Impact of an open-chest extracorporeal membrane oxygenation model for in situ simulated team training: a pilot study.

OBJECTIVES: To develop an affordable realistic open-chest extracorporeal membrane oxygenation (ECMO) model for embedded in situ interprofessional crisis resource management training in emergency management of a post-cardiac surgery child. METHODS: An innovative attachment to a high-fidelity mannequin (Laerdal Simbaby) was used to enable a cardiac tamponade/ECMO standstill scenario. Two saline bags with blood dye were placed over the mannequin's chest. A 'heart' bag with venous and arterial outlets was connected to the corresponding tubes of the ECMO circuit. The bag was divided into arterial and venous parts by loosely wrapping silicon tubing around its centre. A 'pericardial' bag was placed above it. Both were then covered by a chest skin that had a sutured silicone membrane window. False blood injected into the 'pericardial' bag caused expansion leading to (i) bulging of silastic membrane, simulating tamponade, and (ii) compression of tubing around the 'heart' bag, creating negative venous pressures and cessation of ECMO flow. In situ Simulation Paediatric Resuscitation Team Training (SPRinT) was performed on paediatric intensive care unit; the course included a formal team training/scenario of an open-chest ECMO child with acute cardiac tamponade due to blocked chest drains/debriefing by trained facilitators. RESULTS: Cardiac tamponade was reproducible, and ECMO flow/circuit pressure changes were effective and appropriate. There were eight participants: one cardiac surgeon, two intensivists, one cardiologist, one perfusionist and three nurses. Five of the eight reported the realism of the model and 6/8 the realism of the clinical scenario as highly effective. Eight of eight reported a highly effective impact on (i) their practice and (ii) teamwork. Six of eight reported a highly effective impact on communication skills and increased confidence in attending future real events. CONCLUSIONS: Innovative adaptation of a high-fidelity mannequin for open-chest ECMO simulation can achieve a realistic and reproducible training model. The impact on interprofessional team training is promising but needs to be validated further.

Bartonella henselae endocarditis of percutaneously implanted pulmonary valve.

Percutaneous pulmonary valve implantation (PPVI) has revolutionized the management of right ventricular outflow tract dysfunction after repaired congenital heart disease. Although the technology is considered to be safe with a relatively low complication rate, infection is a described complication, with five cases of culture-positive infective endocarditis of percutaneously implanted pulmonary valve having been reported to date worldwide. Herein is reported the first ever case of culture-negative endocarditis following PPVI, caused by Bartonella henselae, diagnosed five years after implantation in a 15-year-old patient with a repaired truncus arteriosus.

Fenestration closure in a calcified ventricular septal defect patch.

Ventricular septal defect closure with a fenestrated patch is a recognized rescue maneuver to decrease the risk of right ventricular failure after complete repair in patients with pulmonary atresia. If the fenestration needs surgical closure, severe calcification of the patch may make it extremely difficult. We describe the closure of such a defect in a 6-year-old boy, using a double Dacron patch sandwich.

Bartonella henselae endocarditis of percutaneously implanted pulmonary valve: a case report.

Percutaneous pulmonary valve implantation (PPVI) has revolutionized the management of right ventricular outflow tract dysfunction after repaired congenital heart disease. The technology is considered to be safe, with a relatively low complication rate. Infection is one of the described complications of PPVI, and to date five cases of culture-positive infective endocarditis of percutaneously implanted pulmonary valve have been reported worldwide. Herein is reported the first ever case of culture-negative endocarditis of a percutaneously implanted pulmonary valve, caused by Bartonella henselae, five years after implantation in a 15-year-old patient with a repaired truncus arteriosus.

Severe bronchomalacia treated by combination of Nuss procedure and aortopexy: an unusual therapy combination.

Aortopexy is the treatment of choice for clinically significant tracheobronchomalacia from external vascular compression. When a marked chest depression is present, aortopexy may be less effective. We report 2 patients with pectus excavatum and vascular compression of the trachea who, despite their young age, benefited from combined Nuss bar insertion and aortopexy.

Impact of shunt type on growth of pulmonary arteries after norwood stage I procedure: current best available evidence.

The past decade has seen a substantial improvement in the outcome following surgical palliation for hypoplastic left heart syndrome. This has been attributed to modifications in the surgical as well as postoperative management strategies. One such modification is the reemergence of the right ventricle to pulmonary artery (RV-PA) shunt as an alternative to the modified Blalock-Taussig (mBT) shunt as the source of pulmonary blood flow. The RV-PA shunt has been shown to improve the immediate surgical outcome compared with the classic Norwood procedure with an mBT shunt. Despite the several reported advantages, the impact of the RV-PA shunt on growth of the pulmonary arteries and incidence of late development of central PA stenosis remains unclear. This systematic review evaluates the current best available evidence to address this issue and concludes that the evidence from retrospective studies and only available randomized controlled trial (RCT) is conflicting. The retrospective studies predominantly suggest that the Norwood procedure with RV-PA shunt may have favorable effects on the development of the pulmonary arteries due to even distribution of pulmonary blood flow with greater distal left pulmonary artery growth, resulting in more balanced distal branch pulmonary artery size albeit with a greater degree of central pulmonary artery hypoplasia needing surgical attention. On the contrary, the RCT reports that the overall size of the pulmonary artery on angiography before the stage II procedure was smaller in the RV-PA shunt group than in the mBT shunt group, with no information available on incidence of central pulmonary hypoplasia.

In young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure?

A best evidence topic in cardiac surgery was written, according to a structured protocol. The question addressed was: in young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure? The pulmonary autograft with its inherent advantages of viable autologous transplant, central laminar flow, freedom from prosthetic valve complications, side effects of anticoagulation, and growth potential is considered a well-accepted option for aortic valve replacement in young patients. However, the use of a pulmonary autograft in young patients with rheumatic aortic valve disease is controversial. We analyse existing evidence to determine the suitability of the pulmonary autograft as a substitute for the diseased aortic valve in patients with rheumatic disease. Altogether 901 papers were found using the reported search terms, from which eight represented the best evidence to answer the clinical question. In addition, a meta-analysis also superficially addressed this issue. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All eight publications were from two institutions with one reporting outcomes for a Ross operation vs. mechanical valve implantation and two compared results of the Ross operation in rheumatic vs. non-rheumatic aortic valve disease. We conclude that the current available evidence suggests that pulmonary autograft is susceptible to rheumatic involvement. Use of pulmonary autograft in young patients (<30 years) with rheumatic aortic regurgitation and concomitant mitral regurgitation requires a cautious approach as there is an impaired autograft durability in this subgroup of patients.

In hypoplastic left heart patients is Sano shunt compared with modified Blalock-Taussig shunt associated with deleterious effects on ventricular performance?

A best evidence topic in congenital cardiac surgery was written according to a structured protocol. The question addressed was: in hypoplastic left heart patients is Sano shunt compared with modified Blalock-Taussig (mBT) shunt associated with deleterious effects on ventricular performance? Sano shunt modification of Norwood procedure involves construction of a right ventricle to pulmonary artery (RV-PA) conduit as an alternative source of pulmonary blood flow. Compared with the mBT shunt, the RV-PA conduit provides a more stable haemodynamic state in the immediate postoperative period and is reported to be associated with lower interstage mortality. However, concerns regarding the impact of ventriculotomy on short- and long-term performance of single ventricle have been expressed. Altogether 101 papers were found using the reported search terms, from which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. None of the echocardiographic or clinical outcome studies showed poor ventricular performance after ventriculotomy of the systemic RV for construction of Sano shunt. A small autopsy study of 11 patients showed greater remodelling of the ventricular myocardial extracellular matrix in patients with RV-PA conduit with potential implications for poor ventricular performance. We conclude that the current available evidence, although weak, does not show any adverse effects of ventriculotomy on ventricular performance in patients with Sano shunt in the short- and medium-term. However, all the existing studies are limited by small numbers, non-randomised design and retrospective nature with failure of correlation of echocardiographic indices to clinical outcomes. It is expected that the Pediatric Heart Network randomised controlled trial will address this important issue.