Commentary: A unified chain of command for organized team performance.

Fumiya Yoneyama, MD, and Iki Adachi, MD

A team cannot function properly without a commander. The surgeon must play a key role to make the team approach successful.

See Article page 295.

In this issue of the Journal, Greene and colleagues describe a case of a neonatal patient with a large right coronary artery fistula to the right ventricle that had been successfully treated with the “hybrid” approach. The treatment journey started with fetal diagnosis, followed by an emergent cesarean section and intubation immediately after birth. Because of the ongoing escalation of inotropic support, the patient was taken to the catheterization laboratory to confirm the diagnosis as well as for hemodynamic assessment. In the laboratory, the authors came up with the idea of leaving a 0.014″ guide wire in the fistulous tract from the femoral artery to help identify the fistula in the subsequent surgical repair. The patient was then transferred to the operative room.

The operation was conducted without much difficulty, leading to excellent early and mid-term outcomes. This type of operation can be very challenging both anatomically and physiologically., In particular, the presence of substantial coronary steal makes cardiopulmonary bypass management complicated in terms of maintenance of systemic perfusion and myocardial protection. The success of their multidisciplinary approach would be a reflection of each individual specialty, including cardiology, intensive care, and surgery, fulfilling its own role at the highest standard. It is incredible to see how smooth the patient's clinical journey was despite the expected challenges. Such clinical capabilities is one reason why the authors' institution is so well respected in our field.

Also of note is what ultimately makes the authors' multidisciplinary approach successful. Having good clinicians in each specialty does not necessarily guarantee adequate performance of the combined effort, because a team cannot function properly without a commander. It is the unified chain of command that makes individual actions aligned toward the ultimate goal. This is very true when the mission is complex. Even though the leadership role within the authors’ team is not specified in the report, there is little doubt that the surgeon must have played a key role. In other words, it would not be an overestimation to assume that the superb surgical leadership would be what made their team approach ultimately successful. This may be the most critical element of their case report, from which our surgical community can learn beyond just the technical pitfalls of coronary fistula management.