The hybrid approach for palliation of hypoplastic left heart syndrome: Intermediate results of a single-center experience.

INTRODUCTION: Hypoplastic left heart syndrome (HLHS) is a major cause of cardiac death during the first week of life. The hybrid approach is a reliable, reproducible treatment option for patients with HLHS. Herein we report our results using this approach, focusing on its efficacy, safety and late outcome. METHODS: We reviewed prospectively collected data on patients treated for HLHS using a hybrid approach between July 2007 and September 2014. RESULTS: Nine patients had a stage 1 hybrid procedure, with seven undergoing a comprehensive stage 2 procedure. One patient completed the Fontan procedure. Five patients underwent balloon atrial septostomy after the hybrid procedure; in three patients, a stent was placed across the atrial septum. There were three deaths: two early after the hybrid procedure and one early after stage two palliation. Overall survival was 66%. CONCLUSIONS: In our single-center series, the hybrid approach for HLHS yields intermediate results comparable to those of the Norwood strategy. The existence of dedicated teams for the diagnosis and management of these patients, preferably in high-volume centers, is of major importance in this condition.

Mitro-aortic aneurysms in children: single-centre experience and review of the literature.

OBJECTIVES: This publication aims to report the cases of four children with pseudoaneurysm of the mitral-aortic intervalvular fibrosa and carry out a review of the literature. BACKGROUND: Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a very rare anomaly in children. It can be either congenital or acquired, namely, after bacterial endocarditis or cardiac trauma. This pathology does not usually cause specific symptoms but its outcome may be potentially fatal. METHODS: We report the cases of four patients presenting with pseudoaneurysm of the mitral-aortic intervalvular fibrosa, referred for treatment in a paediatric cardiology clinic. Patient clinical notes were retrospectively reviewed for aetiology, clinical presentation, diagnostic work-up, surgical treatment, and follow-up. Literature on the subject was extensively reviewed. RESULTS: In three patients, pseudoaneurysm of the mitral-aortic intervalvular fibrosa was acquired, being secondary to bacterial endocarditis in two cases and establishing after mitral surgery in another case. The remaining patient had a "congenital" aetiology - no other cause could be traced. The diagnosis was achieved by transthoracic echocardiography for all patients, and confirmed in all by trans-oesophageal echocardiography, to better define morphological details and to access flow into the aneurysmal formation. All patients were submitted to corrective cardiac surgery. Of the patients, three survived and were cured by surgery, staying asymptomatic, and one died after repeated interventions, for persistent endocarditis. CONCLUSIONS: Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a rare but potentially fatal anomaly. In our experience, surgical cure was achieved for the majority of the cases, except for a case for which infection could not be locally eradicated, leading to multiple reinterventions.

Giant pericardial cyst mimicking dextrocardia on chest X-ray.

Pericardial cysts are rare benign congenital malformations, usually small, asymptomatic and detected incidentally on chest X-ray as a mass located in the right costophrenic angle. Giant pericardial cysts are very uncommon and produce symptoms by compressing adjacent structures. In this report, the authors present a case of a symptomatic giant pericardial cyst incorrectly diagnosed as dextrocardia on chest X-ray.

Characterization of non-technical skills in paediatric cardiac surgery: communication patterns.

OBJECTIVES: The management of non-technical skills in complex surgical domains, such as paediatric cardiac surgery, is being recognized as a major factor for both performance and safety. Communication patterns are very relevant for safety and were analysed in this human-factor observational study. METHODS: One behaviour observer taped and video-recorded the communication patterns for 10 consecutive paediatric open-heart cases, at a university institution, performed by variable, informal teams. Records were analysed for communication frequency, direction, type, content and pattern on the one hand, and on the other hand for factors influencing communication. RESULTS: A total of 10 167 communication flows were read, with an average of 1017 ± 170.9 per procedure over an average duration of 136.15 ± 19.52 min. The frequency of communication was maximal between the main surgeon and the scrub nurse (16% of all communications), followed by the main surgeon to the first surgical assistant (13.8%) and the main surgeon to the perfusionist (12.4%). Communication between the main surgeon and the anaesthetist was not more than 5%. Types of communication varied from requests, questions, answers, statements, informations and explanations, and being different for distinct staff roles: the main surgeon to the scrub nurse involved 84.2% requests, the main surgeon to the first surgical assistant 59.9% statements and the perfusionist to the main surgeon 65.4% answers. Communication patterns varied, being 'closed-loop' (with feedback and double-check) only between the main surgeon and the perfusionist, and mostly open among other team members. Communication-disturbing factors such as noise, technology-related events, resource-based problems and supervisory and training-related issues were also found. CONCLUSIONS: Communication is very frequent in paediatric cardiac surgery and shows a complex pattern. There is room for improvement, namely by a more formal and standardized communication flow structure that can be achieved with the help of behavioural, technological and organizational initiatives.