A Public Death: Bill Paxton’s death certificate points to surgery’s role in fatal stroke

There are many things to dislike about our national obsession with celebrities. But one of the side effects of this obsession is the tendency of TMZ to dig deeper into mysterious deaths.

TMZ got a hold of Bill Paxton’s death certificate. It summarized the findings in a headline: “Bill Paxton death certificate: Valve replacement surgery triggered stroke.” The site also helpfully posted Paxton’s death certificate — with a few details redacted.

The document reveals a few key pieces that help tell a fuller story of Paxton’s final days. First, the heart problems he had as a child very well could have been the beginnings of his troubles. Paxton had said in interviews that he suffered from rheumatic fever as a child and that it had caused damage to his heart valves. But it appears he may have been born with the heart valve problem that ended up playing a role in his death.

Paxton’s death certificate listed “bicuspid aortic valve” as the third underlying cause of death, underneath aortic aneurysm, and stroke. (Note that the death certificate does not cite any surgical errors among the causes of death.)

A normal aortic valve looks like the Mercedes logo, a circle broken up by three lines that meet in the middle. The lines are the edges of the valve leaflets that open and close to let blood through. A bicuspid aortic valve only has two of these leaflets. This can cause the valve to malfunction and prevent blood from flowing correctly from the heart to the aorta or could allow blood to flow backwards from the aorta into the heart. People with bicuspid valves often have aortic aneurysms, too. That’s a bulging of the aorta that can ultimately lead to a fatal rupture.

The death certificate shows that Paxton went in for surgery on Feb. 14 to repair both his valve and the aortic aneurysm. He did not die on the operating table. He did not die the next day, either. He died nearly two weeks later, on Feb. 25, according to the death certificate, at Cedars-Sinai Medical Center in L.A. Paxton was 61.

This means it is likely that the surgery resulted in something getting loosened up during the surgery and traveling into the brain or a blood clot forming and traveling to the brain. Either way, a blockage caused a stroke later. That’s one of the classic surgery risks and something that should be part of any conversation with a patient before a surgery.

“No operation is ever zero percent risk. Most straight-forward things are pretty low risk,” Dr. Bryan Whitson at Ohio State University’s Wexner Medical Center told Mia de Graaf at the the Daily Mail. ”But there are lots of potential ways people can get a stroke during heart surgery.”

Whitson provided an interesting assessment of the different ways heart surgeries can lead to strokes. One scenario: calcium breaking off and causing a stroke.

“The aorta has multiple layers in there, so it’s delicate. It can be like an egg shell,” Whitson told the Daily Mail. “People can get calcium deposited in the artery, so we have to clamp the aorta to re-route the blood. That can cause cracks, meaning a piece of calcium can dislodge or not be completely removed.”

Another thing to note about the death certificate is the name of the attending physician, Dr. Ali Khoynezhad, director of the thoracic aortic surgery program at Cedars-Sinai. It is worth noting that there are no obvious indicators that Khoyenzhad did anything wrong here. He has no publicly available record of enforcement actions from the Medical Board of California. And he is certified in both surgery and thoracic and cardiac surgery, according to the American Board of Medical Specialties.

Often these celebrity deaths have a second act where the medical providers come under scrutiny. All signs here, though, point to a situation where someone was born with a defect that ultimately had to be repaired and then that repair led to an early death. It’s one reason why shared decision-making in health care is so important, with surgery, therapy, medicine, and “wait and see” all presented as options.

Correction: An editing error in an earlier version of this post suggested the death certificate did cite a surgical error. The sentence in question should read: "Note that the death certificate does not cite any surgical errors among the causes of death."

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A Public Death: Bill Paxton’s surgery-related death should raise tough questions