Is There Gender (In)Equality in Pediatric Surgery? An Online Survey on Gender-Related Career Opportunities.

INTRODUCTION: The highest percentage of female surgeons is found in pediatric surgery but most departments are led by men. The aim of this study is to evaluate gender-related career goals, perceived career opportunities, and reasons for differences. MATERIALS AND METHODS: An online questionnaire was created and distributed to pediatric surgeons in Germany, Switzerland, and Austria between July and September 2020. Participants were asked to state current position, career goals, and perceived career opportunities in comparison to a colleague of the opposite gender. Reasons for gender-related differences were asked for as free-text comments. RESULTS: A total of 182 questionnaires were analyzed. The overall gender ratio was balanced but junior positions were predominantly held by women, while there were more men in leading positions. Most women pursued a position as a consultant, while the majority of men aimed for a leading position. Men mostly regard both genders to have the same career opportunities, whereas most women believe the chances of men to be better. From the free-text answers, three following categories for gender-related differences in career chances were derived: (1) absences due to maternity, (2) differing support and bias arising from gender-related stereotypes, and (3) assumed personality traits. CONCLUSION: There are gender-related differences in career opportunities in pediatric surgery. Gender equality is needed not only to overcome injustice but also to maximize team efficiency and collaboration. Career support needs to be gender-independent and (unconscious) bias needs to be recognized and eradicated.

A qualitative analysis of critical incident reporting in a paediatric hospital: benefits and weaknesses.

AIMS OF THE STUDY: The value of critical incident reporting systems (CIRSs) has been shown before but data for paediatric facilities are scarce. We aimed to evaluate a CIRS in a paediatric hospital to analyse its benefits, weaknesses and opportunities. METHODS: In a qualitative analysis, all incidents reported in 2018 with the anonymous reporting tool (CIRS) of the Children's Hospital Lucerne were evaluated. In an iterative process, categories to group the incidents were created and the data analysed accordingly. The focus was on the problem created through the incident, the type of error and possible avoidance. RESULTS: 496 incidents were reported in 2018: 307 incidents led to medical errors directly effecting patients, 82 incidents led to organisational problems increasing expenditure and 107 incidents were found to not result in any problem. In the majority of cases (398/496) there was no evidence that the caregiver responsible was informed. Personal feedback was documented in 46 cases. Fifty-two incidents were self-reported. CONCLUSION: A number of reported incidents helped to identify system-based errors and for these the reporting system proved indispensable. Many of the reported errors were found to have an individual component, or only organisational or no consequences. Our data give evidence that instead of giving direct personal feedback, the anonymous reporting system was utilised. The CIRS is essential to identify system-based errors, but personal feedback needs to become obligatory so caregivers can learn from their error: an additional tool to ensure individual feedback and overcome communication difficulties needs to be created.

"A bend in time": Shaping the sheath facilitates left atrial appendage closure.

OBJECTIVES: The purpose of this study is to determine feasibility, safety, and effectiveness of the "shape-the-sheath" method in left atrial appendage closure. BACKGROUND: LAA occlusion is often a difficult procedure, due to not just the learning curve but also the three-dimensional variable nature of the left atrial appendage. Multiple sheaths have been created for various takeoffs. The purpose of this article is to show the feasibility of the "shape-the-sheath" method in left atrial appendage closure. METHODS: Ten consecutive patients undergoing LAA occlusion without the "shape-the-sheath" method were compared to 10 consecutive patients undergoing LAA occlusion with the "shape-the-sheath" method using the Amplatzer Cardiac Plug (ACP) system and the Amplatzer TorqVue 45×45 sheath. RESULTS: The "shape-the-sheath" method resulted in significant decreases in fluoroscopy time (7.2±3.0 min vs. 13.7±6.7 min, P<0.05), number of partial recaptures (0% vs. 50%, P<0.05), with a trend toward decrease in the number of complete recaptures (0 vs. 40%, P=0.09) compared to conventional sheath use. CONCLUSIONS: Shaping-the-sheath is a simple, elegant way to help conform delivery systems to better access the LAA and ensure stable position. Further experience with this procedure optimization step is warranted.

Use of EchoNavigator, a novel echocardiography-fluoroscopy overlay system, for transseptal puncture and left atrial appendage occlusion.

Structural heart disease requires a coordinated effort to join echocardiographic and fluoroscopic data. Various methods have been used, including echocardiography, CT, and MRI. We report on the use of EchoNavigator (Philips Inc., Amsterdam, Netherlands), a novel echocardiographic-fluoroscopic fusion system. This new system allows real-time integration and marking of important structures that track on fluoroscopy even with movement of the C-arm. In this article, we describe potential uses for this system in respect to transseptal puncture and left atrial appendage closure.

Left Atrial Appendage Ligation in Nonvalvular Atrial Fibrillation Patients at High Risk for Embolic Events With Ineligibility for Oral Anticoagulation: Initial Report of Clinical Outcomes.

OBJECTIVES: This study sought to assess long-term clinical outcomes in adults with nonvalvular atrial fibrillation (AF) who are ineligible for oral anticoagulation therapy and underwent left atrial appendage (LAA) ligation with the Lariat device. BACKGROUND: LAA exclusion has been used to prevent thrombus formation within the LAA in AF patients and is believed to decrease the risk of cardioembolic events. METHODS: LAA ligation with the Lariat device was performed in 139 patients with nonvalvular AF. LAA closure was verified during the procedure by LA angiography and transesophageal echocardiography. A follow-up transesophageal echocardiography was performed at 30 to 45 days post-procedure. After the procedure, patients received aspirin only, clopidogrel only, aspirin plus clopidogrel, or no antithrombotic drugs. Patients did not receive transition oral anticoagulation therapy post-LAA ligation. Patients were followed for LAA closure and adverse events, including stroke, systemic events, and death. RESULTS: Acute closure was accomplished in 138 of 139 treated patients (99%). In 1 patient, a posterior lobe was partially closed. At the day-30 to day-45 transesophageal echocardiography (n = 127), 114 (90%) had complete LAA closure, and 13 (10%) had a 2- to 4-mm leak. There were no leaks ≥5 mm. The periprocedural adverse event rate was 11.5%, including 2 cardiac perforations and 1 death due to pulmonary embolus. Over a mean follow-up of 2.9 ± 1.1 years, the event rate for the composite endpoint of stroke and systemic embolism was 1.0% per year (n = 4). The combined stroke, embolism, and death of any cause event rate was 2.8% (n = 11) per year. CONCLUSIONS: The findings from this analysis of post-procedure event rates suggest that LAA ligation with the Lariat device effectively closes the LAA and may be a beneficial approach to reduce the risk of embolic events in AF patients ineligible to oral anticoagulation therapy. However, future randomized clinical trials are needed to verify these results and to determine device and procedural safety.

Left atrial appendage occlusion in octogenarians: short-term and 1-year follow-up.

OBJECTIVES: To determine the procedural safety, safety, and efficacy of left atrial appendage (LAA) occlusion in octogenarians. BACKGROUND: Elderly patients with atrial fibrillation (AF) often do not receive appropriate anticoagulation. LAA occlusion is an option for patients with AF and contraindications to anticoagulation. Not much is known about the procedural safety and clinical efficacy of LAA occlusion in the very elderly. METHODS: A retrospective review of LAA cases at our institution between 2002 and 2013 in patients 80 years of age or older was performed. Demographic, echocardiographic, procedural, and clinical follow-up data were collected. RESULTS: Seventy-five cases were attempted in patients 80 years of age or older (average age 83.4 ± 2.8 years, 53.3% males). Hypertension, coronary artery disease, and heart failure were present in 96, 41.3, and 36%, respectively. Mean CHADS2 and CHA2DS-VASc scores were 3.3 and 5.2. Devices used included the WATCHMAN, ACP, PLAATO, Lariat, and Coherex devices, which were attempted in 34.7, 36, 17.3, 5.3, and 5.3%, respectively. Overall procedural success, safety endpoint, and 1-year device efficacy was 90.1, 3.9, and 97.4%, respectively. CONCLUSION: LAA closure is a safe and efficacious method of stroke prevention in the very elderly with AF.

Transcatheter Aortic Valve Replacement and Left Atrial Appendage Occlusion - A Stitch in Time?

Many patients have now been able to receive transcatheter aortic valve replacement (TAVR) therapy for severe aortic stenosis. These patients have atrial fibrillation and are placed on warfarin for stroke prophylaxis. The opportunity for treatment with left atrial appendage occlusion (LAAO) in place of warfarin for this population exists, especially for those with increased bleeding risk. This paper discusses the prevalence and aetiology of stroke in patients presenting for TAVR (with a focus on the risk from chronic and acute atrial fibrillation) and also the benefit of LAAO closure in this population.