of administration, the strength of the 10 medication? 11 A. Sure. 12 Q. And so what I am trying to 13 determine is, cardioplegia is a medication, 14 correct? 15 A. Absolutely. 16 Q. And so when a dose of cardioplegia 17 is given to a patient on bypass, whose 18 responsibility is it to determine the strength 19 of medication, the route of administration, 20 and the interval of administration? 21 MS. KINKOPF-ZAJAC: Objection. 22 A. Well, the communication about 23 cardioplegia usually happens between the 24 perfusionist and the attending performing the 25 operation. 0142 1 Q. (By Ms. Perse) And does the 2 thoracic surgeon tell the perfusionist when to 3 give the cardioplegia? 4 MS. KINKOPF-ZAJAC: Objection as to 5 the general nature of the question. Go 6 ahead. You can answer it. 7 A. Yeah. For example, you can't give 8 the cardioplegia until the aorta is 9 cross-clamped and the perfusionist -- 10 perfusionist would be sitting there. 11 So usually when you cross-clamp the 12 aorta, you communicate to the perfusionist to 13 start cardioplegia. 14 Q. So that is the communication from 15 the cardiothoracic surgeon to start the 16 cardioplegia? 17 A. Yeah. Once the aorta is 18 cross-clamped, so you can arrest the heart 19 and perform the operation. 20 Q. And who makes the determination of 21 how much cardioplegia is given to patient? 22 MS. KINKOPF-ZAJAC: Objection. 23 A. I think that's -- I -- I don't 24 know specifically who decides how much volume. 25 Whether it's the staff surgeon or it's the 0143 1 perfusionist. You give enough to arrest the 2 heart. 3 Q. So is it the surgeon that watches 4 the heart and make sure that it arrests? 5 A. Absolutely. 6 Q. What happens if too much 7 cardioplegia is given? 8 MS. KINKOPF-ZAJAC: Objection. 9 A. I am -- well, the heart arrests. 10 I -- I don't know that I really have a -- 11 I'm -- I'm not sure I'm completely 12 understanding your question. 13 Q. (By Ms. Perse) Can you ever give 14 too much cardioplegia? 15 MS. KINKOPF-ZAJAC: What was the 16 first part of your question? 17 Q. (By Ms. Perse) Can you ever 18 give -- 19 MS. KINKOPF-ZAJAC: Can you. 20 Okay. 21 Q. (By Ms. Perse) -- too much 22 cardioplegia? 23 A. Well, I don't -- I don't know that 24 I have a good answer for that question. 25 Q. And what happens to the 0144 1 cardioplegia? 2 A. It goes into the coronary arteries, 3 and then it eventually gets -- gets washed 4 out at the end of the -- at the end of the 5 operation. 6 Q. Is there a half life to 7 cardioplegia? 8 A. Is there a half life? Well, I 9 don't -- I can't say there is a half life, 10 per se. But there -- you certainly can see 11 some return of cardiac activity at various 12 different time points. 13 Q. What is the purpose of 14 cardioplegia? 15 A. To arrest the heart. 16 Q. And why should the heart be 17 arrested? 18 A. Well, in general, you want complete 19 cardiac standstill so you can see and perform 20 the operation. Particularly if you are inside 21 the heart. 22 Q. When the heart is not beating, is 23 that what you mean by cardiac arrest? 24 A. Yes. 25 Q. If the heart is beating, besides 0145 1 the technical advantage of being able to see 2 what you're doing, is there any risk to the 3 myocardium or the heart muscle, itself? 4 MS. KINKOPF-ZAJAC: You're talking 5 about intra-operatively? 6 MS. PERSE: I'm-- thank you for 7 clarifying. 8 Q. (By Ms. Perse) I'm talking about 9 when a patient is on full cardiopulmonary 10 bypass and the aorta is cross-clamped. Is 11 there any risk to the myocardium to -- if it 12 were not arrested during that period of time? 13 A. Again, it depends on the operation. 14 Beating heart surgery is done all the time 15 for coronary bypass. 16 Q. But in the -- in a patient that 17 is on full bypass and the aorta is 18 cross-clamped, is the hear beating? 19 A. Not usually. You typically arrest 20 the heart if you cross-clamp the heart. 21 Q. And why does -- with -- in a 22 circumstance where the heart is cross-clamped 23 and a patient is on bypass, why is the heart 24 not beating? 25 A. It is because you give 0146 1 cardioplegia. 2 Q. And why do you do that? 3 MS. KINKOPF-ZAJAC: Objection. 4 A. To arrest the heart. 5 Q. (By Ms. Perse) Can we agree that 6 cardioplegia is used to preserve the 7 myocardium? 8 A. That's another function of it as 9 well. Certainly. 10 Q. And if the heart begins to beat or 11 is not arrested when the patient is on bypass 12 and the aorta is cross-clamped, that injures 13 the myocardium, true? 14 MS. KINKOPF-ZAJAC: Objection. 15 A. I wouldn't say that absolutely. 16 Q. (By Ms. Perse) There is a risk of 17 myocardial injury when the patient is 18 cross-clamped, on bypass, if the heart is not 19 in arrest? 20 A. Are you referring to full cardiac 21 contractility? 22 Q. I'm referring to the cardiac arrest 23 that is instituted when a patient is on 24 bypass? 25 A. Well, if the heart is arrested, 0147 1 then the myocardium should be protected. 2 Q. But if the heart is not arrested. 3 The myocardium is not arrested, true? 4 A. If the heart is arrested, the 5 myocardium is not arrested? 6 Q. Unprotected. 7 A. Is that what you said? If the 8 heart is arrested, the myocardium is usually 9 protected. 10 Q. And if the heart is not arrested 11 during bypass, then the myocardium is not 12 protected. Correct? 13 A. Well, again -- 14 MS. KINKOPF-ZAJAC: Objection. Go 15 ahead. 16 A. I wouldn't -- I wouldn't say that 17 absolutely. 18 Q. (By Ms. Perse) If the heart is not 19 arrested during cardio pass -- cardiopulmonary 20 bypass, there is a risk of myocardial injury, 21 true? 22 MS. KINKOPF-ZAJAC: Objection. Go 23 ahead. 24 A. No. Not in general. Because, 25 again, if you do -- we -- beating heart 0148 1 surgery is done all the time on 2 cardiopulmonary bypass. 3 Q. (By Ms. Perse) In a patient, such 4 as Michael Orra, who has -- has been 5 cannulated and is on full bypass and the 6 aorta is cross-clamped. If the heart is not 7 fully arrested, there is a risk of myocardial 8 injury, true? 9 MS. KINKOPF-ZAJAC: Objection. 10 A. If the heart isn't fully arrested, 11 we would usually give more cardioplegia. 12 Q. (By Ms. Perse) That's not what I 13 asked. 14 I asked whether there was a risk to 15 the myocardial muscle tissue, if the patient 16 is on full bypass and the aorta is 17 cross-clamped, such as in Michael Orra's case? 18 MS. KINKOPF-ZAJAC: Objection. 19 A. Again, I wouldn't say that 20 completely. 21 Q. (By Ms. Perse) Is there a risk? 22 MS. KINKOPF-ZAJAC: Objection. 23 A. Again, I wouldn't say that 24 completely. 25 Q. (By Ms. Perse) I'm not asking you 0149 1 whether it's a complete risk. I'm asking you 2 is there a risk? 3 A. I wouldn't say that completely. 4 Q. Why is it that a patient -- why 5 is it that you administer more cardioplegia 6 to a patient that shows evidence of 7 myocardial function when you are on full 8 bypass and the aorta is cross-clamped? 9 A. To arrest the heart so you can 10 complete the operation. 11 Q. And, again, the only reason you 12 are doing that is so that you can complete 13 the operation? 14 A. No. Also for myocardial 15 protection. 16 Q. And why -- what is it about the 17 cardioplegia that provides myocardial 18 protection? 19 A. Well, one thing is that it tends 20 to be cold. Cold decreases the metabolic 21 rate of the myocardium. 22 Q. Anything else? 23 A. Sure. There are preservatives, 24 glucose and other nutrients in the 25 cardioplegia for the myocardium. 0150 1 Q. And when the muscle has to -- 2 begins to work again, are you producing any 3 dangerous by-products? 4 A. Well, again, I need to clarify 5 what you mean by work again. 6 Q. If the cardioplegia wears off? 7 A. Then we give more cardioplegia. 8 Q. Because? 9 A. To arrest the heart and to 10 continue to protect the heart. 11 Q. So cardioplegia protects the 12 myocardium, correct? 13 MS. KINKOPF-ZAJAC: Objection. 14 Asked and answered. 15 A. Yes. In addition to arresting the 16 heart. 17 Q. (By Ms. Perse) What was the volume 18 of cardioplegia that was used in this case? 19 MS. KINKOPF-ZAJAC: Objection. 20 A. I -- I -- I don't have that 21 number. 22 Q. (By Ms. Perse) And where would 23 that be? 24 A. Well, it is not the operative 25 note. I suppose the profusion record. 0151 1 Q. And do you have the profusion 2 record? 3 A. I haven't seen the profusion 4 record. 5 MS. PERSE: Ingrid, can you show 6 the doctor the profusion record? 7 MS. KINKOPF-ZAJAC: Well, I just 8 going to say that it is ten minutes to 12:00 9 here. 10 MS. PERSE: I am sorry. You -- 11 I didn't hear your question. 12 MS. KINKOPF-ZAJAC: I said -- I 13 was just going to say, it is ten minutes to 14 12:00 here. So you need to start at least 15 wrapping up or reaching a point where it 16 would be a good time -- time to stop. 17 MS. PERSE: Well, you know, if we 18 are going to suspend the deposition. Yeah. 19 We can stop whenever you want, but I need to 20 be able to reconvene. And we know that the 21 -- we have the discovery schedule issue in 22 this case. So I know that we are both very 23 anxious to -- 24 MS. KINKOPF-ZAJAC: Well -- 25 MS. PERSE: -- information we can. 0152 1 MS. KINKOPF-ZAJAC: So are we -- 2 are we in a good place to stop or -- or 3 what? What are we doing? 4 MS. PERSE: It -- it would be 5 fine to stop here, and then we could 6 reconvene. But we need to try to get this 7 deposition sooner rather than later. 8 MS. KINKOPF-ZAJAC: Well, I can do 9 what I can do. I never imagined that it was 10 going to take this long given his limited 11 involvement. But, whatever. All right. So 12 we are going to -- all right. We are going 13 to go off the record? 14 MS. PERSE: I just want to make 15 it clear that I do reserve my right to 16 return to this deposition, and I appreciate 17 your time, Doctor. I know that -- 18 THE WITNESS: You are welcome. 19 MS. PERSE: -- it's a -- 20 MS. KINKOPF-ZAJAC: And just so -- 21 MS. PERSE: -- big visit on your 22 part to participate in this process. But, 23 again, I do need to make sure that I have 24 the opportunity to speak with you again. 25 MS. KINKOPF-ZAJAC: And I am just 0153 1 going to state for the record, that we're not 2 going to revisit anything we have already 3 revisited if we reconvene this deposition. I 4 mean, you know, obviously you are entitled to 5 question him, you know, about things that we 6 -- you haven't gotten to yet, but we're not 7 going to revisit anything. No. 8 MS. PERSE: Under -- understood. 9 MS. KINKOPF-ZAJAC: Fair enough. 10 Okay. Have a good day. 11 MR. MARGOLIS: Have a good flight, 12 Ingrid. 13 THE VIDEOGRAPHER: Going off the 14 record. The time is approximately 11:52 a.m. 15 MS. KINKOPF-ZAJAC: I am sorry, 16 Ron. What? 17 MR. MARGOLIS: I said have a good 18 flight. 19 MS. KINKOPF-ZAJAC: Oh, thank you. 20 (Deposition recessed at 11:52 a.m.) 21 (Exhibit-B was marked.) 22 . 23 . 24 . 25 . 0154 1 DESCRIPTION OF EXHIBITS 2 Exhibit Description 3 A (CV) 4 B (Echo heart) 5 . 6 . 7 . 8 . 9 . 10 . 11 . 12 . 13 . 14 . 15 . 16 . 17 . 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 . 0155 1 REPORTER'S CERTIFICATION 2 STATE OF TEXAS 3 COUNTY OF HARRIS 4 I, JUDY H. GALLO, Certified 5 Shorthand Reporter for the State of Texas, do 6 hereby certify that the foregoing transcript 7 is a true, correct and complete transcription, 8 to the best of my ability, of the proceedings 9 had at the time and place stated in the 10 caption hereto. 11 Given under my hand and seal of 12 office on this the _____ day of _____________ 13 2008. 14 ____________________________ 15 JUDY H. GALLO, Texas CSR 794 16 Expiration Date: 12-31-08 17 . 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 . 0156 1 CAPTION 2 The Deposition of Roosevelt Bryant, 3 III, MD, taken in the matter, on the date, 4 and at the time and place set out on the 5 title page hereof. 6 It was requested that the deposition 7 be taken by the reporter and that same be 8 reduced to typewritten form. 9 It was agreed by and between counsel 10 and the parties that the Deponent will read 11 and sign the transcript of said deposition. 12 . 13 . 14 . 15 . 16 . 17 . 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 . 0157 1 CERTIFICATE 2 STATE OF : 3 COUNTY/CITY OF : 4 Before me, this day, personally 5 appeared, Roosevelt Bryant, III, MD, who, 6 being duly sworn, states that the foregoing 7 transcript of his/her Deposition, taken in 8 the matter, on the date, and at the time and 9 place set out on the title page hereof, 10 constitutes a true and accurate transcript of 11 said deposition. 12 13 Roosevelt Bryant, III, MD 14 . 15 SUBSCRIBED and SWORN to before me this 16 day of , 2008 in 17 the jurisdiction aforesaid. 18 19 My Commission Expires Notary Public 20 . 21 . 22 . 23 . 24 . 25 . 0158 1 DEPOSITION ERRATA SHEET 2 . 3 RE: SetDepo, Inc. 4 File No. 18541 5 Case Caption: Amne Orra, Vs. Cleveland 6 Clinic Foundation, et AL 7 Deponent: Roosevelt Bryant, III, MD 8 Deposition Date: June 6, 2008 9 . 10 To the Reporter: 11 I have read the entire transcript of my 12 Deposition taken in the captioned matter or 13 the same has been read to me. I request 14 that the following changes be entered upon 15 the record for the reasons indicated. I 16 have signed my name to the Errata Sheet and 17 the appropriate Certificate and authorize you 18 to attach both to the original transcript. 19 . 20 Page No. Line No. Change to: 21 22 Reason for change: 23 Page No. Line No. Change to: 24 25 Reason for change: 0159 1 Page No. Line No. Change to: 2 3 Reason for change: 4 Page No. Line No. Change to: 5 6 Reason for change: 7 Page No. Line No. Change to: 8 9 Reason for change: 10 Deposition of Roosevelt Bryant, III, MD 11 . 12 Page No. Line No. Change to: 13 14 Reason for change: 15 Page No. Line No. Change to: 16 17 Reason for change: 18 Page No. Line No. Change to: 19 20 Reason for change: 21 Page No. Line No. Change to: 22 23 Reason for change: 24 Page No. Line No. Change to: 25 0160 1 Reason for change: 2 Page No. Line No. Change to: 3 4 Reason for change: 5 . 6 . 7 SIGNATURE:_______________________DATE:___________ 8 Roosevelt Bryant, III, MD