Subaxillary bidirectional cavopulmonary anastomosis in an infant

Reply: Ethical considerations while attempting congenital heart surgical care with limited resources at disposal: One scar is still better than two

“…Vervoort and colleagues 1 challenge my response in an invited commentary 2 regarding a report on an infant with single-ventricle physiology who qualified for a primary bidirectional cavopulmonary anastomosis (Glenn operation), in the setting of a developing program with limited resources and a visiting team helping the local team as best they could. 3 I commended the authors for achieving good outcomes, perioperatively and out to 2 years follow-up, while sparing preoperative catheterization and cardiopulmonary bypass to perform off-pump surgery using a temporary veno-venous shunt. This was done by relying on intraoperative direct pressure measurements (which is smart) and out of financial necessity for the program (which is commonplace in many underserved countries with constrained resources), respectively.…”

“…Having had the privilege to go on yearly congenital heart surgical humanitarian missions in underserved areas, I realize the demographic needs, understand the goal in achieving the same results with less resources available than back home, and treat as many children as possible in the shortest time available. I have been in the shoes of Predegan and colleagues, 3 who boldly improvise under difficult conditions, and still get the children through with laudable outcomes. [5][6][7] Their innovation is to be commended and is not at question.…”

“…In agreement with the authors, in a setting with minimal resources, real cost considerations, and the desire to help as many patients as possible during a limited time span, I also would have skipped the costly and cumbersome preoperative diagnostic cardiac catheterization, obtained intraoperative measurements to confirm the safety of the procedure, and performed the bidirectional Glenn surgery off-pump. 3 However, the procedure could have been done through a median sternotomy, extubation could have been done in the operating room to spare precious ventilators and nursing staff, and the infant could have been discharged from the intensive care and hospital in the same time frame. Whether the child will be lost to follow-up-common in certain countries-or whether future adhesions will be minimized when going back through the front for Fontan completion is speculative.…”

“…2 In addition, as mentioned by Vervoort and colleagues and us previously, the CEDIMAT team's decision to proceed with a minimally invasive Glenn procedure was made for the patient's benefit in a setting where resources are limited and seeing follow-up patients is not guaranteed. 1,3 As long as such advancements adhere to medical ethics and are shown to be safe in randomized studies, the global CHD community should be firmly supportive of the innovators.…”

Commentary: Minimally invasive approaches in congenital heart surgery—A service we owe children to help them thrive, not a gimmick to make our lives easier

“…What, however, would have been the best surgical approach? Although the desire to limit catheterization and bypass machine costs is understandable, it is standard to perform a bidirectional Glenn through a median sternotomy, rather than resorting to the midaxillary thoracotomy approach chosen and justified by Pradegan and colleagues, 1 to avoid potential scar tissue in the future when anticipating a median sternotomy for the next staged palliation. How did Pradegan and colleagues 1 plan?…”