Development of Interventional Paediatric Cardiology in CMH Dhaka

Special Article: Ref: child HJ 2006;22(1):29-30.

NN Fatema

Introduction

Congenital Heart Disease (CHD) is the commonest single group of congenital abnormalities accounting for about 30% of the total, incidence being at least 8/1000 live births.There are eight common lesions which account for about 80% of all cases, in descending order of prevalence are Ventricular Septal Defect (VSD), Patent Ductus Arteriosus (PDA), Atrial Septal Defect (ASD), Tetralogy of Fallot (TOF), Pulmonary stenosis (PS), Coarctation of the Aorta (COA), Aortic stenosis (AS) and Transposition of the Great Arteries (TGA). The remaining 20% or so is made up of a variety of more rare and complex lesions.^1-5

The important paediatric cardiology mile stones are successful ductus arteriosus ligation in 1938 in Boston by Robert Gross, repair of coarctation of Aorta in 1945 in USA by Gross and Ilufnugal ,repair of Artial Septal Defect using cardiopulmonary bypass in 1953 by Gibbon.^6,7 The life saving intervention of balloon atrial septostomy for cyanotic babies was introduced in the late 1960 by Dr. William Rashkind of Philadelphia.^2,4 This emergency procedure enabled a large number of neonates a candidate for subsequent switch operation. In the late 1970 introduction of prostaglandin E for the treatment of ductus dependent pulmonary or systemic circulation provided a measure of securing adequate oxygenation in a number of blue neonates, thus delaying emergency cardiac catheterization or palliative operation in a very ill hypoxemic and acidotic newborn. On the other hand injection indomethacin is used for closing haemodynamically significant PDA in new born.⁸ First PDA coil occlusion was performed in 1967 and first ASD device closure was done by king & Mill in 1976. First balloon valvoplasty was introduced in 1979.⁹ First VSD device closure was performed in 1990’s.

Paediatric Cardiology

Bangladesh perspective

Paediatric cardiology unit was established in CMH Dhaka in September 1998. This is the only hospital in

Consultant, Paediatric Cardiologist, Department of cardiology, Combined Military Hospital, Dhaka

Bangladesh where interventions from newborn to children are available with facility for maximum intensive care in pre or post interventional period. But there is no cardiac surgery counterpart in this hospital for neonates and infants specially. So after doing necessary work-up and intervention patients are referred to other cardiac centers of home and abroad for surgical correction.In National Institute of Cardiovascular Disease (NICVD) and National Heart Foundation (NHF) noninvasive test and diagnostic catheterizations are performed but life saving interventions in neonates or curative interventions are limited. Cardiac surgeon in these hospitals are doing surgeries for almost all simple congenital lesions and some of the complex lesions like Tetrology of Fallot and others. Palliative surgeries like Blalock Taussig (BT) shunt and Glenn shunts are also performed in these places. But surgeries for neonates, infants for more complex lesions are not available in those places. Other than these two center some private cardiac hospitals have facilities for children and surgery for simple heart lesions.

Activities of paediatric cardiology unit of CMH Dhaka Paediatric cardiology unit has 17 beds with 4 intensive care beds with facility for ventilatory support and continuous monitoring. Main aim of this unit is to diagnose cases in earliest possible chance and to do the work up and planning. After planning some patient remain in follow up, some go for cardiac catheterization and/or intervention and some are sent for surgeries. Cardiac interventions which are possible in CMH Dhaka include :

Balloon Atrial Septostomy Pulmonary valvoplasty Aortic valvoplasty Coarctation angioplasty Pericardiocentesis

Temporary pace maker implantation Stenting of RVOT

Interventions in children (other than neonates) include: ASD device closure

PDA Coil / device closure

VSD device closure (muscular variety) VSD device closure (Perimembranous variety) Pulmonary valvoplasty

Aortic valvoplasty Coarctation angioplasty

Venoplasty & peripheral angioplasty Pericardiocentesis

Coil embolization of collaterals

Paediatric cardiology milestones in CMH Dhaka First classical balloon atrial septostomy was performed in January 1999.² First pulmonary valvoplasty in neonate was performed in March 20009. First coarctation angioplasty in newborn was performed in October 2000.⁷ Aortic valvoplasty in newborn was performed in December 2001. First PDA coil closure was done in November 2000⁶. First ASD device closure was performed in April 2001^10. First VSD (Muscular type) device closure was performed in 20th August 2005. First stent implantation in RVOT in a case of severe sub pulmonary stenosis in newborn was performed in October 2005. First VSD (Perimembranous type) device closure was performed in 4 April 2006.

Screening of newborns

Any newborn with unexplained cyanosis, respiratory distress should be screened. Investigations like blood gas analysis and hyperoxic test should be done in all cyanosed newborn to exclude congenital heart disease

. Chest x-ray and ECG also gives some clue. The patient should be referred immediately to a tertiary center where cardiologist and management facility is available. Safe transport of the baby should be assured during referral to avoid hypothermia. Some newborn who are asymptomatic should also be screened properly because of presence of some condition where association of heart disease is a common phenomenon

e.g. baby with Down’s syndrome, cleft lip or palate, SLE mother, mother getting hormone therapy , congenital heart disease in other siblings,baby of diabetic mother etc.

Some of the children remain asymptomatic for long time in spite of the presence of simple heart disease like ASD, VSD, PDA etc. So there should be well baby clinic in every hospital to pick up these cases. Auscultation of heart of all babies should be done during routine immunization. This will help picking up more children with

asymptomatic heart disease having murmur. Diagnosis and therapy should be done at earliest possible chance. Training program on this subspecialty should be started soon to increase trained manpower. Our ultimate aim must be the early recognition of these malformations and their prevention.

References

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Begum NNF, Ahmed ZU, Ahmed Transposition of great Arteries: Report on eight cases. Bangladesh Medical College Journal 2002; 7: 1-5.
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5 Begum NNF, Rahman MH, Ahmed QS, Ahmad ZU, Alam J. Report on 56 cases of Heart Disease in children undergone cardiac Catheterization . Bangladesh Journal of Radiology and Imaging 2001; 9:5.

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