HCA International Foundation Travelling Fellowship REPORT

Mr Ed Peng FRCSEd(CTh)

Background

I am currently a Consultant Cardiac Surgeon at the Royal Hospital for Children Glasgow and Golden Jubilee National Hospital, Clydebank. I was granted the HCA International Foundation scholarship at the end of my higher surgical training in 2015 to consolidate my training post-CCT. 

Training Background

I trained in the Northern England Cardiothoracic Training Program (NTN) and the East Midland rotation (LAT).  I owe my career to late Mr Pradip K Sarkar (Sheffield) who helped to shape my early training, and also to my following mentors, Mr Andrzej Majewski, (Nottingham), Prof Manuel Galinanes & Mr Apo Nakas (Leicester), Mr John Wallis, Mr Andrew Goodwin (Middlesbrough), Prof John Dark, Prof Stephan Scheueler, Mr Jonathan Forty, Mr Leslie Hamilton, Mr Krzysztof Tocewicz, Mr Thasee Pillay and Mr Asif Hasan (Newcastle). Having a primary interest in Paediatric Cardiac Surgery, I chose Northern region for my NTN training as the Freeman Hospital serves as one of the two centers in the UK for paediatric heart transplant. Mr Sasha Stamenkovic, my training program director then, had thoughtfully placed me under the mentorship of Mr Asif Hasan to oversee my entire training in the region as my educational supervisor.  

After my training in adult cardiothoracic surgery, I was able to rotate to the paediatric unit at the Freeman to gain advanced experience in congenital.  The congenital service at the Freeman caters for highly complex patients for both paediatric and adult congenital cardiac patients including a strong mechanical circulatory support and transplant program, besides referral for complex surgery such as high risk Ross-Konno etc. I am most grateful to Asif Hasan, a very fine surgeon, who is a great mentor, not just in surgery but many things in life! With his support, I further undertook an out of programme fellowship in North America.  An extensive preparation was required including USMLE and visas, but my 18 months’ of fellowship in the Children’s Hospital of Colorado, Denver was the most rewarding one. Under Dr Dave Campbell (Prof, Director of Congenital Cardiac Surgery Residency), Dr James Jaggers (Prof, Chief of Surgery) and Dr Max Mitchell (Prof, Chief of Mechanical Support), the unit provides an outstanding congenital heart surgery fellowship. I am most grateful to all of them, superb surgeons and wonderful mentors, for the opportunities to acquire a vast knowledge of management of complex congenital heart diseases, and first operative experience in complex surgery, from neonatal surgery including Norwood, arterial switches to paediatric heart transplantation and mechanical circulatory support.   

Aims of scholarship

I applied for the HCA scholarship to gain further advanced exposure in peadiatric heart valve repair/reconstruction (aortic, mitral, and tricuspid, including Cone reconstruction for Ebstein) as well as complex congenital heart surgery (including double switches, root translocation, borderline left heart).  

Structure of scholarship

I commenced my scholarship after starting my appointment as a consultant. I decided to optimize my scholarship time by visiting several units to maximize my clinical exposure, whilst minimizing the impact on my clinical commitment. As an independent consultant surgeon, my primary focus was not to gain technical training but to concentrate on learning new surgical approaches and techniques from various renowned units around the world. The scholarship time was undertaken in 6 separate trips abroad, amounting to a total time of 3 months, and was completed during my first 2 years of appointment as consultant.  

German Paediatric Heart Centre (Deutsch Kinderherzenntrum)  Sankt Augustin, Germany - Dr Viktor Hraska, Dr B Asfour (Prof) 

The Sankt Augustin’s children heart unit has the largest volume of surgery in Germany. The unit has also one of the world’s largest experience in neonatal and paediatric valve repair and reconstruction.  

I learned the approach of aortic valve repair in neonates and young infant including techniques of aortic commissurotomy and shaving off the myxomatous tissues.  The aortic valve is tricuspidised where possible to achieve best long-term outcome. Patch material is avoided where possible in the younger age group, as this has been shown to be associated with reduced durability of repair. When patch material is not required, neo-commissure is created, if not then the entire diseased cusp will require reconstruction. The technique of cusp augmentation of the free edge is avoided as this can restrict the growth potential of the leaflets in children, as well as the risk of coronary ischemia which has been reported to be associated with the technique. When cases were not available for specific technique, I had the opportunity to learn from video recording from cases in the past.   

Aortic valve disease, which presents early in life can be a component of a wider spectrum of diseases, known as Shone’s complex, which affects the left sided heart structure. The mitral valve can be small and aortic arch may be hypoplastic with coarctation, and the left ventricle can be affected by endocardial fibroelastosis (EFE). The left ventricle can be hypoplastic at the end of the disease spectrum, which requires Norwood repair. In the middle of the spectrum is a borderline left heart hypoplasia, which is conventionally managed with single ventricle pathway. New surgical strategies have been pioneered to rehabilitate the left ventricle to provide biventricular repair and physiology. Dr Hraska demonstrates the surgical 

approach to resect EFE during second stage rehabilitation, which results in improvement of LV cavity size, as well, as aortic valve repair. This infant was previously palliated in the neonatal period with Damus (connection of main PA to the ascending aorta) and fenestrated ASD closure during the first stage of surgery (by Dr Asfour). The concept of restricting the atrial communication with fenestrated closure during first stage is to encourage more antegrade fow through the left ventricle and therefore promote potential left sided growth. Dr Hraska also preserves the Damus shunt and construct a RV to pulmonary artery conduit, with flow predominantly from LV to aorta via aortic valve, and RV to lungs via conduit, the native pulmonary valve in the Damus remains closed but act as a safety net in a borderline LV.  

Dr Asfour has also been generous in sharing his surgical experience, and amongst operations observed were hypoplastic aortic arch repair, paediatric Cone reconstruction. 

The experiences gained in Sankt Augustin have helped me to apply these techniques for patients in Scotland. Upon returning from Sankt Augustin, the very first patient I operated upon with critical congenital bicuspid aortic valve stenosis was a neonate who also presented with severe coarctation and distal arch hypoplasia. The baby’s aortic arch was repaired off-pump from median sternotomy, and under cardiopulmonary bypass, the critical AS was relieved with effective commissurotomy to tricuspidise the valve, along with shaving of myxomatous tissues from the leaflets and creation and resuspension of neo-commissure. The baby had good recovery following surgery. 

From Dr Hraska’s study from Sankt Augustin, aortic valve which can be tricuspidised will have the best long-term outcome in terms of freedom from reintervention rate. What is less certain is which valve can be tricuspidised and which not pre-operatively. From my own practice, I believe that this is easier achieved at an earlier age as it does not take too much to create a neo-commissure in neonates compared to older age, and the earlier we can make this neonatal aortic valve to function as tri-foliate the better it will be.  Traditional valvotomy does not equate to creation of neo-commissure as the earlier tends to be more conservative and limited, with always the policy of just enough to relieve AS, in order to avoid aortic incompetency. When a neo-commissure is created, a full commissurotomy is performed  and more importantly, this neo-commissure need to be reinforced and resuspended at a slightly higher level to make it competent. Surgery can also rehabilitate this neonatal aortic valve better by thinning the leaflets, making them more mobile by removing those myxomatous leaflets, and more effectively removing any obstruction, an important part of the intervention that is not addressed by conventional surgical valvotomy or balloon valvuloplasty. The primary aim for intervention in neonatal AS is to rehabilitate the leaflets in order to make it as normal as possible towards trifoliate, which will result in the best longterm durability; in addition to provide most effective relief of obstruction.   

Figure: Asklepios Children`s Hospital Sankt Augustin (above) and my photo with Dr V Hraska in scrub room, operating theatre (below)

University Hospitals of Saarland, Homburg/Saar, Germany  - Dr. med. Hans Joachim Schäfers (Professor) 

Prof Hans Joachim Schäfers is a pioneer in aortic valve repair and has the largest reported aortic valve repair experience for aortic regurgitation. Instead of replacement with aortic valve prosthesis, a consistent and reproducible repair is currently made possible by an objective evaluation for prolapsed aortic leaflets. Prof Schäfers introduces the concept of geometric and effective heights for aortic leaflets, an important new understanding in the field for surgeons to reproduce and achieve durable trileaflet and bileaflet repair.   

 

I committed 3 weeks during this period to focus on repair techniques in aortic valve regurgitation (AR) in the adult population. This included two courses, i.e. the Journey across Aortic Valve, EACTS Academy and 2016’s Aortic Valve Repair Summit, Brussels, organised by Prof G El-Khoury and Prof HJ Schäfers, which preceded my visit to Homburg-Saar. I found the courses to be extremely instructive with lectures by experts from Europe and North America. The learning was reinforced by observing live surgery performed during the course.  

In Homburg-Saar, I attended the operating theatre daily and observed all ranges of cases performed in the unit with special attention to aortic surgery. In the operating room, he took me through step by step his methodical assessment of prolapsed aortic valve. Prof Schafers is known for the caliper he has devised specifically to obtain quantitative evaluation of the aortic leaflets. The correct method to use the caliper was demonstrated intra-operatively (which must be held parallel to the long axis of the left ventricular outflow tract). The measurement of geometric height differentiates between a prolapsed leaflet due to degenerative process, and less common leaflet restriction. Whilst central plication is now a standard technique to correct prolapsed leaflet, the latter cannot be readily repaired with good durability.  

Prof. Schafers’ research had made important contribution towards understanding   of the key factors which reduced the durability of aortic valve repair. His work had identified that ventriculo-arterial junction (VAJ) >28mm and effective height of less than 9mm post-repair are two factors which reduced the longevity of repaired cusp. Prof HJ Schafers introduces the use of suture annuloplasty in isolated aortic valve repair when the aortic annulus is above 25mm. He demonstrates his technique step by step intra-operatively using Goretex 0 suture. When restrictive cusp is present, aortic annuloplasty may also help to improve the degree of AR. When the aortic root dilatation is present, valve sparing aortic root replacement will be required, in which case, Prof Schafers uses Yacoub’s remodeling technique. 

 

I also had the opportunity of one to one discussion and tutorial from Prof HJ Schafers to improve my understanding on unicuspid aortic valve repair (UAV). This is more common in younger patients and more commonly present with mixed aortic regurgitation and stenosis. Prof HJ Schafers has described his technique of bicuspidisation of UAV. Although there was no UAV case during my time in Homburg, I’ve observed live UAV surgery performed by Prof Schafers in Aortic Valve Repair Summit in Brussel. During one to one discussion, I was able to learn from  him in detail on his technique. He also discussed the limiting factors for UAV repair. When greater than half of the leaflet is diseased, the repair would not be repairable with good durability. Another limitation is secondary to the choice of patch material, which had evolved based on his experience. Currently, his first choice of patch material, which has been durable in more recent experience is bio-engineered patch (Cardiocel®). 

In the Scottish Adult Congenital Cardiac service in Clydebank, we receive referral for adult patients with diseased bicuspid aortic valve who require repair. The experience gained has allowed the technique to be integrated in our valve repair program for bicuspid aortic valve disease with dilated VA junction.  

Mayo Clinic, Rochester USA. - Dr Joe Dearani (Professor) 

I spent one week with Professor Joe Dearani in the Mayo Clinic, Rochester, US. Prof Dearani has the most extensive experience in Cone Reconstruction of the Tricuspid Valve in Ebstein Anomaly. Ebstein malformation of the tricuspid valve is one of the most complex valve lesion to repair. The malformation involves failure of delamination of the tricuspid valve leaflets during embryogenesis resulting in atrialisation of part of the right ventricle. The constellation of malformations lead to tricuspid regurgitation, reduced RV cavity, variable degree of right ventricular outflow tract obstruction, and squashed LV in extreme case.  

During my time visit Prof Dearani, I attended pre-operative clinic consultation with patients with Ebstein malformation. The clinic received referrals from all around the US and globally for surgical repair. I reviewed echo imaging with Prof Dearani and 

learned the interpretation of valve that is repairable and the ones that are less likely to achieve good repair.  I also learned from the counseling provided to the patients during clinic consultation.  

In the operating room, I was able to observe closely the techniques involved in repairing this complex valve malformation. The leaflets are carefully delaminated from the RV wall and interventricular septum. The anatomical location of membranous septum and conduction tissues were demonstrated clearly by Prof Dearani and marked by Vein of D. An important advice from him is thorough delamination of the posterior leaflet to avoid any degree of tethering as even the slightest degree can cause post-op regurgitation in his experience. I also learned from him that the absence of septal leaflet will preclude Cone Repair and a small septal leaflet will need to be augmented by pericardial patch to avoid tension to the neo-septal leaflet. He also taught me the Mayo’s modification of the Cone which involves the use of a band or ring to reinforce the repair. Prof Dearani demonstrated to us the weak area of the repair that will require reinforcement, i.e. where the tricuspid annulus is plicated. Another important step of the surgery is also plication of the redundant RV wall, and very crucially, I learned the exact location where this should be undertaken, and the importance to be aware the proximity of the posterior descending artery and the right coronary artery. We also go through the indications of performing a cavo-pulmonary shunt in these patients. The strategies to come-off bypass and also the critical part of the early post-operative care in the ICU were also observed. Prof Dearani emphasizes on the importance of avoiding volume overloading of the RV after surgery to reduce tension and risk of dehiscence of the delicate reconstruction. 

In addition to Cone reconstruction, I’ve also learned the approach of tricuspid valve replacement in Ebstein anomaly, when the valve is not repairable. This is distinctly different from non-Ebstein tricuspid valve and involves intra-atrial placement. He also demonstrated his approach to place annular sutures to avoid complete heart block in these patients. The sizing of the prosthesis and his choice of prosthesis were also discussed. I also learned his techniques of repairing non-Ebstenoid valve with the use of Goretex neo-cords, where these neo-cords are placed and the use and sizing of the band or ring to reinforce the tricuspid valve repair. 

Whilst my main objective in Mayo Clinic is to learn surgical management of Ebstein’s Malformation of Tricuspid Valve, I’ve opportunities to observe and learn from other types of surgery, in particular mitral valve repair and surgery for Hypertrophic Obstructive Cardiomyopathy. I’ve a “close-up” observation of Mayo’s approach in repairing degenerative mitral valve disease.  Mayo Clinic is one of the world’s leading expert in robotic valve surgery, and the use of robotic approach allows the surgical technique to be observed closely on the monitor. The Mayo Clinic has a simplified approach toward MV surgery, where triangular resection is used for posterior leaflet disease and neo-chord is used for anterior leaflet disease. In P1 disease, leaflet plication is used. In order to reinforce the repair, the unit uses standard Mayo’s band of 28mm diameter, 63mm in length, and a standard size is 

used for all sizes annuli for annuloplasty (based on their philosophy that one size (of ring) fits all!). 

The Mayo Clinic is also well known for the surgical management of Hypertrophic Obstructive Cardiomyopathy and the unit has probably the most extensive experience for this condition. In Glasgow, the congenital surgical team receives referral for HOCM due to our familiarity of LV outflow tract surgery. We use the Mayo’s technique of transaortic extended septal myectomy. In addition to this approach, Mayo’s clinic also uses the transapical approach, which had not been used in Scotland before. Prof Dearani was able to demonstrate this approach live to me. The approach is particularly useful when the aortic annulus is small, or the obstructive muscles are too distal to be approached via the transaortic route. The approach could also be useful in patients with diffuse HOCM to relieve LVOTO and also to increase the LV volume in patients with small LV cavity. 

 

 

Figure – Mayo Clinic has been ranked as the best hospital in the US (photo taken outside its downtown campus in Rochester, MN)

Professor Shigeyuki Ozaki Toho University Ohashi Medical Center, Tokyo, Japan. (Invited as Proctor for Ozaki Procedure in Scotland) 

As part of the endeavour to enhance my valve surgery experience and also to consolidate the valve surgery program for congenital patients in Scotland, my senior colleague, Mr Mark HD Danton and myself travelled to Barcelona to meet Prof Ozaki during the EACTS 2016 Annual meeting. With the facilitation from Japanese Organisation for Medical Device Development (JOMDD), one to one dry lab training session was organised to allow us to learn and practise the Ozaki procedure under the guidance from Prof Ozaki himself. 

When native valve could not be repaired due to severely diseased or calcified leaflets, typically the aortic valve will be replaced with a prosthesis or pulmonary autograft i.e. Ross Procedure. In Ozaki’s procedure, a neo-tricupsid aortic valve is reconstructed using patient’s own native pericardium, Each cusp is sized and shaped independently using Ozaki’s approach, which produces a newly 

reconstructed valve that achieves a favourable geometry and competent valve with low trans-valvular gradient. 

Following our trip, a governance proposal was submitted to introduce Ozaki Procedure in the Scottish Services. The procedure is intended to benefit our patient population with non-repairable valve, paediatric or young adult patients with smallish aortic annulus to fit in a decent sized prosthesis, when mechanical prosthesis and warfarin is contraindicated or not desirable, and when longevity of bioprosthesis is limited in young patients. 

With Clinical Governance Approval, Prof Ozaki was invited to Glasgow as a Proctor in the first two Ozaki procedures in Scotland. The first two patients whom we operated upon were two young adults patients with congenital aortic valve stenosis and smallish aortic annulus. The first patient was a 28-year old man, who had been followed up with bicuspid aortic valve stenosis and became symptomatic recently.  Due to the nature of his occupation (as a stone mason), mechanical prosthesis and warfarin was not a good option as he sustained a lot of cuts and bruises during work and anticoagulation could also affect his lifestyle. The second patient was a 32-year old lady, with unicuspid aortic valve stenosis who wished to get pregnant and opted for Ozaki procedure to avoid anti-coagulation. The post-operative recovery for the two patients had been swift and uncomplicated. Since then, we were able to establish the procedure within our paediatric and adult congenital cardiac service and more recently, extend the technique to more complex subgroup in redo aortic valve surgery, concomitant ascending + /- arch, and also patient who required annulus/root enlargement 

Royal Children’s Hospital Melbourne - Dr Christian Brizard, Igor Konstantinov, Yves d’Udekem (Professors) 

I spent two weeks in RCH Melbourne participating in their daily operating theatres and ICU rounds.  During my two weeks’ attachment here, I have learned a great deal and improved my understanding in valve surgery and complex congenital heart surgery. Where possible the aortic valve is repaired without patch material, but if patch material is needed, leaflet extension is no longer recommended (no growth potential). In mitral valve disease, Dr Brizard has recently described a novel approach of implantation of mitral valve prosthesis in small paediatric patients. The smallest available mechanical prosthesis is 16mm and usually patients will be around 2 year-old before they have adequate annular size for 16mm prosthesis. When a malformed mitral valve is irreparable in young children, the option available to replace is extremely limited. Dr Brizard described a novel approach for implantation of bovine valved jugular vein (ContegraTM) at the intraannular mitral position. In the mitral position, the conduit is trimmed and scalloped above the leaflets and suspended to the papillary muscles and additionally to the LV apex using Goretex chord. During my visit, the very first patient to have received this stentless Contegra in mitral position 4-year ago underwent redo mitral valve 

replacement. The leaflets of the bovine jugular vein appeared to be relatively preserved, but required replacement due to restrictive annulus. Prior to this redo surgery, the gradient across the bovine jugular valve was improved by balloon dilatation as temporizing measure. It was interesting to note that a 12mm Contegra conduit was able to accept larger Hegar (up to 15mm) during redo surgery, perhaps suggestive of stretchable biological material. The patient’s LV function was also relatively preserved, which was probably facilitated by suspension of the papillary muscles to the commissure of the bovine jugular valve, which had had preserved the LV geometry and prevent globular dilatation. 

For patients with transposition of great artery, some 20% have left ventricular outflow tract obstruction with pulmonary valve stenosis. Conventional surgical approaches are associated with some concerns, especially the function and durability of the  neo-aortic valve following arterial switch operation. When VSD is present, Rastelli operation is an option by baffling the LV via VSD to the aortic valve. Small VSD will require enlargement for Rastelli procedure, and a long baffle can be problematic due to late risk of baffle obstruction.  A surgical solution for this will be performing aortic root translocation (Bex-Nikaidoh operation).  During my visit in RCH, Dr Brizard had  a 15 year-old patients with transposition of great arteries and VSD with pulmonary stenosis who underwent double root translocation. It is an extension of Bex-Nikaidoh operation, and the pulmonary root is also translocated in addition to the aortic root. The procedure adds further benefit to Bex-Nikaidoh procedure by negates the need of a conduit in the RV to PA position, hence reducing the need of redo operations in the future. The 15-year old recovers well postoperatively with good neo-aortic valve function and mild gradient across the neo-RV outflow tract. 

I also had an extensive discussion with Dr Brizard on his vast experience in surgery for congenitally corrected transposition. In particular I had the opportunity to watch his video on his Senning with modified Schumacker technique. We discussed the important technical pitfalls and to reduce risk of systemic and pulmonary venous baffles. We also discussed about morphological LV training and PA band. Furthermore, he shared his experience in instituting mechanical support for these patients post-operatively especially for those who were operated upon late. 

Figure: The Royal Children’s Hospital Melbourne

Boston Children’s Hospital - Dr Pedro del Nido (Prof), Dr Christopher Baird 

I spent my final two weeks’ of HCA scholarship at the Boston Children’s Hospital with Professor del Nido and Dr Chris Baird. At Boston, I observed and learned a number of techniques of valve repair (including Ebstein’s). I also learned their approach in managing borderline left heart, and had the opportunities of observing several conversions of palliated heart in single ventricle pathway into biventricular circulation, including patients who needed Fontan takedown.  

Boston Children’s has been leading the experience in recruitment of borderline LV, publishing their literature and results in this new area. The Boston Children’s Heart Centre employs echocardiographic, and/or CMR evaluation to determine their strategies in borderline left heart (BLH). Echocardiography remains their primary assessment tool in the neonatal period, taking into account the Z-score values of the valves, LV volume, its long-axis as well as the presence of EFE and whether antegrade or retrograde flow into the native ascending aorta. If the LV is inadequate, the strategy will be either Norwood 1 or hybrid approach using ductal stent and bilateral PA band, the earlier being preferred if a longer period is anticipated for LV rehabilitation before it is ready for conversion. CMR is used at later stage to assess the adequacy of the LV before being considered for conversion.  The adequacy of LV volume depends on the underlying cardiac defect as well as the presence or absence of EFE. Surgical strategies to recruit smallish LV include resection of endocardial fibroelastosis (EFE) from the LV endocardium usually at 4-6 months of age, repairing the mitral and aortic valves and restricting of the interatrial communication.  The preferred route of EFE resection is trans-mitral approach.  

I also learned about Fontan take down and conversion into 2-ventricle repair. This is very rarely undertaken elsewhere, but Boston has accumulated a sizable experience in the past years. This involves complex repair to convert the palliated single ventricle into two-ventricle physiology.  During my visit, a 12-year old boy (referred from abroad), underwent conversion of his Fontan into two-ventricle repair. The patient had protein losing enteropathy associated with failing Fontan circulation, and had been listed for transplant. Dr del Nido performed a one-half ventricle repair, by taking down the lateral tunnel Fontan, arterial switch procedure (coronaries to native PV), baffle of IVC into LA (hemi Musatard), reconnection of native aortic valve to distal PA using homograft. This effectively converts the Fontan into two-ventricle with systemic RV as the morphological LV is still small.   

The Boston’s unit has also adopted the Ozaki approach to reconstruct aortic valve in paediatric population (Dr Chris Baird is the Director of Valve Repair and Reconstruction in Boston).  The Ozaki approach was devised for adult patients by Prof Ozaki from Tokyo, the technique however has gained a lot interest amongst congenital surgeons to reconstruct aortic valve which is otherwise cannot be repaired conventional approach. The Ozaki procedure in paediatric population is more demanding due to the need to deal with small annulus. In previous report (by 

Ozaki), the Boston group has used this approach in patients as young as 23-month old but more recently has performed the surgery in babies less than 1 year-old, in conjunction with annular enlargement using Konno incision (Ozaki-Konno).  The Ozaki technique has also been used in aortic valve in the presence of Fontan circulation. 

I have also observed many different techniques of mitral valve repair during my time here. These include leaflet augmentation (both anterior and posterior), splitting of papillary muscle, creation of interchordal space, closure of leaflet’s cleft, and annuloplasty. These techniques are applied in a variety of congenital mitral valve disease. Although I have applied many of these techniques in my own practice, the intra-operative assessment is further reinforced as well as adopting new techniques. One important aspect I learned when dealing with mitral stenosis is mobilizing the thickened mitral leaflet, which is otherwise rigid. This involves peeling of the intra-leaflet membrane (EFE-like tissues) on the atrial aspect of mitral leaflets to mobilise the thickened leaflets in order to improve its mobility and reduce the transmitral gradient. When repair is not achievable, mitral valve replacement in young infant can be performed using Hancock prosthesis  (as small as 14mm implanted in one patient). The prosthesis is derived from Hancock valved RV-PA conduit and implanted in mitral position. This adds another option in the armamentarium of mitral valve replacement in the very young population. 

Boston Children’s is also one of the few centers worldwide with large experience in Cone Reconstruction for Ebstein Malformation of the tricuspid valve. I observed the technique of recruiting the Ebstein’s leaflet, plicating the RV as well as reduction of annulus. Dr del Nido has been less aggressive in plicating the RV unless there is a large atrialised portion. Like the Mayo Clinic, he also preferred Glenn (rather than fenestrated ASD) and uses annuloplasty in bigger patients to reinforce the repair. 

There is also a large practice of Norwood surgery for hypoplastic left heart syndrome. I have learned various new approaches during Norwood Stage 1 operation, and these include the “dunk-in” technique to place the proximal Sano shunt into the RV (this techniques has obliterated the problem with proximal conduit obstruction), as well as placing a composite Sano shunt made of femoral vein homograft and ring reinforced Goretex shunt. 

I have spent a lengthy time in the operating theatre in Boston to observe and learn their surgical techniques, as well as having in-depth discuss with various attending surgeons including Dr del Nido, Chris Baird, Jorge Salazar and Ram Emani. 

Acknowledgement 

I wish to thank the HCA Foundation enormously for their grant, which made all these endeavours possible. I am grateful to Ms Sue Smith from the HCA for her flexibility and support to allow me to split my visits, which not only maximised my learning experience in a number of institutions, but also greatly helped to minimise the impact of my clinical commitment at the Royal Hospital Children of Glasgow.  

I also wish to express my utmost gratitude to Dr V Hraska, Prof B Asfour, Prof Schafers, Prof Dearani, Prof C Brizard, Prof del Nido and Dr Chris Baird for providing me the opportunities to visit and learn a great deal from them. I also want express our gratitude to Prof Ozaki for his visit to Scotland to guide us in our first Ozaki Procedure. Additionally, I will like to thank Prof I Konstantinov, Y d’Udekem (Melbourne), Ram Emani, Jorge Salazar and L Quinonez (Boston) whom I have learned from during my time spent in their institutions.    

Last but not least, I wanted to thank all my surgical colleagues in Scotland (Mr Kenneth MacArthur, Mr Mark Danton and Mr Chuck McLean). They have always been supportive of my endeavours to travel abroad and learn from other units.