1. THE HEART OF THE MATTER:
INTERPRETING PEDIATRIC CARDIAC SURGERY
Alejandra E. Picado
THE HEART OF THE MATTER:
Welcome everyone! I am Alex Picado, I work with Children’s Medical Center in Dallas, and I feel privileged to be here with you guys today. I have been a stationed interpreter in the cardiology clinic for about 3 years now, and I learn something new every day!
Thank you for coming and I hope that I am able to help you at least in some small way in your future encounters.

2. What Participants Will Learn From Today’s Presentation.
1. How to prepare for a cardiac pre-operative interpreting session. (Knowing your terms, procedures, and common preparations, as well as the emotional preparations.)
2. What the most common pediatric cardiac conditions are, and what the procedures are to repair these.
3. How to interpret with professionalism, while also showing compassion and helping in what little ways we can.
4. Working with the chaplains, child-life and social workers for the difficult conversations prior to surgery.
5. How interpreting a Pediatric cardiac surgery is different from adult cardiac surgeries.

3. So, As Medical Interpreters, We are Here to Serve as …
Cultural broker.
Support,
Communication manager.
Open heart
Even though, as interpreters, we are primarily here to bridge a gap in the communication between the healthcare team and the patient / patient’s family, we do so much more.
We serve as a ,
In addition to and as part of the medical team, to help the family through this very difficult time.

4. Terror, Anger, Desperation, Confusion!
What Is The First Thing That Comes to Mind When You Say “Open Heart Surgery?”
Terror, Anger, Desperation, Confusion!
On top of that, picture that neither you nor the doctor know how to speak each others’ language!
That, is what nightmares are made of.
In pediatric cardiology, things can be as simple as an innocent heart murmur, and range all the way to open heart surgery, a heart transplant, and in many occasions discussions of life and death.

5. How Do You Begin A Cardiac Pre-Operative Interpreting Session?
Being briefed before the encounter can make a world of difference to both you and the encounter.
Take note of the environment and silently assess.
Pre-session.
First of all, just like any other interpreted session between a provider and a patient / patient’s family, you must start off with a pre-session with both provider and patient.
Remember, that anytime you are going to interpret, it helps to find out the subject matter and any special circumstances or issues that you might encounter before entering the session along with the provider.

6. Very Common Terms For Interpreting Cardiac Surgery Are As Follows:
Catheterization
Heart Lung bypass machine
Chest tubes
Pacemaker wires
Steri – strips
Sternotomy / Mini-Sternotomy
Cath - (Inserting a thin, noodle like catheter through a vein or artery in the groin or neck)
HEART LUNG BYPASS MACHINE-(Machine that re-routes / deviates and cleans blood so that the body and organs can remain functioning while the heart is being worked on
Chest tubes - (Tubes placed in the chest to drain the chest of fluids after surgery)
Pacemaker wires - (placed on the heart and stick out of chest in case of any arrhythmia.
Steri-Strips - (Adhesive strips used to keep the external incision closed.)
Sternotomy – Mini – Sternotomy : (Cut through the sternum in order to gain access to the heart for surgery
Mini – for bikini season. (it helps to lighten the mood)
Cardiac Catheterization - (Inserting a thin, noodle-like catheter through a vein or artery in the groin or neck area) going to the heart.
Heart Lung bypass machine -Machine that re-routes / deviates, cleans and oxygenates blood, so that the body and organs can remain functioning while the heart is being worked on.
Chest tubes- Tubes placed in the chest to drain the chest (lungs and pericardium of blood and fluid after surgery.)
Pacemaker wires -Wires placed on the heart that stick out of after surgery) chest and may be connected to an external pacemaker, in case of an arrhythmia. (often come out after a couple of days
Steri – strips - Adhesive strips used to keep the external incision closed, after surgery.
Sternotomy / Mini-Sternotomy – Cut made through the sternum in order to gain access to the heart for surgery. After surgery, it is held together with stainless steel wires that will remain in the patient for good.

7. The Session Will Begin With possible…
urine tests
blood tests
echo-cardiogram (ECG)
electro-cardiogram (EKG)
Cardiac Catheterization
Remember your positioning and professionalism, but don’t be afraid to show compassion (The OPEN HEART.)
with the explanation of all of the tests that may need to be performed on this date or before surgery, In some cases, before surgery, the patient will also undergo a cardiac catheterization.
(Sometimes, the catheterization will take the place of the surgery, depending on the findings and outcomes of the procedure.)

8. What Are Some of the Most Common Cardiac Defects / Diagnosis in Pediatrics?
1. PDA (Patent Ductus Arteriosis)
2. ASD (Atrial Septal Defect)
3. VSD (Ventricular Septal Defect)
4. AV Canal (Atrioventricular Septal Defect)
5. Coarctation of the Aorta
6. TOF (Tetralogy of Fallot)
7. AS (Aortic Stenosis)
HLHS (Hypoplastic Left Heart Syndrome)
Single Ventricle Anomalies
9. Single Ventricle Anomalies: {some of the related anomalies are ( tricuspid atresia / hypoplastic left heart syndrome / double inlet left ventricle/many of the heterotaxy defects / some variations of double outlet right ventricle.)

9. PDA (Patent Ductus Arteriosis)
Allows blood to flow from the pulmonary artery to the aorta.
1.) Patent Ductus Arteriosis 2.) Ligated PDA
The ductus arteriosus is a blood vessel that is present in all babies while still in the womb that allows blood to bypass the pathway to the lungs; it …
When the baby is born and the umbilical cord is cut, the lungs are now needed to supply oxygen. The lungs expand, their blood vessels relax to accept more flow and the ductus arteriosus usually closes within the first hours of life. On occasion, however, the ductus arteriousus does not close on its own and this is referred to as a patent (“patent” means open) ductus arteriosus.
Surgery consists of placing a clip or sutures to close the vessel and is usually performed from an incision on the side of the chest.

10. ASD (Atrial Septal Defect)
A hole between the 2 upper chambers of the heart
The heart is divided into four separate chambers. The upper chambers, or atria, are divided by a wall called the septum.
Atrial septal defects are one of the most common heart defects seen.
Repair is based on anatomy and the size of the hole.
Small - Medium holes that are centrally located may have a device closure in the Catheterization Lab.
Large holes require a surgical patch closure.
When an atrial septal defect is present, blood flows through the hole primarily from the left atrium to the right atrium. This shunting increases the blood volume in the right atrium which means more blood flows through the lungs than would normally.
If left untreated, atrial septal defect may cause problems in adulthood. These problems may include pulmonary hypertension (which is high blood pressure in the lungs), congestive heart failure (weakening of the heart muscle), atrial arrhythmias (which are abnormal rhythms or beating of the heart) and an increased risk of stroke.

11. A hole between the right and left pumping chambers of the heart.
VSD (Ventricular Septal Defect)
A hole between the right and left pumping chambers of the heart.
Normally there is no hole between the two ventricles, but some infants are born with these holes called ventricular septal defects.
Ventricular septal defects are probably one of the most common reasons for infants to see a cardiologist.
Ventricular septal defects are among the most common congenital heart defects, occurring in 0.1 to 0.4 percent of all live births and making up about 20 to 30 percent of congenital heart lesions.
Some types of VSD’s close on their own (muscular and membranous). Others need to have a patch repair closure.

12. AV Canal (Atrioventricular Septal Defect)
To make it simple: You have 4 apartments. 2 upstairs and 2 downstairs.
the whole middle wall is missing.
AVSD
Top view of Valve
Repaired AV-Canal
(AVSD) are a relatively common family of congenital heart defects.
They account for about 5 percent of all congenital heart disease, and are most common in infants with Down syndrome.
The primary defect is the failure of formation of the endocardial cushions are responsible for separating the central parts of the heart near the tricuspid and mitral valves (AV valves), which separate the atria from the ventricles.
An atrioventricular septal defect may involve failure of formation of any or all of these structures.
Repair of this defect is carried out by placing patches to close the ASD & VSD and separate the common AV Valve into two separate valves.

13. Coarctation of the Aorta
Is a narrowing of the aorta, the main blood vessel carrying oxygen-rich
blood from the left ventricle of the heart to all of the organs of the body.
Repairs:
End to End Anastomosis
Bypass (Sub-Clavian Flap Repair)
Thoracotomy (incision on left side)
The narrowing decreases the blood flow to the body, therefore causing the heart to pump harder against the smaller than normal opening.
The ductus arteriosus is a blood vessel that is normally present in a fetus and has special tissue in its wall that causes it to close in the first hours or days of life. It is thought that coarctation may be caused by the presence of extra ductal tissue extending into the adjacent aorta which results in aortic narrowing as the ductal tissue contracts. In babies with coarctation, the aortic arch may be small (hypoplastic). Coarctation may also occur along with other cardiac defects, typically involving the left side of the heart.
The defects most commonly seen with coarctation are bicuspid aortic valve and ventricular septal defect. Coarctation may also be seen as a part of more complex, single ventricle cardiac defects.
Coarctation of the aorta is common in patients with some chromosomal abnormalities, such as Turner's syndrome.
In the presence of a coarctation, the left ventricle has to work harder, since it must generate a higher pressure than normal to force blood through the narrow segment of the aorta to the lower part of the body.
If the narrowing is severe, the ventricle may not be strong enough to perform this extra work resulting in congestive heart failure or inadequate blood flow to the organs of the body.
Repair of this coarctation is done by either:
Cutting out the narrowed part of the aorta and sewing the two ends together. (end to end anastomosis) or
By using a blood vessel from the arm to widen the narrowed area (subclavian flap repair).
Surgery is done through a thoracotomy (side) incision on the left side.
Coarctation
Coarctation Repair

14. Tetralogy of Fallot (TOF)
An anomaly that refers to a combination of four
related heart defects that commonly occur together.
Pulmonary Stenosis
Right Ventricular Hypertrophy
Overriding Aorta
VSD (Ventricular Septal Defect)
Surgery for TOF depends on the anatomy and saturations.
The four defects include:
Pulmonary stenosis (narrowing of the pulmonary valve and outflow tract or area below the valve, that creates an obstruction (blockage) of blood flow from the right ventricle to the pulmonary artery
Ventricular septal defect / VSD
Overriding aorta (the aortic valve is enlarged and appears to arise from both the left and right ventricles instead of the left ventricle as occurs in normal hearts)
Right ventricular hypertrophy (thickening of the muscular walls of the right ventricle, which occurs because the right ventricle is pumping at high pressure)
A small percentage of children with tetralogy of Fallot may also have additional ventricular septal defects, an atrial septal defect / ASD or abnormalities in the branching pattern of their coronary arteries.
Some patients with tetralogy of Fallot have complete obstruction to flow from the right ventricle, or pulmonary atresia. Tetralogy of Fallot may be associated with chromosomal abnormalities.
The pulmonary stenosis and right ventricular outflow tract obstruction seen with tetralogy of Fallot usually limits blood flow to the lungs. When blood flow to the lungs is restricted, the combination of the ventricular septal defect and overriding aorta allows oxygen-poor blood ("blue") returning to the right atrium and right ventricle to be pumped out the aorta to the body.
This "shunting" of oxygen-poor blood from the right ventricle to the body results in a reduction in the arterial oxygen saturation so that babies appear cyanotic, or blue. The cyanosis occurs because oxygen-poor blood is darker and has a blue color, so that the lips and skin appear blue.
The extent of cyanosis is dependent on the amount of narrowing of the pulmonary valve and right ventricular outflow tract. A narrower outflow tract from the right ventricle is more restrictive to blood flow to the lungs, which in turn lowers the arterial oxygen level since more oxygen-poor blood is shunted from the right ventricle to the aorta.
Kids with TOF/pulmonary atresia may have tiny PA’s and need staged repairs to get the PA’s to grow.
[ Blalock Taussig (BT) Shunt / Unifocalization surgery to bring PA’s Together.]
Consisting of :
Closing a VSD,
relieving pulmonary stenosis by patching the RVOT (right ventricular outflow tract
pulmonary arteries
or placing an RV -> PA conduit.

15. AS(Aortic Stenosis)
Aortic Stenosis refers to a condition that causes obstruction to blood flow
between the left ventricle and the aorta.
Valvar AS
Subvalvar
Supravalvar
The most common abnormality occurs when the aortic valve has only two (instead of three) leaflets.
This is called a bicuspid aortic valve (or BAV).There are a variety of causes, including muscular obstruction below the aortic valve, obstruction at the valve itself, or aortic narrowing immediately above the valve.
The most common form of aortic stenosis is obstruction at the valve itself, referred to as aortic valvar stenosis, which is the subject of this section.
The normal aortic valve consists of three thin and pliable valve leaflets. When the left ventricle ejects blood into the aorta, normal aortic valve leaflets spread apart easily and cause no obstruction to outflow of the blood from the heart.
Aortic stenosis occurs when abnormalities of the aortic valve lead to narrowing and obstruction between the left ventricle and the aorta.
The most common abnormality occurs when the aortic valve has only two (instead of three) leaflets. This is called a bicuspid aortic valve (or BAV). Often the valve leaflets are thickened and less pliable than normal, and the lines of separation between them (or "commissures") are fused together to a variable degree. When the aortic valve does not open freely, the left ventricle must work harder to eject blood into the aorta.
To compensate for this additional workload, the muscle of the left ventricle (the myocardium) gradually thickens to provide additional strength to left ventricular ejection. The increased left ventricular muscle, also known as hypertrophy, is rarely a problem itself. Instead, hypertrophy is an indication of significant valve obstruction.
When the aortic valve is severely obstructed, the left ventricular muscle may not be able to compensate satisfactorily. In these very severe, but fortunately rare, instances the left ventricle may fail to pump blood effectively and the patient may develop cardiac failure. If this occurs it is almost always in a newborn infant with very severe valve obstruction. Heart failure rarely occurs later in childhood.
Repairs involve :
Valvar AS – usually a Catheterization balloon procedure
Subvalvar – needs surgery
Supravalvar – associated with Williams Syndrome needs surgery.

16. HLHS (Hypoplastic Left Heart Syndrome)
Several abnormalities of development occur on the left side of the heart in HLHS:
Mitral stenosis (poorly formed) / Mitral atresia (not formed)
Left ventricular hypoplasia.
Aortic stenosis
Aortic atresia).
The main artery leaving the left side of the heart, the aorta, is underdeveloped.
Coarctation of the aorta
Normal Hypoplastic Left Heart
1.The valve from the left top heart chamber to the left bottom chamber is poorly developed
2.The bottom left heart chamber is poorly developed
a.)the valve from the bottom, the left heart chamber to the main artery is poorly developed
b.) to not formed
The aorta is narrowed as well

17. Different Procedures to Repair HLHS (Hypoplastic Left Heart Syndrome)
Norwood
Bidirectional Glenn
Fontan
1st Repair nd Repair 3rd Repair
-Norwood - Performed in the first week of life.
A.) aortic arch reconstruction
B.) BT Shunt / Sano Shunt RV-PA Conduit
C.) Atrial septectomy
- Glen (4 – 6 Months of age)
Take down source of PBF done at Stage 1, connect SVC(superior vena cava) to PAS
Fontan(2 -3 years of age)
Connect IVC to PAS (All blue venous blood goes to PA’s.)
The surgical options for HLHS include cardiac transplantation and a series of procedure done at different times based on age and development.

18. Single Ventricle Anomalies
Only one of the two ventricles is of adequate functional size.
Some of the anomalies described as single ventricle defects include:
Tricuspid atresia –
Hypoplastic left heart syndrome–
Double inlet left ventricle–
Many of the heterotaxy defects-
Some variations of double outlet right ventricle –
The term "single ventricle anomaly" is purposely non-specific. It is used to describe a group of cardiac defects that may differ quite dramatically from each other but share the common feature that
Because of this feature, the ultimate plan for reconstruction is actually quite similar for most of these anomalies.
All will generally undergo staged reconstructive procedures ultimately resulting in a "Fontan circulation."
Tricuspid atresia is a type of congenital heart disease in which the valve between the right atrium and right ventricle fails to develop.
Double inlet left ventricle
Many of the heterotaxy defects
Some variations of double outlet right ventricle
As a newborn –
Need to assess pulmonary blood flow & systemic blood flow if pbf is limited (cyanotic), the child will need a BT Shunt to increase pbf.
If arch (systemic bf) is obstructed, the child will need arch reconstruction (Norwood family of surgeries).
Some kids are relatively balanced and may be left alone for a few months. (Some PS would be showing good saturation levels of 75% to 85%)

19. Working with Child Life because you are speaking a “kids” language.
Child life has a very important role in the hospital. They don’t just “play” with the children, but rather, they role play and make the children comfortable enough to be able to discuss or at least understand in terms that they can comprehend, what all the scary stuff is about.
Child Life has many tools at their disposal, and so through videos, pictures, and toys and equipment, they can present to children, ways that will help them understand better what they are going through, what the whole process will mean for them, and let the kids feel comfortable in the clinical environment.
Not only do they explain and help with the patients, but also their siblings as well. (It can be “pretty scary” knowing my sis or brother will be cut open!)
Interpreting for a Child Life employee can often times be very rewarding,
because you are speaking a “kids” language.
In order to be able to pull this off, you have to learn to be a kid once again. The tone of your voice, your posture and expressions should match that of the Child Life employee, and thus making it a more relaxed and “trusting” environment for the children.
This is something that is learned with time, and the best way to do this is to mimic their actions, get a feel for the child’s reactions and their understanding.
Do not be afraid to use all of your resources as an interpreter, multi-cultural broker and liaison, to make sure that everything is understood.

20. Working with Social Work and Chaplains
Social workers are a very vital in the preparation for pediatric cardiac surgery.
Resources
Loving and support
Chaplains play a very important part in the families experience in the hospital.
Spiritual and Moral Support
Ear to listen with
Social Workers - They have knowledge of all of the resources available to the families throughout their hospital experience.
Chaplains - Regardless of the religion or beliefs, they are there for spiritual and moral Support.
They let the families know all the resources that are available to them. (transportation, parking, meals, support, telephones, support groups, even sitters)
They make sure that the family feels a sense of support from members of the hospital who aren’t clinical, and they allow families to express any issues related or non-related to the surgery, that may be causing issues in their lives, therefore affecting their experience during the difficult time of preparing for a child’s cardiac surgery.
Again, when interpreting for social work, take note of the body language, the things said and the Silence, the empathy and sympathy, and add all of this to your interpretation, so that you come across as an extension of that Social worker.
Chaplains will not only pray with the family, but will ease the families heavy hearts in some way, and again, you must relay this in a way that it feels as authentic as the original message. Not just words, but HEART felt. Praying in different languages is not as easy as it seems! Prepare.
Also, don’t forget that the Chaplains are there for everyone! Even the interpreters, just to be able to Debrief with difficult cases.
An extension of the Social Worker basically refers to the oneness that the family should feel. You are a team, and you are on their side. You are there for support, such as is the Social Worker and their dept.

21. Keeping the Professionalism while still showing compassion and heart.
Even though we as interpreters should always maintain our poise and remain professional, we can’t lose sight of the fact that we are human beings.
Why is this important?
Because machines can’t relate to people, they can analyze, but not “FEEL.”
Hand them a tissue when you see the tears threatening to fall.
Put your hand on the mom or dad’s shoulder.
That is why it is imperative that we use our actions and words in a way that tells the parents, “we know this is difficult, but we are all behind you and understand.”
Tell them, “I know this is hard, but we are with you. We are here for you!”
Don’t be afraid to show sympathy.
This should not be a prolonged action, but believe that those little things, make a huge difference and lighten the hearts at least a little bit.

22. The main differences of interpreting for adult cardiac surgery and pediatric cardiac surgery.
In adults, the conversation between the physician and the patient is usually more matter of fact, terminology (register) is often used at a higher level, and you are mainly dealing directly with the patient and perhaps some family members.
In pediatric cardiology, you are talking about someone’s CHILD. The terminology often the same, but explained in plainer terms. Illustrations often are included. The way of expressing oneself, softer and with HEART!
Adults have lived their life and have damaged their bodies, hearts included.
When someone feels chest pain as an adult, it is common sense to investigate the heart first.
Why? Because the coronary arties get clogged over time with cholesterol, as well as deteriorate with age. It is part of nature for the heart to weaken over time.
Children, on the other hand, haven’t had enough time to damage their hearts to those degrees. However, children are born with abnormalities that can be anywhere from mild to life threatening.
Matter of Fact
Less detailed explanation of
procedure.
More serious
Softer Tones
More illustration and breaking
down of terms.
Less serious, more relaxing

23. Interpreter Self Care Take care of YOU!
We often forget to take care of the most important factor in order to interpret.
Mentally prepare
Spiritually prepare
Deep Breathing
Ask for Support
Connection with Peers or
Colleagues
Pamper yourself
Create your own self-care
list
Take care of YOU!
Briefing and acknowledging that there will be difficult conversations and situations
No matter what your religious or spiritual beliefs are, look within for that strength and know that your strength will transfer to those you deal with
Breathing calms the mind, the body and cleanses and gives us a chance to be “still” and focus
When things get too stressful, talk to someone. Whether it is a member of the clergy, social work, or friend. (without giving any identifying information away.
DE-BRIEF Sometimes, talking about it, (venting) makes you feel better.
Massages / manicures or pedicures or even getting a new doo, are NEVER over-rated!
* Danielle Sandage & Silvia Boerboom “Children’s Hospital & Clinics of MN”.

25. THE END and…. The Beginning!
Lead with your heart!
Any questions I might answer for anyone?
Please remember, you should NEVER be afraid to show your human side, and everyone can get emotional, but it should not impede you from doing your job!