Year : 2011 | Volume
: 14 | Issue : 2 | Page : 79--81
Pediatric cardiac program in India: Changing perspectives
Suresh G Nair
Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences, Ponnekara, Cochin, Kerala, India
Suresh G Nair
No 17, Spring Tide Villas, Tagore Lane, LFC Road, Elamakkara, Cochin
|How to cite this article:|
Nair SG. Pediatric cardiac program in India: Changing perspectives.Ann Card Anaesth 2011;14:79-81
|How to cite this URL:|
Nair SG. Pediatric cardiac program in India: Changing perspectives. Ann Card Anaesth [serial online] 2011 [cited 2020 Jul 9 ];14:79-81
Available from: http://www.annals.in/text.asp?2011/14/2/79/81559
India is a country with more than a billion population and a crude birth rate of 27.2/1000 population. This would amount to about 28 million live births every year. Going by an incidence of congenital heart disease (CHD) of 8/1000 live births, we could expect about 180,000 children born with an abnormal heart every year.  Of these, nearly 60,000-90,000 suffer from critical CHD requiring early intervention.
The total number of pediatric cardiac surgeries performed in 2004 was less than 2500  In the year 2004, there were only 14 cardiac centers in the country scattered primarily in the capital or the southern part of the country. There were just about a dozen established pediatric cardiac surgeons in the country.
Many of the pediatric cardiac programs in the country are still "supported" by the adult cardiac program. This is primarily to "offset" the economically unviable pediatric program. The pediatric cardiac surgical program is rendered unviable due to economically weaker young couple at the start of their careers not able to afford the cost of the surgery and lack of governmental support. As a result, the specialty remained a "service" by the healthcare delivery systems to the society rather than remunerative. On the other hand, large adult cardiac units consider having a pediatric cardiac program as a mere "status" symbol, in order to claim that their facility is indeed a complete cardiac surgical unit.
Comprehensive pediatric health care that includes prenatal diagnosis, neonatal and infant surgery, and catheter interventions can only be provided in sophisticated tertiary corporate sector hospitals. Governmental institutions with their limitations of infrastructure, equipments and specialized support systems required cannot afford such facilities in large numbers. Perhaps, realizing their inadequacy, many of the states, especially in the southern part of the country, have chosen to support such patients through insurance schemes to facilitate surgeries at tertiary referral private hospitals. There has been an overwhelming response to this initiative and has resulted in a sudden growth in the number of small and large cardiac centers throughout the south. In addition, with growing awareness among pediatricians, a greater number of neonates are being diagnosed with CHD early and referred to centers offering help to those.  The emergence of nuclear families in the recent years has increased the value of babies unlike earlier days, and the parents who can afford better facilities are now eager to do everything possible to get their offsprings well. All these factors have resulted in an increase in pediatric cardiac surgical numbers in the last 5 years.
Training in Pediatric Cardiac Surgery
With just a handful of centers doing significant numbers in pediatric cardiac surgery, most trainee cardiac surgeons completing their cardiac surgery program have limited exposure to the subspecialty.  Thus, the interested among them find it compelling to spend a few years in busy centers overseas to improve their skills and knowledge. In order to improve the end product, a change in "attitude" of the pediatric surgeons toward providing structured training programs may become necessary. Adequate exposure to operative procedures is the least that can be expected from a teacher.  Despite the flawed training program, the long hours of work on high-risk patients, prolonged training required, modest remuneration and at times uncertain future, it is laudable that many young cardiac surgeons have taken up pediatric cardiac surgery as their career profession in recent years. 
New Drugs and Equipment
New drugs and equipment are now available and these have improved the outcome in the intensive care unit (ICU). The availability of milrinone, inhaled nitric oxide and sildenaphil has made life easier for the cardiac surgical team members in the operating room (OR) and ICU. Modified and conventional ultrafiltration has reduced the number of children being transferred out of OR to ICU with an "open chest". Mechanical ventilators now are more sophisticated with facilities that can support the infant's ventilation for prolonged periods. Ventilator strategies that optimize right ventricular hemodynamics are now well established. Perhaps the most important determinant in the improved outcome is the availability of the transesophageal echocardiography (TEE) in the OR. Perioperative TEE has made a significant impact on surgical and medical decision making in the OR and is now considered as an essential monitoring in the OR. With the availability of micromultiplane TEE probes, almost every neonate and infant can be assessed after emergence from CPB for assessing the completeness of the surgical correction. Hopefully, in the near future, three-dimensional ECHO would be a reality in the OR, and in the author's opinion, it might make a significant difference in the way postoperative pediatric patients are assessed and managed.
The availability of high-quality echocardiogram has significantly reduced the number of children requiring diagnostic cardiac catheterization procedures. Cardiac magnetic resonance imaging (CMRI) can noninvasively delineate the structure and function of the heart as well as quantify the flows and gradients across various structures.  CMRI can be very useful in evaluation of complex congenital cardiac lesions. Although CMRI may be useful for preoperative delineation of complex anatomy, in the postoperative period, cardiac catheterization still has a major role in the early diagnosis of ambiguous situations. However, cardiac catheterization should be done early for diagnostic dilemmas in the postoperative period. Hybrid procedures combining the skills of the cardiac surgeon and the pediatric cardiologists are an emerging field where the cardiac anesthesiologists play a major role.
Cost Containment in Pediatric Cardiac Surgery
As most pediatric cardiac units in India still continue to be "subsidized" , cost containment continues to play an important role in pediatric cardiac program. Some of these policies may not sound ideal or match up to Western standards. Sharing of facilities with adult cardiac surgery program and reuse of catheters for cardiac intervention or catheterization procedures are some examples of measures aimed toward cost containment. For example, the Ross procedure is a significant cost-saving surgery as it avoids the use of costly conduits and reduces requirements of anticoagulation; also, the valve has potential for growth and reduces the need for re-operations. Multitasking by pediatric cardiologists and cardiac anesthesiologists as echocardiographer, interventional cardiologists or intensivist can lead to cost savings.
Emerging Role of Anesthesiologists
From the position of a mute spectator standing at the head end of the child (who was not even allowed to place central lines in infants in the earlier days), the cardiac anesthesiologists today may be considered to be on equal terms with the surgeon in terms of responsibility and status. Anesthetic techniques have evolved to an extent where "fast tracking" in pediatric cardiac surgery is a reality.  Today, the pediatric cardiac anesthesiologist can take on several roles in the OR and in the ICU. They coordinate with the perfusionist during deep hypothermic circulatory arrest, hypothermic low flow bypass and for pH stat blood gas management during CPB. Anesthesiologists have also turned to managing the ICU and become pediatric cardiac intensivists. Their knowledge of postoperative pathophysiology, ionotropes and critical care makes them ideal physicians to take up this responsibility.
Perhaps the greatest challenge that the anesthesiologist has taken up and conquered is the use of echocardiogram in the OR. Although there is much controversy as to who should be doing these procedures in OR, the anesthesiologist who is dedicated to pediatric cardiac surgery is as good as any pediatric cardiologist in assessing the repair at the end of surgery. Their close professional association with the cardiac surgeon and actual visualization of the anatomy makes them more comfortable in evaluation of the postoperative echocardiogram.
The future of pediatric cardiac surgery indeed looks bright. Neonatal cardiac surgery is a common sight, at least in major cardiac centers. The arterial switch operation which is considered as a sort of "gold standard" in neonatal care is being done at many Indian centers, with a mortality <5%. 
Surgeries which were considered rare earlier are now more frequent. The first successful Norwood procedure was done last year. Norwood procedure is considered by many as the ultimate challenge to the pediatric cardiac team. Balancing systemic and pulmonary blood flow through subtle ventilator maneuvers, ionotropes and vasopressors can be very taxing to the intensive care team and requires the cohesive effort from an entire team. Initiation of total circulatory arrest for surgical repairs which was commonly practiced earlier to improve the visibility of the cardiac structures during surgery has gradually waned and has been replaced with the technique of deep hypothermia with low flow bypass.  Most centers are now attempting complete repair rather than palliative procedures at birth. Devices for trans-catheter techniques have become more miniaturized with sophisticated designs. Hybrid procedures are increasing in numbers.
Realizing the importance of specific training in the field of pediatric cardiology, a structured training program was initiated by the National Board of Education, New Delhi, in Pediatric Cardiology (Fellowship). The Indian Association of Cardiovascular and Thoracic Anaesthesiolgists (IACTA) laudably started a workshop in in association with Indian Association of Echocardiography. A Fellowship in TEE is also awarded by the IACTA. Realizing the importance of pediatric cardiac surgery in the country, the Medical Council of India is starting post doctoral courses in Pediatric Cardiology, in Cardiac Anesthesia and Mch in Pediatric Cardiac Surgery.
The success of a pediatric cardiac surgery program is dependent on the development of a cohesive team of individuals comprising the pediatric cardiologist, the cardiac surgeon, the pediatric cardiac anesthesiologist, perfusionists, nurses and respiratory therapists. Challenges for the future include development of independent pediatric cardiac surgical programs, further development of hybrid procedures and development of innovative indigenous technology which can reduce the cost of pediatric cardiac programs. There definitely is light at the end of the tunnel.
Finally, as a cardiac anesthesiologist, the question that naturally comes to the author's mind is, "Is it time for the society (IACTA) to recommend the formation of a subspecialty in pediatric cardiac anesthesia"?
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