This was 2009 April when during a hot summer afternoon an impoverished couple from Orissa walked into my room with their four month old girl who was diagnosed to have corrected transposition or abnormal atrioventricular and ventriculoarterial connections. All they understood was that their only child has a serious heart problem and there is hardly any hope. Unfortunately they neither had the money or knowledge to proceed further and most of the doctors said “Accept your fate “. Only the parents were determined to give their only child the best chance. She underwent a major open heart surgery called Double Switch Operation. Today that baby is one and a half year old happy playful toddler. I just wish all of us have that dogged determination.
Congenital heart diseases (CHD) are defects produced in the baby’s heart during development inside the mother’s womb. About 8-9/1000 live born babies suffer from CHD although many are under diagnosed or missed completely.In India, about 200000 children are born with heart disease every year and 50,000 die before their first birthday.
STEP I: How to suspect that a child has heart disease?
a. Frequent cough & cold
b. Poor weight gain
c. Bluish discolouration of lips and nails(Cyanosis)
d. Gets tired easily
e. Fast breathing
f. Difficulty in feeding
g. Excessive sweating of forehead
h. Delayed development( delay in sitting, standing, walking etc)
i. Fever with joint pain and swelling
j. Unexplained unconsciousness
k. Viral infection in mother in first three months of pregnancy
l. Addiction to alcohol, cigarette
m. Mother having medicines for epilepsy (convulsions), diabetes, thyroid disorder
n. Marriage between relatives
STEP II: Now what to do?
a) Visit your child specialist. The pediatrician hears your child’s chest with a stethoscope and can diagnose abnormal sounds called murmurs. He will also check the Blood pressure, pulses and measure the oxygen percentage in your child with an instrument called Pulse Oximeter. Sometimes he asks for an ECG (Electrocardiogram) or Xray of chest.
b) If any of these are abnormal, he will refer your child to a pediatric cardiologist. A pediatric cardiologist is a cardiologist exclusively treating children with heart defects.
c) Depending upon the problem, the pediatric cardiologist usually advises an Echocardiogram, ECG, and Chest X-ray and then decides.
FIRST LINE INVESTIGATIONS( OPD Basis)
1.Electrocardiogram (ECG) : Records the electrical activity in the heart, pacemaker function, heart rhythms, decreased coronary arterial flow etc.
2.Chest X Ray(CXR): Useful in understanding heart size, shape, chest abnormalities, pneumonia etc.
3. Echocardiogram: Echo is an ultrasound of heart where ultrasound waves are applied on the heart by a transducer and the reflected waves from heart and blood vessels are recaptured and reconstructed by the computer to form a structural image of the heart. It tells us about the heart chambers, holes in heart, valve problems, heart function, fluid around heart.
SECOND LINE INVESTIGATIONS:
1. CARDIAC CATHERISATION & ANGIOGRAPHY: It is an inpatient procedure where under anesthesia, a puncture is made in the groin vessels and then a catheter is placed inside the heart and intracardiac pressures, oxygen saturations, valve areas etc are measured. During angiography, radioactive contrast is injected through these catheters and information about heart size, holes, valve problems are obtained. The baby is usually observed in the hospital for 24 hours after angiography.
2. CT Angiogram: It is an alternative modality where radioactive contrast is injected via a peripheral vein and focused CT of heart, lungs and blood vessels is done. The disadvantage is this that intracardiac pressures cannot be recorded.
Ø Fortunately in modern India most of the heart diseases in children can be completely cured.
Ø Most of the CHDs are either holes in heart or valve problems or blue babies.
Ø Blue babies are completely cured by open heart surgeries and nowadays the operation is often done within first month of life.
Ø As far as holes in heart or Shunt Lesions are concerned, some of them close spontaneously while many don’t.
Ø A pediatric cardiologist does an echo to know what is happening and if a hole is big it is closed surgically under cardiopulmonary bypass.
Ø Age and weight are no longer a problem with advancement in medicine and I am proud to report successful open heart surgery in a 900 Gram premature baby in Bangalore.
Ø The valves are the trickiest area. If they are obstructed, they are opened up by balloon angioplasty( a nonsurgical technique). However if it is leaking, a combination of medicines and valve surgeries is required. Often the valves have to be replaced by artificial valves.
Ø The role of medicines is more of symptomatic type.
Ø Many Indian families delay surgery fearing the cost factor. The costs of cardiac surgery in corporate setups vary between 70,000 – 250,000 Rs as a package. Fortunately many social health schemes like Yasawsini, Arogya Bhagya, Chief Minister Relief Fund, Prime Minister Relief Fund, Needy Heart Foundation etc are regularly helping poor patients below poverty line. I dream of a day when a child with heart disease is not turned out because of lack of funds.
OUTCOME AFTER CARDIAC SURGERY IN CHILDREN:
Ø The outcome in most cases are excellent.
Ø Recovery period = 6 weeks
Ø Then the child is ready to go to school, play and do everything his playmates are doing.
Ø Some of our early postoperative patients are now adults and many of them are married and have a family.
Ø However, in late operations or unsuccessful operations or very complicated heart diseases (like absence of ventricles) might need lifelong cardiac follow up, medications and might even have restricted physical capacity.
Ø Also children with associated genetic defects like Down’s syndrome might suffer from other organ malfunction even if heart is repaired.
Take Home Message:
Ø Heart diseases in children are curable.
Ø But still our picture is so gloomy because we either don’t recognize the heart disease or go for the correct treatment at a preterminal stage.
Ø Conscious and aware parents can themselves pick up the ‘tell-tale signs’.
Ø Early diagnosis, prompt referral and successful treatment can save many lives from this potentially treatable disorder.