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 Visit to the Department of Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, USA Dr Alyson Walker, MBChB BSc MRCP FRCA Consultant Paediatric Anaesthetist, Royal Hospital for Sick Children, Glasgow, Scotland June 2014 Funded by a travel fellowship from the Madeleine Steele Fund Texas Children’s Hospital (TCH) has one of the largest congenital cardiac surgery programmes in the world. They performed almost 800 cardiac operations in 2012 and predict that this number may be closer to 1000 by the end of this year. TCH recently moved into second place in the US News Best Children’s Hospitals for this Cardiology and Cardiac Surgery department. During my visit to TCH I gained a rich experience of past, present and future practices. I am very grateful to the Madeleine Steele Fund for the opportunity to have visited this institution. Operating room TCH have three busy cardiac theatres and three cardiac catheterisation laboratories. I saw a variety of clinical cases including: Tetralogy of Fallot repair, atrioventricular septal defect repair, arterial switch, lung transplant, heart harvest and transplant, Heartmate ® ventricular assist device insertion among others. During these cases, I had the opportunity to observe and discuss the chosen anaesthetic techniques with the anaesthetic team. I also had some fascinating discussions with the perfusionists who explained the rationale behind Cardiopulmonary Bypass at TCH their perfusion strategies which vary slightly from those I have experienced to date. www.maddysteel.com Paediatric Cardiac Anaesthesia, the TCH way Although there are many similarities in anaesthetic practice between our institution and TCH, there are several differences. Examples of such differences include Aprotinin not being available in the USA and their use of ε-­‐amonicaproic acid and recombinant factor VII (NovoSeven®). The TCH cardiac anaesthesia department has expertise in the field of neuroprotection during cardiac surgery and have published widely on the subject. Bilateral NIRS monitoring is used for all cases. We also use this technique in the Royal Hospital for Sick Children in Glasgow and so further experience in its interpretation and, in particular, resultant actions was useful. Meeting Dean Andropolous (Chief of Anesthesiology) & Emad Mossad (Director) Dexmedetomidine is used at TCH for peri-­‐operative sedation-­‐ a drug I have not yet used in clinical practice. This drug is gaining interest in the paediatric anaesthetic community because of the possibility that it may lead to less neuroapoptosis and so lead to improved neurological outcomes following cardiac surgery. This theory has yet to be proven in the clinical setting. TCH is currently researching the pharmacokinetics and safety profile of dexmedetomidine in paediatric cardiac surgery. I observed its use in theatre and intensive care and will be interested to read the results of this study when they are published. Educational & Organisational Meetings There is an environment of continuing education within the department and many meetings to attend. Dean Andropolous and Emad Mossad are editors of one of the main textbooks on anaesthesia for congenital cardiac surgery (1). During my visit, I attended the cardiac conference, grand rounds on the subjects of Tetralogy of Fallot and Transposition of the Great Arteries and departmental clinical discussions. Cardiovascular Intensive Care Unit Situated next to the OR suite, the CVICU has 21 beds. I joined the ward round on several occasions overseeing the great variety of cardiac patients at TCH. I met children on ventricular assist devices (e.g. Berlin EXCOR Heart ®). The only centres in the UK who fit these for children are the Freman Hospital in Newcastle and Great Ormond Street Hospital, London. www.maddysteel.com A historical perspective There is a great sense of history amongst the large medical center complex in Houston. Many of the buildings are named after famous innovative physicians, scientists and surgeons. I visited two cardiac museums during my visit: the Michael DeBakey Library & Museum and the Denton Cooley Museum. These two surgeons pushed the boundaries and carried out many firsts in cardiac surgery, including development of the cardiopulmonary bypass machine, the design of Dacron grafts (e.g. for aortic aneurysm repair) and implantation of the first artificial heart. Looking back only a few decades on these achievements highlighted just Michael DeBakey's loops.
how far we have come in medicine today. And how far things will go in the decades to come. A future perspective I had an opportunity to look into the future of cardiac surgery during visits to the laboratory of Dr Doris Taylor. Guided round by Dr Luiz Sampaio, a surgeon with expertise in regenerative medicine, I was astonished to see the research in this laboratory. The team here is working on developing beating hearts on the laboratory bench-­‐top. Their paper in Nature, published in 2008 (2) set the scene for the future of cardiac transplantation. They are developing a process of decellularising a heart so as to leave the extracellular matrix, allowing this to be used as a scaffold which can then be populated by the recipients own cadiomyocytes. It seems feasible that by the end of my career, I could be anaesthetising patients for implantation of such ‘custom grown’ hearts. The research was simply mind-­‐blowing (3). Dr Doris Taylor and I a t the Texas Heart Institute Thank you I learned a great deal during my visit to the Texas Childrens Hospital and it is a trip that will stay with me for a long time. I would again like to thank the Madeleine Steele Foundation for having made this visit possible. I hope to bring many of the lessons learned during this trip to my practice in the National Health Service. Alyson Walker 15th June 2014 www.maddysteel.com References 1. Andropolous DB, Stayer SA, Russell IA, Mossad EB (eds.). Anesthesia for Congenital Heart Disease. 2nd Edition. Wiley-­‐Blackwell: 2010. 2. Ott HC, Matthiesen TS, Goh SK, Black LD, Kren SM, Netoff TI, Taylor DA. Perfusion-­‐
decellularised matrix: using nature’s platform to engineer a bioartifical heart. Nature 2008;14:213-­‐221. 3. Dara O’Briain’s Science Club. Series 2. Episode 2: Adventures in Time. London: BBC; 1st August 2013. http://www.bbc.co.uk/programmes/p01dfkgd www.maddysteel.com