Re-operating Internationally On Fallot's Complex - A Comedy Of Errors
Aubyn MARATH, MBBS MS FRCSEd, Renzo CiFUENTES, MD, Janine Henson, RN, BSN, CCRN, Mariano BRIZZIO, MD.
CardioStart International, Tampa, FL, USA.
Reoperation scenarios invariably carry an increased risk of unanticipated complications that challenge the entire team. In clinically substandard settings they are especially daunting and may have an uncertain outcome.
Methods: A 16-year-old son of divorced parents from a remote, rural community at 14000ft altitude, presented for aortic valve replacement (re-operation). It followed previous total correction of his Fallot’s tetralogy by another visiting team at four years of age. History was inadequate, but he had strongly suspected rheumatic infection at the aged of 8 and 10 years without treatment. The patient complained only of dyspnea of effort. Examination suggested, and echocardiography confirmed early calcific aortic tri-leaflet entrapment with stenosis and regurgitation, but minimal left ventricular hypertrophy
Results: Surgery was carried out in an emerging tertiary care cardiac surgery center in Southern Peru. Immediately before surgery, the (drunken) father made lethal threats to the local senior surgeon, who chose not to operate. Equipment was carefully evaluated; intra-operatively, manual re-entry and enlarging the aortotomy to accommodate the only prosthetic valve available, were required. Both ventilator and cautery failed, the heart was unresponsive to internal paddle defibrillation, and sudden heater-cooler dysfunction prevented traditional re-warming.
Conclusions: Post-operative outcome was satisfactory, but this patient example throws up practical and ethical concerns in providing international assistance: adequacy of patient information, clinical management, operative choices in re-operation scenarios for congenital and/or acquired cardiac disease, reliance on local equipment, valve management when available sizes and type are very limited and of equal importance, retention of team morale.