"I had worked at almost every hospital in town at one time or another," Midei said in the interview, his tone defensive. "And nobody ever questioned me once."
'The cure for disease'
Years passed without incident. But then MACVA got into some trouble.
In a 2001 lawsuit filed by a group of cardiac surgeons known as CSA, MAVCA was accused of using its referral power to commit extortion from other health care organizations.
MACVA was also accused in a separate 2004 court filing of stealing patients from the CSA surgeons under false pretenses. The filing claimed that Midei personally misled a heart patient at St. Joseph, claiming the man's CSA surgeon wasn't available and steering him toward a MACVA member.
Midei said in a statement to The Sun at the time that he was "happy to have my friends and colleagues who know the truth stand by me." He would express a similar sentiment years later in a different situation.
Meanwhile, stents were soaring in popularity as a relatively risk-free alternative to bypass surgery, particularly after a drug-coated version of the tiny mesh tubes was approved for use in 2003. It prevented scar tissue from forming around the stents, sharply reducing the need for follow-up procedures.
"We really thought we had the cure for disease, and we were using these things aggressively," Midei said last week.
The devices are similar in shape to the spring inside a ballpoint pen but slimmer. They're threaded into place through an artery by interventional cardiologists, like Midei, then expanded to open up blockages and improve blood flow, relieving symptoms such as chest pain.
Stent use in Maryland peaked in 2006, at about 14,255 procedures, according to data from the Health Services Cost Review Commission. Midei alone averaged about a thousand stent procedures per year.
The practice guidelines in use at that time, crafted in 2005, recommended that an artery be at least half blocked before using the devices, and that other, less invasive, medical therapies be tried first. The minimum blockage was increased to 70 percent in 2009.
Stents slightly increase a person's risk for blood clots, which could be deadly, and require that patients take blood thinners for various lengths of time.
Most interventional cardiologists determine an artery's blockage by talking with patients about their symptoms and eyeballing a live X-ray image of their arteries, taken during a cardiac catheterization procedure. But recent data suggest that those estimations weren't very good. A report published this summer in the Journal of the American Medical Association claimed that half of the non-emergency stent procedures in the United States may be either medically questionable or outright unnecessary.
Midei, however, considered himself a master at the diagnostics and the procedure, his friends said.
"I do think that Mark reached a stage in his life where he believed that he was very, very attuned to a patient and their needs, and he knew when somebody needed to be fixed," said Brinker, Midei's mentor.
Midei's skills attracted the attention of MedStar Health, which owned several hospitals in the area. It proposed a $25 million merger with MACVA in 2007 — as long as Midei and was part of the deal, which meant he would have to leave St. Joseph.
The Towson hospital fought back, offering Midei triple his MACVA salary of about $500,000 and a full-time job on St. Joseph's staff.