GUEST EDITORIAL

Dr. Mani Ram Krishna*

Paediatric Cardiologist, Kauvery Hospital, Trichy-Heartcity, India

*Correspondence: mann.comp@hotmail.com

When I received this opportunity to write a guest editorial for the Kauverian, I baulked at the enormity of the task in front of me. My mind immediately started framing a polite refusal which would not offend the Editor-in-Chief, Dr. Venkita S. Suresh. However, a few moments of quiet introspection convinced me that this was not an opportunity to be missed. The Kauverian is read by a wide referral network of pediatricians, obstetricians, physicians and general practitioners from central Tamil Nadu who refer their sick patients to Kauvery. In essence, it is read by the very set of doctors I hope to sensitize about the need for a comprehensive pediatric cardiac care program in central Tamil Nadu.

Congenital Heart Diseases (CHD) have an incidence of 0.8–1.2% irrespective of the population [1–3]. This means that approximately 1 in 100 pregnancies is complicated by CHD. In India, a substantial effort is being made by the government and private sectors to reduce the Infant Mortality Rate to globally acceptable standards. Throughout most of the past five decades, the efforts were focused on the so called “three big killer diseases” in children – malnutrition, diarrheal diseases and respiratory tract infections. The efforts are starting to bear fruit, and this has reflected in a rapid drop in the Infant Mortality Rate to less than 30 per 1000 live births in the southern states including Tamil Nadu and Kerala. However, further efforts to push this number down encountered roadblocks in the form of congenital disorders. A system focused almost exclusively on treating the traditional disorders did not have the skills to recognize and treat these “non-traditional” disorders. CHD are the leading cause of death due to congenital abnormalities worldwide. Experience from the West has taught us that early recognition and comprehensive care could result in excellent outcomes for most neonates and infants with CHD. Centers of excellence capable of taking care of this vulnerable population and providing outcomes comparable (if not superior) to the West are available in many parts of our country but there is an unequitable geographical distribution of such centers. In Tamil Nadu, such centers of excellence are limited to Chennai in the north and Coimbatore in the West. This leaves large parts of central and south Tamil Nadu to fend for themselves. A cursory glance at statistics provided by the Department of Health and Family Welfare suggests that the two large government obstetric teaching institutes in central Tamil Nadu – “Thanjavur Medical College” and “Trichy Medical College” conduct the 2nd and 3rd greatest number of deliveries among government institutes in the state. These institutes together deliver close to 30,000 babies per year. The 1% rule suggests that 300 neonates with CHD (roughly 1 a day) are born in these two institutes every year. If you add the number of deliveries in smaller public and private hospitals, the enormity of the problem becomes apparent. One cannot help but wonder why a center of excellence is already not in place to cater to this population.

As soon as I sat to prepare for the task of writing this guest editorial, I went back to an article written by my mentor, Dr. Raman Krishna Kumar in one of his early editorials after taking over as the Editor-in-Chief of Annals of Pediatric Cardiology, the official journal of the Pediatric Cardiac Society of India (PCSI). In this editorial titled “Delivering pediatric cardiac care with limited resources”, Dr. Kumar had elegantly presented the challenges faced in establishing and sustaining a pediatric cardiac program in low- and middle-income countries and the attributes needed to overcome the challenges [4]. A recurrent theme in the article were a “desire to reach out and serve the needs of the average child” and the ability to “improvise, innovate and invent” solutions to cater to the local needs and challenges. The abundance of these characteristics permitted some of the Indian centers of excellence to become global leaders in providing “quality care at affordable costs” (often considered an oxymoron by healthcare experts). Two years later, another editorial in the same journal explored how the West could learn from the emerging economies on prudent but quality healthcare [5].

Establishing a center of excellence after the need has already arisen necessitates a multi-pronged approach. The community of obstetricians, pediatricians and general physicians would need to be sensitized about the importance of recognizing congenital heart diseases and the need for evaluation by a pediatric cardiologist to optimize the outcomes of intervention. The provision of specialized pediatric and fetal cardiac services will ensure accurate diagnosis of the CHD and help in counseling the parents on the expected course of management and the anticipated outcomes. Once these two goals are achieved, the child with congenital heart disease will have to be provided definitive management. This usually involves cardiac surgery or a per-cutaneous intervention. Pediatric cardiac care is among the most resource intensive health care specialties. The pediatric cardiologists and cardiovascular surgeons would need to be surrounded by a team of trained pediatric cardiac anesthetists, intensivists, critical care nurses, cardiac technologists, radiographers, cath lab nurses and other para-medical personnel. The working hours are long and intense. A major challenge facing units caring for children with heart disease is attrition and loss of morale among health care workers. The hospital administration hence needs to be alert to ensure that this does not adversely affect the quality of the program. It is important to identify and support leaders among each sector of health care workers who can nurture new recruits. To ease the burden during the initial stages, most large pediatric cardiac centers have attempted to feed off established adult cardiac centers by sharing some of the common services while building the unit. Kauvery Heart City is among the leading adult cardiac centers in central Tamil Nadu catering to a large referral population with state-of-the-art cardiac interventional and surgical expertise. This places it as the ideal stepping pad for a pediatric cardiac center of excellence. During the last eight months, we have performed 28 pediatric cardiac interventions and six pediatric cardiac surgeries despite the challenges posed by the pandemic. This has included a few complex procedures such as SVC stenting, PDA device closure in a child with interrupted IVC, ASD closure in children weighing < 10 kg (often considered a contraindication for device closure) and ASD closure in children with deficient margins. The journey has begun, and I am reminded of a popular Italian saying “Se non ora, Quando?” – If not now, When?

Reference

  1. Vaidyanathan B, Sathish G, Mohanan ST, Sundaram KR, Warrier KK, Kumar RK. Clinical screening for congenital heart disease at birth: a prospective study in a community hospital in Kerala. Indian Pediatr. 2011;48(1):25–30.
  2. Saxena A, Mehta A, Sharma M, Salhan S, Kalaivani M, Ramakrishnan S, et al. Birth prevalence of congenital heart disease: a cross-sectional observational study from North India. Ann Pediatr Cardiol. 2016;9(3):205–9.
  3. Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol. 2002;39(12):1890–900.
  4. Kumar RK. Delivering pediatric cardiac care with limited resources. Ann Pediatr Cardiol. 2014;7(3):163–6.
  5. Balaji S, Kumar RK. Partnership in healthcare: What can the west learn from the delivery of pediatric cardiac care in low- and middle-income countries. Ann Pediatr Cardiol. 2015;8(1):1–3.

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