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Delivered at Little Hearts Matter's 20th Anniversary Open Day, 22/03/2014, by W.J. Brawn of Birmingham Children's Hospital.
Citation preview
“The history, future treatment and
care of children born with single
ventricle hearts”
W.J. Brawn Cardiac Services
“However beautiful the strategy you should occasionally look at the results”
“Success is the ability to go from one failure to another with no loss of enthusiasm”
• 1947 early closed valvotomy series – 6 consecutive deaths
• Harken very depressed, went to bed.
• Cardiology friend Lawrence Brewster Ellis came to see him
and persuaded him to continue:
“He should not waste the experience of the 6 early deaths”
• Success followed
Dwight Harken
Interview with Gerald Rainer 2004
Transplantation• December 1967 first human
heart transplant – Dr. Christian Barnard
• 1971 146 of 170 transplants had died
• Dr. Norman Shumway of Stanford persisted with the introduction of cyclosporine (soil from Norway’s Hardangerfjord) opened a new era of heart transplantation
How has practice changed over the years?
0
50
100
150
200
250
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011*
Nu
mb
er
of
case
s
Specific Catheter Interventions
PDA occlusion ASD closure Stenting VSD closure Embolisation
0
20
40
60
80
100
120
140
160
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011*
Nu
mb
er o
f cas
es (p
er y
ear)
Univentricular Surgical Activity
Norwood Glenn Fontan/TCPC
Surgery for uni-ventricular hearts • Advent of prostaglandin, ICU resuscitation and support, the dominant
lesion has become Hypoplastic Left Heart Syndrome (HLHS) and it’s
variants
• These are systemic right ventricular circulation
Surgery for uni-ventricular hearts
Modified Blalock-Taussig shunt
Surgery for uni-ventricular hearts
The Fontan procedure
Surgery for uni-ventricular hearts
Evolution of the Norwood procedure
a) ‘Classical’ Norwood b) Left RV-PA Conduit c) Right RV-PA Conduit
Surgery for uni-ventricular hearts
The ‘Hybrid’ approach
Surgery for uni-ventricular hearts
Second stage palliation – the Glenn or CP shunt
Surgery for uni-ventricular hearts
Third stage palliation – the Fontan or TCPC
Surgery for uni-ventricular hearts
0
10
20
30
40
50
60
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011*
Nu
mb
er o
f cas
es (p
er y
ear)
Fontan / TCPC activity
>600 over 22 years
The BCH experience
• The uni-ventricular program began in 1992, since then:
• There have been 728 stage I procedures (the
Norwood operation)
• There have been 744 stage III operations (the
Fontan/TCPC operation)
Survival (days)
Pro
po
rtio
n a
live
0 30 60 90 120 180 240 300 360
0.0
0.2
0.4
0.6
0.8
1.0
206 183 180 174 166 163 158 155 146 143 136 134 132
Survival post Norwood
All Norwood procedures from 2008-2013
NHS Safe and sustainable programme
• Bristol - Kennedy Review 2001
• Monro - NHS Review 2003
• National Review of Experts 2006
• Medical Director NHS Sir Bruce
Keogh instigated Safe and
Sustainable review.
Working environment• There is a delicate balance between the courage
to perform complex risky surgery and the
humility to question one’s own ability on a day
to day basis. This is particularly so for the young
doctor.
• We work under the constant glare of public
scrutiny
Mentorship
• Powerful personal development and
empowerment tool
• Requires a close working partnership
• Requires mutual trust and respect
• Aim to challenge, motivate and inspire
Ott H.C. et al, (2008) Nat. Med.14: 213-21
LV assist devices
Finally
• First do no harm (Hippocrates)
• “We could do this procedure, but should we?” (Waterston)