3. Discussion The delay of selleck U0126 the diagnosis was 4 days indicating the variety of the clinical appearance of the BTDR. The missing typical symptoms can mask the severity of the injury and lead to increasing morbidity. Although large prospective long-term studies regarding outcome after laparoscopic approach are still missing [1], laparoscopy was the method of choice in our case and safely performed, particularly when severe side injuries are absent. We could show, that laparoscopy has advantages in isolated diaphragmatic ruptures compared to traditional laparotomy, which is still preferred by some authors [8, 9]. Laparoscopy mostly allows easy reposition of herniated organs, sufficient inspection of the thoracic, and abdominal cavity and immediate laparotomy if necessary.

Balloon valvuloplasty for fetal critical aortic stenosis has been shown to alter the developmental trajectory of some fetuses from hypoplastic left heart syndrome (HLHS) toward restored left ventricular growth [1�C4]. Technical success holds the promise of two ventricle circulation in the neonate, thereby avoiding the need for three-stage palliation to single ventricle circulation or cardiac transplant [4]. The fact that this can be achieved through a single needle insertion through the maternal abdomen into the fetal chest is especially appealing in that it avoids the profound morbidity associated with the diagnosis of HLHS in the neonate, while exposing mother and fetus to minimal risk. There are multiple technical challenges involved in performing fetal valvuloplasty.

Some of these difficulties have to do with communication among team members during the navigation of the needle through the maternal abdomen, uterine wall, fetal chest wall, and into the left ventricle pointing directly at the aortic root. While learning to function as a team, the members of the interventional program must agree on a standard orientation for ultrasound imaging that takes into consideration the needle trajectory and target. Finally, complications occur during fetal cardiac intervention such as arrhythmia, hemopericardium, and cardiac tamponade that require a rapid and coordinated response. Use of a large animal training paradigm, typical for surgical training on medical device implantation, could allow the team to learn the technique, develop effective communication, and practice appropriate responses to complications.

We describe the learning curve encountered by a multidisciplinary team of maternal-fetal medicine, interventional cardiology, and fetal echocardiography subspecialists during the initiation of a minimally-invasive fetal cardiac intervention program. Our aim is to demonstrate that technical challenges are significant but are surmountable. Brefeldin_A Practice in a large animal training model should be considered before proceeding to the human fetus. 2. Materials and Methods 2.1.