Editorial

The Practice of Pediatric Cardiology

Enormous progress has been made in the diagnosis and treatment of congenital heart disease over the last six decades. This has been the main driving force for the development of subspecialty of pediatric cardiology. In the United States of America, the subspeciality of pediatric cardiology was formally established in 1961, a prior training in general pediatrics is mandatory. In India, however, most of the pediatric cardiologists have not been formally trained in pediatric cardiology. The need for such training programmes is now being recognized because of the realization that both the volume and complexity of congenital heart disease is high.

The advances in the subspeciality of pediatric cardiology include better qnderstanding of genetics and environmental etiology, availability of precise non- invasive diagnostic tools and introduction of therapeutic catheter techniques. In addition, the pediatric cardiologists are directing their efforts towards neonates and infants in the current era, since the morbidity and mortality from congenital heart disease is greatest in this group of patients.

The development of echocardiography has revolutionized the field of pediatric cardiology. The impact is so enormous that the younger generation of pediatric cardiologists are unable to function without echocardiography. The number of diagnostic cardiac catheterizations and angiograms has diminished markedly as more reliance is being placed on this noninvasive diagnostic tool. A large amount of information about morphology and hemodynamics of various congenital heart malformations can be acquired by means of cross sectional echocardiography, Doppler and color flow imaging.

The knowledge of echocardiography has been extended for diagnosis of congenital heart disease in the fetus. Fetal diagnosis of congenital heart disease has opened avenues for perinatal treatment. In case a fetal cardiac abnormality is diagnosed, the baby may be delivered in a centre better geared to take care of such cases, thereby increasing the chances of newborn 's survival. Although there are legal and ethical issues, which are emerging with introduct ion of fetal echocardiography, its scope is widening in current practice of pediatric cardiology.

The field of therapeutic cardiac catheterization has shown remarkable advances in the last two decades, although the first such useful procedure was introduced

by William Rashkind in 1%6. He described balloon atrial septostomy for severely hypoxemic newborns with complete transposition of great arteries. There was remarkable improvement in oxygenation following the procedure so that these babies could survive for several months when they could undergo a "corrective" surgical procedure. The interventional procedures are now being applied successfully for the relief of valvular (pulmonary, aortic, mitral and tricuspid) and vascular (coarctation of aorta, branch pulmonary artery and others) obstructive lesions, for closure of atrial septal defect, patent ductus arteriosus and certain types of ventricular septal defects and occlusion of unwanted vascular channels. Often transcatheter therapeutic procedures are being used as complement to definitive cardiac surgery e.g. relief of postoperative peripheral pulmonary artery stenosis by transcatheter introduct ion of vascular stents and transcather closure of fenestration after a Fontan procedure.

There has also been a continuous improvement of surgical techniques since the first operation for patent ductus arteriosus, performed by Robert Gross in 1938. The use of cardiopulmonary bypass techniques led to performance of open heart surgery for various lesions, beginning with atrial septal defects in 1950. Further, improvement in bypass techniques and cardioplegia, miniaturizat ion of instruments and microsurgical techniques resulted in extending surgical correction to neonates. The operative mortality in neonates and infants is reduced to less than 10% in most centres, even for complex lesions.

The latest development has been in the field of molecular biology and genetics. This knowledge is being used for trying to unravel the mystery of anatomical and functional aspects of developing heart; clinical usefulness of such efforts, we hope, will soon be realized.

Indian Scenario

As India has one of the highest birth rates, the burden of congenital heart disease is likely to be heavy. Assuming an incidence of congenital heart disease similar to that seen around the world, more than 1.5 lakhs of children are born each year with congenital heart disease in India. Of these, at least 50,000 newborns will need some form of intervention in the first year of life alone. In contrast, the resources for dealing with this enormous load are very

Indian Journal of Pediatrics, Volume 69--April, 2002 313

A. Saxena and P.S.S. Rao

limited. There are only 10-15 centres, if that many, all over India, capable of providing optimal medical and surgical care to the newborns and infants needing intervention early in life. According to an estimate, hardly 1,000 infants undergo cardiac surgery every year.

Added to the burden of congenital heart disease, is the load of rheumatic heart disease, which is another commonly encountered cardiac lesion in young Indian children. The prevalence rate of rheumatic heart disease is 1-5/1000 in school-going children. An unusual ly aggressive nature of the disease combined with poor secondary prophylaxis result in a large number of young children requiring valve surgery during childhood.

It appears from the available data that less than 2% of the children with heart disease get optimal care in India. Total number of trained manpower is a tiny fraction of what is required for providing this optimal care. Added to this is the problem of late recognition and hence late referrals of certain cases with simple congenital heart disease resulting in higher morbidity and mortality. The

financial resources are limited and government policies for pediatric cardiac care are practically nonexistent.

In this special symposium on "Pediatric Cardiology" an attempt has been made to include topics which are of educational value to the practicing pediatricians. Some of the articles are of general interest and were written by distinguished authors. In addition, we have tried to include some articles addressing specific disease processes which are relatively new in the field of pediatric cardiology or are of frequent occurrence and hence may be commonly encountered by the pediatricians.

Anita Saxena, All India Institute of Medical Sciences

New Delhi, India

P. Syamasundar Rao Division of Pediatric Cardiology, University of

Wisconsin, Houston Texax, USA

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314 Indian Journal of Pediatrics, Volume 69--April, 2002