Training and mentoring of the congenital heart surgeon for India.

Congenital heart surgery is one of the most demanding subspecialities in surgery. To become a competent surgeon, a lot of investment of time, in-depth study, training under a committed mentor, acquisition of the necessary fine surgical skills, and development of a three-dimensional appreciation of corrections are needed to be cultivated. These make it not only a speciality of skills, but also a cerebral speciality. It is commonly felt amongst the residents training in cardiovascular and thoracic surgery that they perform far less operative work to make them even "somewhat" confident of doing procedures independently towards the end of their residency. If this young cardiac surgeon needs to subspecialize in congenital heart surgery, more exposure to newer concepts and a much higher level of skill-based training become mandatory for achieving competence. Taking all this into consideration, this article will dwell on some of the traits and abilities that are desired in the candidates choosing to train in congenital heart surgery (CHS), the requirements of the speciality, and some tips to the trainers/mentors to help in effective devolution of thoughts, principles, and skills. Salient points of the mentoring process have also been discussed. A modular plan for staged acquisition and transmission of surgical skills, as well as surgical management of common congenital cases, has been outlined. Finally, a note is added to sensitize the young congenital heart surgeon to learn to embrace the nuances of practicing this speciality in India. This could also apply to many other developing and low- and middle-income countries.

Coronary transfer in the arterial switch operation: the modified closed technique.

Arterial switch operation for transposition of great arteries (TGA) is the choice of surgical treatment for this condition. Conventional "open" coronary transfer technique has been commonly employed with good results in experienced hands. A modified "closed" technique of coronary transfer, with a more accurate coronary artery placement taking into account a distended aorta, along with anterior interrupted sutures to reduce purse stringing and other advantages is described.

Hypoplastic left heart syndrome: current modalities of treatment and outcomes.

Hypoplastic left heart syndrome is a constellation of malformations which result from the severe underdevelopment of any left-sided cardiac structures. Once considered to be universally fatal, the prognosis for this condition has tremendously improved over the past four decades since the work of William Norwood in the early 1980s. Today, a staged surgical approach is applied for palliating this distinctive cohort of patients, in which they undergo three operative procedures in the first 10 years of their life. Advancements in medical technologies, surgical techniques, and our growing experience in the management of HLHS have made survival into adulthood a possibility. Through this review, we present the different phases of the staged approach with primary focus on stage 1-its modifications, current technique, alternatives, and latest outcomes.

Elective delayed sternal closure portends better outcomes in congenital heart surgery: a retrospective observational study.

INTRODUCTION: Delayed sternal closure is used in paediatric cardiac surgery as a management strategy for patients with unstable hemodynamics or postoperative bleeding routinely. We hypothesise that planned postponement of sternal closure leads to better outcomes than emergent reopening in the intensive care unit (ICU) in patients exhibiting some hemodynamic indication for the same. METHODS: We retrospectively analysed the outcomes of delayed sternal closure 220/2111 (10.42%) out of which 14 sternums were opened in the ICU after shifting the patients. RESULTS: A total of 220/2111 (10.42%) sternums were left open postoperatively, out of which 14 were opened after shifting to the ICU. Total mortality of the delayed sternal closure was 33/220, i.e. 15%. The patients whose sternums were left open from the theatre had a mortality of 23/206, i.e. 11.16%, whereas those patients whose sternums were opened in the ICU had a mortality of 10/14, i.e. 71.42%. CONCLUSION: In doubtful postoperatively hemodynamic, the choice of leaving the sternum open electively has better outcomes, rather than opening the sternum as a terminal bail out procedure.

Anomalous origin of left coronary artery from right pulmonary artery in an infant with coarctation of the aorta.

Anomalous origin of the left coronary artery from the right pulmonary artery is a very rare congenital anomaly, and its occurrence with coarctation of the aorta has been reported in very few patients. We report a neonate where the coronary anomaly was missed preoperatively and diagnosed after repair of the coarctation. The patient thereafter underwent ligation of the left anomalous coronary artery and had an uneventful convalescence.

New technique of right heart bypass in congenital heart surgery with autologous lung as oxygenator.

BACKGROUND: Modifications have been made in cardiopulmonary circuit to reduce the inflammatory deleterious effects and cost. We present our experience of one such right heart bypass (RHB) circuit utilizing autologus lung as oxygenator. METHODS: From September 2001 to December 2002, 15 patients underwent congenital heart surgery with this technique. Bypass circuit consisted of a reservoir and a roller pump along with a cardiotomy sucker. The left pulmonary artery and main pulmonary artery were used for arterial return, and venous drainage was achieved with innominate vein cannulation. Inferior vena cava cannulation was performed when needed. Thirteen patients underwent bidirectional Glenn shunt surgery (12 to 24 months, 6 to 10 kg). One patient (26 years old) underwent central shunt with enlargement of confluence and left pulmonary artery. Another patient (18 months old) underwent 1.5 ventricle repair. RESULTS: There were no hospital deaths. Mean flow achieved on RHB was 0.57 +/- 0.3 L/min/m(2), central venous pressure was 3.3 +/- 1.8 mm Hg (0 to 7 mm Hg), and mean arterial pressure could be maintained satisfactorily in all patients (54 +/- 14 mm Hg). Mean RHB time was 54 +/- 14 min. Mean central venous pressure was 10.1 +/- 2.4 mm Hg after procedure and saturation was similar to that on (RHB 88% +/- 8%). The mean amount of drainage was 9.1 +/- 4.2 mL/kg per 24 hours. Avoiding an oxygenator and reducing the number of tubings achieved a combined cost savings of 40% for all procedures. CONCLUSIONS: Right heart bypass is a simple, safer, and less expensive alternative to conventional cardiopulmonary bypass. This technique allows effective decompression of superior vena cava, adequate oxygenation, and predicts saturation after Glenn shunt. It can also be applied for central shunts and pulmonary artery reconstructions with cost containment.

Tricuspid valve detachment for transatrial closure of ventricular septal defects.

Tricuspid leaflet detachment improves visualization and accuracy of closure of ventricular septal defects via the transatrial route. Between July 1998 and March 2001, surgical correction was performed in 296 cases of isolated ventricular septal defect, 215 cases of tetralogy of Fallot, and 16 cases of double-outlet right ventricle. Of these, 132 patients (79 with isolated ventricular septal defect, 49 with tetralogy of Fallot, and 4 with double-outlet right ventricle) underwent transatrial repair with temporary detachment of tricuspid leaflets for ventricular septal defect closure. The septal leaflet was detached in most cases, with anterior or posterior leaflets being detached when indicated. Median duration of intensive care was 3.6 days, and median hospital stay was 7 days. There was no incidence of tricuspid regurgitation attributable to leaflet detachment, as confirmed by postoperative echocardiography. Reoperation was not required for a residual defect or tricuspid regurgitation. The benefits of temporary leaflet detachment for transatrial repair of various difficult defects far outweigh the risk of postoperative tricuspid regurgitation.