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Interview With Awais Ashfaq: Winner of the 2019 CTSNet Resident Video Competition

Friday, June 5, 2020

CTSNet is excited to announce that "Double Switch Operation (Senning and Rastelli)" by Awais Ashfaq has won first place in the 2019 Resident Video Competition. Dr Ashfaq is a congenital surgery fellow at Cincinatti Children's Hospital in Ohio, USA. In this interview, CTSNet Associate Editor Joel Dunning asks him about the case presented in his winning video, the skills and technology used to record and edit the video, and advice for other residents interested in creating surgical videos.

Joel Dunning for CTSNet: Tell us about the case you presented in this video.

Awais Ashfaq: The patient had early life care at an outside hospital and presented to us with some unusual characteristics. She was a 23-month-old, 8 kg girl with double outlet right ventricle, subaortic ventricular septal defect, pulmonary atresia, atrioventricular discordance, and left atrial isomerism with dextro-mesocardia. In addition, she had left superior vena cava connected to right innominate vein, a midline inferior vena cava, and right aortic arch with mirror image branching.

She underwent a left BT shunt and PDA ligation as a neonate but subsequent cath at four months showed her pulmonary arteries were discontinuous, a surprising finding. After thorough review, it was evident that her right PA had been inadvertently ligated thinking it was the ductus.

She was then transferred to us for consideration of biventricular repair that involved anatomic correction and restoration of atrioventricular concordance via an atrial switch (Senning portion) and ventriculoarterial concordance through an intraventricular baffle (Rastelli). The operation was performed through a standard median sternotomy, aortic and bicaval cannulation with antegrade cardioplegia, and moderate hypothermia. As soon as cardiopulmonary bypass is commenced, the shunts were isolated and ligated.

The atrial switch portion was performed first with an incision from the base of the right atrial appendage to the inferior vena cava, parallel to the AV groove. The septal flap was created and a left atrial incision was made from the superior aspect of the left upper pulmonary vein to the inferior aspect of the left lower pulmonary vein. At this instance, the ventricular septal defect was examined and a right ventriculotomy site was marked for future right ventricle to pulmonary artery conduit. Muscle bundles were resected and the VSD was enlarged, ensuring the location of the conduction system.

The atrial flap was then sutured to the morphologic let atrium, creating the floor for the systemic venous baffle. Subsequently, the SVC and IVC blood was directed to the morphologic right ventricle, completing the systemic venous baffle. The pulmonary venous baffle was constructed using autologous pericardium. Then the baffle between the left ventricle and aorta was created using bovine pericardium. The pulmonary artery branches were connected using a homograft patch. The aorta can be transected at this instant for better visualization of the branch PAs and then re-attached. And then lastly, the RV to PA conduit was completed.

CTSNet: How did you record the case? Was this a head camera or a fixed camera?

AW: This was recorded using a BFW head camera.

CTSNet: You used some wonderful graphics to bring the video alive. How did you do this?

AW: We are lucky to have passionate people in the team. One of our physician assistants, Alan, is the man behind the scenes. You may have seen more videos published by him. We capture almost every operation and then depending on rarity or unusual nature of the case, Alan edits and annotates it. And you see the great result!

CTSNet: Do you have any other cases that you are editing that we should watch out for?

AW: Definitely, there are a lot more in the pipeline. Most are involving complex congenital cardiac issues, some related to mechanical circulatory support and some in single ventricle patients. So stay tuned!

CTSNet: Do you have any tips for other residents thinking of editing videos and sending them to CTSNet?

AW: One of the most helpful things is to break down the video and annotate what the anatomy represents. I think most of the viewers understand the basic steps of the operation but visualization is key. Having good recording equipment helps, but once it’s annotated, a viewer can clearly see how the surgeon views it and then have a blueprint in your mind.

View all of the winners of the 2019 Resident Video Competition.


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