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  • 1. C O N G E N I T A L C A R D I O L O G Y T O D A Y News and Information for Pediatric and Congenital Cardiovascular Physicians and SurgeonsVol. 5 / Issue 7 WWW .C ONGENITAL C ARDIOLOGY T ODAY . COMJuly 2007North American Edition L.I N K E D B Y A C O M M O N P U R P O S E : G L O B A L . INSIDE THIS ISSUE E F F O R T S F O R I M P R OV I N G P E D I AT R I C H E A R T Linked by a Common H E A LT H : Purpose: Global Efforts for Improving Pediatric Heart Health: A Report by A REPORT BY CHILDRENS HEARTLINK Childrens HeartLink by Bistra Zheleva, International Programs Coordinator, By Bistra Zheleva, International Programs to. We have tried in this second publication to Childrens HeartLink ~Page 1 Coordinator, Childrens HeartLink again gather some of the latest thinking on pediatric heart disease and the challenges in Highlights From the Western Society of Pediatric addressing it in underserved regions of the world. Cardiology Annual Meeting Childrens HeartLink is an international non- by Paul D. Grossfeld, MD The first section of the report discusses fac- governmental organization whose mission is ~Page 10 tors in treatment and detection of congenital to support cardiac centers in developing heart disease in the developing world. The countries to enhance and expand sustain- second is a shorter discussion of acquired able pediatric cardiac programs so more heart disease in children, spotlighting two children have the opportunity to receive rheumatic heart disease prevention projects, quality treatment for congenital and acquired one in India and one in the Pacific Island of heart disease in their own countries. Fiji and a Chagas disease prevention project In 2005 we published the first edition of what in Ecuador. There is a discussion of the rele- we envisioned to be a series of reports on vance of the United Nations Millennium De- the state of pediatric cardiac services in the velopment Goals to children’s heart disease developing world. The 2005 Children’s in the developing world, as well as one about HeartLink report, “To Save a Child,” gave an the effect the health worker migration crisis overview of acquired and congenital heart has on pediatric cardiac care in the develop- disease and the impact these diseases have ing world. The last section discusses the on children in the developing world. This results from a web survey conducted to ex- CONGENITAL CARDIOLOGY TODAY year we are publishing the second report in plore the views of practitioners in the field of which we offer a more in-depth look at con- pediatric cardiac care concerning the chal- Editorial and Subscription Offices: 16 Cove Road, Ste. 200 genital heart disease, and in particular, the lenges in the successful treatment, detection Westerly, RI 02891 USA and prevention of pediatric cardiac disease. factors that make its diagnosis and treatment Corporate Offices: so difficult outside of the developed world. 9008 Copenhaver Dr., Ste. M For the purposes of this article we will focus Potomac, MD 20854 USA on our findings on congenital heart disease, www.CongenitalCardiologyToday.com As was noted in the first publication, the needs of children with heart disease in the developing the web survey findings, and the health www.CHDVideo.com world are both understudied and un-responded workers migration crisis. © 2007 by Congenital Cardiology Today (ISSN 1554-7787-print; ISSN 1554-0499- online). Published monthly. All rights reserved. Congenital Cardiology pro- vides timely news and information for pediatric and congenital cardiologists. Statements or opinions expressed in Congenital Cardiology Today reflect the views of the authors and sponsors, and are not necessarily the views of Congenital Cardiology Today. See Recruitment Ads on pages: 4, 5, 7, 11, 12, 13, 14
  • 2. CONGENITAL CARDIOLOGY TODAY 3 JULY 2007 care center per 1.4 million people world- wide. B. Few Facilities to Treat Pediatric Heart Disease While there are few general cardiac care facilities (mostly in urban areas), even fewer have the capacity to treat children, particularly young children and infants, with heart disease. When two thirds of the world’s population has no access to advanced cardiac care for adults, access to cardiac care is even scarcer for children and infants with CHD. C. Shortage of Trained Pediatric Cardiac Specialists Compounding the lack of access to car- diac facilities outside of the developed world is the fact that very few doctors orFigure 1: Number of open-heart operations per million people in selected regions. medical specialists have any training inCongenital Heart Disease treating pediatric heart disease, particu- the world’s population. Worldwide, there larly in very small children or neonates.In 2001, childhood deaths from congeni- are over 4,000 medical facilities specifi- There are limited opportunities for train-tal abnormalities in developed countries, cally equipped to support cardiac sur- ing in pediatric cardiac care outside ofwhile still 20% of total childhood mortal- gery, and more than 6,000 cardiotho- the advanced medical centers that spe-ity, totaled approximately 20,000 chil- racic surgeons conduct between 2 and cialize in cardiac care for children. Of-dren. However, congenital abnormalities 2.5 million open heart surgical opera- ten, pediatricians in most parts of thein low-income countries, while only 3.7% tions per year. However, the vast major- developing world are not familiar withof total mortality, took the lives of over ity of these operations occur in the de- the presentation of severe CHD at birth440,000 children. Even though congeni- veloped world (see Figure 1) and these or early infancy, so only a small fractiontal heart diseases account for only some heart centers are predominately located of the heart defects present at birth areof the congenital anomalies in these in the West. At most, they serve perhaps detected and the early signs of CHDestimates, the overall pattern of child- only seven percent of the world’s popu- may be missed.hood mortality undoubtedly holds when lation. In addition, approximately oneconsidering only congenital heart lesions facility capable of open-heart surgery D. Prohibitive Expense of Pediatricin high-income versus low-income coun- exists for every 120,000 people in North Cardiac Treatmenttries: more children die of congenital America, and one center for every mil- While there are pockets of affluence inheart disease in low-income countries lion people in Europe and Australia; almost all countries that can afford high-than in more developed countries. however, there is only one center per 16 quality health care, the vast majority of million people in Asia. Africa is the most people in the developing world cannotFactors Preventing Diagnosis and underserved by cardiac care facilities: afford to pay for surgery and hospitalTreatment of Congenital Heart on average, there is only one center per fees if their children are born with heartDisease in the Developing World 33 million Africans with the facilities, disease. In a world in which one in fiveA. Lack of Access to Cardiac Care equipment, and staff capable of support- people subsist on less than 1 US dollar ing open-heart operations and advanced a day, advanced medical treatments forA basic obstacle to treating pediatric cardiac care. Combined, these statistics CHD are simply out of reach for the vastcardiac diseases is that cardiac treat- indicate that there is only one cardiac majority of the world’s people.ment is simply inaccessible to most of For information, please call 1-800-BRAUN2 (227-2862) w ww .b b rau nu sa. co m Working Together to Develop a Better Tomorrow w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 3. JULY 2007 4 CONGENITAL CARDIOLOGY TODAY E. Lack of Basic Health Care nations. The shortage of health care Pediatric Cardiology workers is a worldwide issue, with an The inability of most of the world’s estimated shortfall of over 4.3 million population to receive cardiac treatment workers globally. Sub-Saharan Africa has is merely emblematic of a much larger We are looking for a non-invasive the most severe shortage, with only 3% problem. Over 80% of modern health Pediatric Cardiologist for the of the world’s health care personnel. This care is performed in the countries of Orlando Florida area. Established shortfall is particularly serious, as this North America, Western Europe, and in1994, we serve the Central region has 11% of the world’s population the developed countries of Asia. Be- Florida area with outpatient clinics, and 24% of the world disease burden. cause the Western world represents inpatient consults, fetal echo’s and only nine percent of the total world’s H. Lack of Investment in Public Health cardiac catheterizations. population, most of the world’s people Sectors Competitive salary and benefits, are left with little or no access to ad- Under-investment in health care in devel- including paid health, disability, vanced medical treatments. Treatment oping or underdeveloped countries has malpractice insurance and CME of CHD requires expensive infrastruc- led to poorly-developed health infrastruc- allowances. ture that most government health-care tures that do not offer enough jobs to systems cannot afford and many coun- Come enjoy Florida with its beauti- absorb the number of available health tries often choose to devote the few ful beaches, lakes, great outdoor care workers. While the US spends 5,274 resources they have to more readily activities, and many cultural and US dollars per person, India, with a popu- treatable pediatric health problems. sporting events. The Orlando area lation of over 1 billion, spends only 96 US boasts ‘A’ schools and a prominent F. Shortage of Health Care Workers dollars per person or 4.4% of its total local University. government spending, on health care. Not only are most of the world’s surgeons For a glimpse into our practice visit and cardiac specialists concentrated in I. Competing Priorities in Health Care our website at: the Westernized world, most of the Treatment of pediatric cardiac diseases www.carson-ap pleton.com world’s doctors and medical personnel requires an expensive health infrastruc- are predominately found in more industri- ture and specially trained staff, which alized countries. According to the World most government-sponsored health insti- Please contact: Thomas Carson, Health Organization, the United States tutions in developing countries are unable M.D. for more details on this great (US) and the United Kingdom (UK), have to afford. Over time, the lack of invest- opportunity via email at: an average of 21.3 doctors and 27.9 doc- ment in health care has created a situa- reddv et@aol.com or our office at tors per 10,000 citizens, respectively. In tion in which poorly staffed facilities with 407-902-2866. comparison, India has 5.9 doctors per few resources are often unable to provide 10,000 people (Southeast Asia has 5.0 Submit your CV via fax to anything more than primary health care. per 10,000), and Kenya has only 1.3 doc- The existing public health systems in 407-902-2585. tors per 10,000 people (Africa has an many of these underdeveloped countries average of 1.8 per 10,000 citizens). In are already struggling to deal with wide- addition, while the US and UK have 125.1 spread malnutrition and outbreaks of and 75.2 health care workers per 10,000, common communicable diseases, such India, and Kenya have only 13.8 and as malaria and tuberculosis and many 10.3, respectively. health care systems are stretched be- G. Migration of Health Care Workers to yond their limits as they deal with the Developed Countries AIDS epidemic. “Brain drain,” the persistent loss of medi- International Strategies to Treat cal workers to more developed countries, Congenital Heart Disease is a major issue for many countries that Because so many countries’ medical sys- cannot compete with the wages, opportu- tems are unable to afford treatment for nities, and advanced facilities of richer W w ww. pi csym posi um . com w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 4. CONGENITAL CARDIOLOGY TODAY 5 JULY 2007children with congenital heart diseases, ence to advocate together for greaterthe international community often steps in investment in health care for the de-to offer treatment for these children and veloping world. Their advocacy caninfants. Numerous nonprofit and non- help keep the issue of poor childrengovernmental organizations, as well as with pediatric heart disease on the Asheville Cardiology Associateshospitals and institutions, work with facili- international community’s agenda. Recruiting BC/BE Pediatricties in developing countries to provide Only if congenital heart disease Non-Invasive Cardiologistinterventional techniques and cardiac comes to the attention of the policy-operations available for children. Many of making international community will Known for clinical excellence, Asheville Cardi-these organizations have been working in this issue receive enough attention to ology Associates is seeking a third pediatricother countries for years, while others increase foreign assistance for inter- cardiologist with advanced skills in both inpa-have begun their partnerships with over- national health in general, and for tient and outpatient arenas. Those with exper-seas hospitals more recently. The ways treatment of CHD in particular. tise in new modality imaging, adult-congenitalin which these organizations offer treat- cardiology, or interest in exercise physiology Managing the Health Worker Migration or electrophysiology, are encouraged to con-ment has also changed over the years Crisis tact us. Development of new programs withinand modes of delivery for treatment have the practice is encouraged.evolved as costs of health care and trans- In order for a young heart patient to re-portation change. The four major strate- ceive top-quality medical assistance, she The Peds Division has a complex patient base, with active fetal and adult-congenitalgies employed by international organiza- needs an entire medical team of trained programs. Outpatient practice encounterstions to treat children with pediatric heart professionals providing her care. When ~3,000 clinic visits, ~2,000 echoes per year,diseases in developing countries are: medical teams lose and cannot replace with a growth rate of 5-7% annually. Inpatient experienced staff in a timely manner, that is performed at Mission Hospitals, consis-1. Transporting children with heart dis- tently rated in Top 100 Heart Hospitals in last patient’s cardiac care is compromised. In ease to other countries for treatment six years. Its new children’s outpatient facility the developing world, where often the hos- is well represented by subspecialists and2. Sending surgical teams to develop- pitals are under-resourced and staff is poorly ancillary services. ing countries to carry out treatment paid and works long hours, maintaining qual- ity personnel is even more difficult. Asheville is a beautiful city of 70,000 (county3. Training local doctors and staff in has 200,000 plus MSA of 391,000). Located developed countries According to the WHO, there are 57 coun- in the Blue Ridge Mts. of North Carolina, it tries with health care systems on the verge offers excellent public and private schools,4. Creating regional centers for treat- universities and colleges. Amenities such as of collapse due to staff shortages. More ment of pediatric heart disease great restaurants, arts, music, & theater put it than four million additional health workers on the list of best places to live in many publi-In addition to continuing their current ac- are needed, in these countries, to fill per- cations. A mild four season climate givestivities, the report’s two main recommen- sonnel gaps. More than half of these addi- opportunities for mountain biking, hiking,dations for international organizations tional workers are needed in Sub-Saharan camping, fishing, golf, whitewater activitiesinvolved in charitable assistance for chil- Africa, an area of the world that shoulders and skiing.dren with heart disease are: 24% of the world’s disease burden, 11% of the world’s population and only 3% of the1. Coordinated efforts between organi- world’s health workers. Visit our website, www.avlcard.com zations, individuals, facilities, and part- for more information. ner hospitals around the world to con- Research shows there are currently four solidate their efforts. methods for managing health workers All inquiries remain confidential. migration utilized by the international com- Please send CV to:2. Advocacy for increased international munity: assistance. Organizations that treat James J. McGovern, MD, FACC congenital heart disease can poten- Retaining Health Workers Fax: (828) 277-6350 tially make a greater long-term im- Email: jimm@avlcard.com Although low salary is an impetus for pact on addressing CHD in develop- nurses and other health professionals to ing countries if they use their influ- w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 5. JULY 2007 6 CONGENITAL CARDIOLOGY TODAY the local pool of qualified health profes- sionals, the pressure to recruit workers from developing countries will decrease. Restraining Health Workers from Leaving One solution to discourage unwanted migration is bonding. Bonding asks those that have benefited from govern- ment financial assistance – for example, physicians that have received govern- ment loans or grants for their training – to pay back their cost of training if they are unable or unwilling to serve a minimumFigure 2: What do you consider the greatest frustration/challenge when you work to treat children with number of years in their own country.heart disease in developing countries? - Children’s Heartlink Web Survey. Abstaining from Unethical Recruitment The UK has been a leader in instituting codes of conduct regarding the ethical recruitment of health professionals from medically underserved countries. Start- ing in 1999, the UK’s Department of Health has discouraged its National Health Service (NHS) from directly re- cruiting health professionals from South Africa and India. Since then, the NHS has included additional nations on the list. Ultimately, the strength of the code of conduct rests upon its enforcement which, according to many developing countries, is weak. Pediatric Cardiac Survey Results In preparation for this publication, Chil- drens HeartLink conducted a web sur-Figure 3: What do you think the International donor community ( NGOs, government, intergovermental vey reaching out to the pediatric cardiacorganizations, community health organizations, etc.) can do to better treat and prevent pediatric heart community to identify the biggest obsta-disease in developing countries? - Children’s Heartlink Web Survey. cles in effectively addressing the burdenconsider working abroad, offering health Training Local Professionals Inside the of CHD in the developing world. Cardiacworkers a clear job description, feed- Country surgeons, cardiologists, and othersback on performance, fair supervision working in the field of pediatric cardiac For years, countries such as the US, UK,and on-the-job training has proven to care from over 90 countries were invited Canada and Australia have relied uponimprove job satisfaction and, in turn, to participate by email. foreign countries to train up to a quarter ofperformance as well. While more pay the physicians that their nations need. When asked to list the biggest frustra-would be welcome by many health Efforts are now underway, within de- tion/challenge in working to treat chil-workers, simply receiving payment on veloped nations, to increase the num- dren with heart disease in the develop-time and in full builds confidence be- ber of locally trained health profes- ing countries, most responses fell intotween worker and institution. sionals. The hope is that by increasing four general categories (see Figure 2): In support of infants, children and teens with pediatric cardiomyopathy CHILDREN’S CARDIOMYOPATHY FOUNDATION P.O. Box 547, Tenafly NJ 07670 Tel: 201-227-8852 info@childrenscardiomyopathy.org www.childrenscardiomyopathy.org “A Cause For Today.... A Cure For Tomorrow” w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 6. CONGENITAL CARDIOLOGY TODAY 7 JULY 20071. Lack of general health infrastructure including, lack of trained medical personnel, lack of supplies and equipment, lack of medicines and other supplies;2. Lack of institutional and financial support;3. Prohibitive cost of treatment; and4. Late referrals and inadequate pre- and post-operative care.Another big frustration appeared to be the patients’ ability to payfor their treatment, which can be directly related to poverty andpoor health care support in the developing world. Yet again, itbrings back the issues of health system and infrastructure andgovernment support for health care.The findings in this survey suggested that children’s heart dis-ease remains a largely unmet challenge in the developing world.Among the factors that contribute to it, lack of funding for treat- Adult Congenital Heart Disease Specialistment and supplies and equipment top the list. However, the cost The Division of Pediatric Cardiology of Sanger Clinicof the treatment and the costs of investing in a tertiary health and Levine Children’s Hospital in Charlotte, NC is re-program suggest that it can be prohibitive for many hospitals to cruiting an adult congenital heart disease (ACHD) spe-even start developing pediatric cardiac centers. Many may consider cialist to help direct a busy and growing service. Thethe challenge of primary care needs to take precedence over the successful applicant should be board certified/eligible indevelopment of tertiary programs such as pediatric cardiac care. pediatric cardiology and preferably have completed a specialty fellowship in ACHD. The successful applicantAnother issue that surfaced was the lack of trained personnel, as will join a rapidly growing practice of seven pediatricdiscussed earlier. Shortage of trained personnel affects the qual- cardiologists and two cardio thoracic surgeons. Theity and quantity of health services and directly affects pediatriccardiac programs in many developing countries. Many respon- Sanger Clinic also has a large and busy adult cardiol- ogy practice with several adult cardiologists involved indents mentioned that losing trained personnel to hospitals in thedeveloped world has been a significant challenge in providing the ACHD service. The candidate should have excel- lent interpersonal skills and ideally an interest/expertisesustainable, quality pediatric cardiac care. in imaging, particularly magnetic resonance imaging.The respondents were also asked to describe programs thathave been successful in treating and preventing pediatric heart dis- The Sanger Clinic is the largest congenital heart center in North Carolina performing three hundred surgeriesease in the developing world. The most often cited components of asuccessful program were commitment to pediatric cardiac care, and three hundred cardiac catheterizations per year. The practice is affiliated with Carolinas Healthcare Sys-good communication among the cardiac team members, and tem, the fourth largest hospital authority in the country,stable financial support from a variety of sources. but operates much like a private practice with very com-The last question of the survey addressed suggestions for the petitive compensation and benefits. The hospital au-international community involvement in addressing the treatment thority is poised to open Levine Children’s Hospital inand prevention of children’s heart disease in the developing the fall of 2007, an eighty-five million dollar state-of-the-world. The responses could be grouped in the following general art facility. Interested applicants should fax or e-mailcategories (see Figure 3): their CVs to Dr. Stern.1. Better training and education for cardiac professionals Herbert J. Stern, MD, FACC Director, Division of Pediatric Cardiology2. Lack of funding and resources Sanger Clinic and Carolinas Heart Institute3. Better coordination of efforts to support pediatric cardiac h s t e r n@ s a nge r - c l i ni c . c om care Fax# 704-543-0018 Evolving Concepts in Management of Complex Congenital Heart Disease A CME Course sponsored by Rady Childrens Hospital and University of California, San Diego Course Moderators: John Lamberti, MD; John Moore, MD; and Anthony Chang, MD Faculty consists of 20 of the finest lecturers in the field Attend the conference in San Diego, October 5-6, 2007 For a brochure: www.rchd.org or call Donna Salas at (858) 966-4072; (858) 966-8587 FAX CMA accredited - 13.75 AMA PRA Category TM 1 credits w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 7. JULY 2007 8 CONGENITAL CARDIOLOGY TODAY4. Better institutional support – work with and better direct their resources and skills Editorial Advisory Committee: Dr. Philipp national and local governments to where they are most needed. The inter- Bonhoeffer, Great Ormond Street Hospital national community of donor and recipient for Children; Dr. Abdon Castro, El HospitalAll four categories can be viewed as inter- governments, nongovernmental organiza- Nacional de Niños; Dr. John Hewitson, Reddependent and most respondents touched tions, and international agencies must work Cross War Memorial Children’s Hospital; Dr.on at least one of them. together to address the root causes of poor Edward Kaplan, University Of Minnesota; Dr.The rates of congenital heart disease are health care in developing countries. Joseph Kiser; Dr. Krishna Kumar, AIMSnot significantly different between develop- Hospital; Dr. Edward Malec, University Chil- Congenital and acquired heart diseasesing and developed countries. However, the drens Hospital of Cracow; Dr. Shanthi affect millions of children around the world,fact it does not get diagnosed or treated in Mendis, World Health Organization; Dr. but the majority of them will never receivethe developing world as early as in devel- James Moller, University of Minnesota; Dr. the treatment they need. These childrenoped countries creates a backlog of un- Mohan Reddy, Stanford University; Dr. Kun have no access to treatment, not only be-treated heart disease cases. In addition, Sun, Shanghai Childrens Medical Center; cause of a lack of access to cardiac care, butacquired heart problems such as rheumatic Dr. Bill Williams, The Hospital For Sick Chil- also because of a general lack of socio-heart disease, almost eradicated in the de- dren; and Dr. Qing-Yu Wu, First Hospital of economic development and health care in-veloped world, still is very prevalent in some Tsinghua University. vestment in their countries. These factorsdeveloping countries. Another dynamic con- work together to create poor public health Report Authors: Ms. Karen Baumgaertner;tributing to this issue is the disproportionate systems, a lack of medical training, and a Mr. John Cushing, Childrens HeartLink; Dr.attention paid to adult cardiac disease as shortage of health care workers that prevent Mario Grijalva, Ohio University Tropical Dis-opposed to pediatric. children from receiving corrective treatment. ease Institute; Dr. Krishna Kumar, AmritaConclusions Pediatric heart disease is a serious issue, Institute of Medical Sciences; Ms. Karisha but it is not a problem created in a vacuum. Kuypers; contributors from the World HeartWhile children’s heart diseases are only one Only when it is placed within the global con- Federation – Dr. Jonathan Carapetis,of a myriad of health problems facing poor text of economic and health care disparities Menzies School of Health Research, Ms.and underdeveloped countries, they are will the international community be able to Samantha Colquhoun, Ms. Alice Grainger-intrinsically linked to many of the other health make real strides toward reducing the Gasser, Ms. Sara Noonan; Dr. Don Watson,problems in the developing world. Interna- prevalence of acquired pediatric heart World Heart Foundation and Ms. Bistrational organizations have a unique position disease and improving the diagnosis and Zheleva, Childrens HeartLink.when it comes to dealing with major issues, management of congenital heart disease.whether they are of a medical nature or not. To receive a copy of the full report and full Only when we improve health care for entireNonprofit organizations can treat problems list of references please go to regions of the world will we ensure that all ofat a local level, and may have a more objec- www.childrensheartlink.org or contact the world’s children with heart disease cantive position than many governments would the author. access and receive the medical care theyon the issues that surround problems and need to live normal, healthy lives. ~CCT~prevent finding easy solutions. Organizationscan also act on a global level, and can use For the last 40 years Childrens HeartLinktheir influence and their high profile within has been dedicated to the mobilization of global resources to prevent, treat and cure Bistra Zhelevatheir home communities to advocate for children’s heart disease. We hope that this International Programs Coordinatorgreater attention and assistance to address report contributes to the knowledge and Childrens HeartLinkproblems. They must begin to advocate for 5075 Arcadia Avenueincreased foreign investment in both tertiary understanding of pediatric heart disease and the efforts to offer greater access to its pre- Minneapolis, MN 55436 USAmedical centers and health care infrastruc-ture, as well as for the creation of national vention and treatment in underserved re- gions of the world. With this report, we hope Toll Free: 888.928.6678health care policies that include pediatric to further the knowledge of the field and Phone: 952.928.4860 ext. 11heart disease management. Organizations come closer to preventing and curing car- Fax: 952.928.4859can also increase their effectiveness byworking with other nonprofits or institutions to diac heart disease for all of the world’s bistra@childrensheartlink.orgimprove their outreach, increase their efforts, children. w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 8. WATCH SELECTED LIVE CASES on the web www.CHDVideo.com Live Cases Produced and Provided byInternational Symposium on the Hybrid Approach to Congenital Heart Disease (ISHAC)Pediatric and Adult Interventional Therapies for Congenital and Valvular Disease (PICS)The International Workshop on Interventional Pediatric Cardiology (WorkshopIPC)If you would like to be notified when other videos in the series are available, please send an email to: LiveCases@CHDVideo.com Video Live Cases Hosted by Congenital Cardiology Today
  • 9. JULY 2007 10 CONGENITAL CARDIOLOGY TODAYH I G H L I G H T S F R O M T H E W E S T E R N S O C I E T Y O F P E D I AT R I CC A R D I O LO G Y A N N UA L M E E T I N GBy Paul D. Grossfeld, MD Michael Ciccolo (U. of Nevada), who level (ectopic atrial, chaotic atrial, and discussed surgical management of AV node re-entrant), AV node LVOT obstructive lesions. These le- (congenital junctional ectopic tachycar-The Western Society of Pediatric Cardiol- sions included valvar, supravalvar, dia), and ventricular. He mentioned thatogy held its annual meeting on April 20-22, subaortic, and multiple levels. Dr. Cic- congenital JET has been reported to2007 at the Four Seasons Hotel in Las colo described a variety of surgical tech- have an overall mortality of 35%. HeVegas, Nevada. One hundred ten mem- niques to address these lesions, includ- also discussed permanent junctionalbers from 12 states attended. Twenty- ing several variants of the Konno proce- reciprocating tachycardia, which onlyfour invited speakers gave presentations dure. accounts for 1% of pediatric SVT, but ison a diverse range of topics. notoriously difficult to manage medically. The next session was on electrophysiol-The meeting began with a historical ac- Finally, he discussed ventricular tachy- ogy. The first talk was by Dr. Ian Lawcount by Dr. William Evans (U. of Ne- cardias, for which he reserves medical (U. of Nevada) on newborns with Longvada), the meeting’s host and organizer, treatment only for those with symptoms. QT syndrome. After providing an inter-on two women pioneers in pediatric car- He recommended ablation procedures esting historical account of LQTS, hediology: Dr. Maude Abbott and Dr. Helen only for those patients with ventricular described how risk stratification corre-Taussig. The first session, Surgery I, tachycardias that are refractory to medi- lates with QTc length. He also dis-was led off by Dr. James Tweddell (U. of cal management. Overall, outcomes are cussed the challenges of calculatingWisconsin). Dr. Tweddell described his favorable, particularly in patients with a reproducibly the QTc, treatments, andten year experience with infants with structurally normal heart. genetic testing. He cited recent studiesHLHS. He emphasized the importance which indicate that about 10% of all The evening session was highlighted byof monitoring SVO2 as an indicator of SIDS cases are likely to be due to undi- a fascinating discussion and debate be-SVR. He reported 93% survival on their agnosed neonatal LQTS. Lastly, he tween Dr. Frank Hanley (Stanford) andseries of 116 consecutive patients. He discussed the possibility of performing Dr. Jane Somerville (Royal Bromptonalso reported that SVO2< 40% corre- screening EKGs on infants to detect Hospital, London), on the managementlated with poorer neurodevelopmental LQTS. The data suggest that, in par- of patients with TOF/PA/MAPCAs. Theoutcomes, as indicated by visual motor ticular, due to the high number of false spirited discussion focused on whetherimpairments. Lastly, he described their positives, screening EKGs are probably any or all patients should be operatedsuccess in systematic home monitoring, not cost-effective at this time. The next on at all (Dr. Somerville), versus earlywhich has been associated with an inter- talk was by Dr. David Bradley (U. of surgical intervention on most patientsstage one/two mortality decrease from Utah) on newborns with preexcitation. (Dr. Hanley). Dr. Somerville cited his-15 to 3%. The next presentation was by Dr. Bradley discussed the anatomy, epi- torical data from her institution, whichDr. Howard Rosenfeld (Oakland), who demiology, and association with con- demonstrates 50% survival at age 35discussed imaging modalities for as- genital heart defects. He then dis- years in patients that did not have sur-sessing defects of the left ventricular cussed the natural history, and de- gery. Dr. Hanley presented his surgicaloutflow tract. He showed examples of scribed the relatively low risk of sudden outcomes: over a 15 year period, 358transthoracic and transesophageal death, especially in younger children. patients were operated on with 5.9%echocardiography, along with MRI and Lastly, he discussed management early mortality, and 7% mid-late mortal-64 slice CT for assessing SubAS, HCM, strategies, including the relative contra- ity. The ten-year actuarial survival wasintracardiac masses, AVCD with LVOT indications for using digoxin or calcium 86%. Both agreed that the jury is stillobstruction, aortic valve defects channel blockers. The last talk of the out on whether Dr. Hanley’s outcomes(including critical AS in the fetus), SVAS, session was by Dr. Mitchell Cohen (U. of will indicate that patients do better withand IAA/VSD with LVOT obstruction. Arizona) on incessant tachycardias. surgery by age 35 than those that do notThe last talk of the session was by Dr. These included those involving the atrial have surgery. Nonetheless, Dr. Somer- Healing hearts. Training minds. Bringing hope. 5075 Arcadia Avenue Minneapolis, MN 55436 U.S.A. Toll Free: 888.928.6678; Phone: 952.928.4860; Fax: 952.928.4859 w w w .c hi ld ren sh ea rt l ink .o rg w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 10. CONGENITAL CARDIOLOGY TODAY 11 JULY 2007Drs. Frank Hanley and Jane Sommerville (left to right).ville most eloquently acknowledged that if Dr. Hanley were thesurgeon at her institution, she would send all of her TOF/PAMAPCAS to him. Well said!The second day consisted of four sessions: Pulmonary hyper-tension, Molecular mechanisms to clinical care, Surgery II,and then a fellows’ session. The first talk of the morning ses-sion was by Dr. Jacqueline Szmuszkovicz (USC). She pro-vided an outstanding overview of the most current medicaltherapies for pulmonary arterial hypertension. These includethose affecting the endothelin pathway (endothelin receptorantagonists), as well as medications affecting the nitric oxidepathway, including phosphodiesterase 5 inhibitors, and finally,prostacyclin. She stated that chronic prostacyclin can benefitthose deemed to be medical non-responders. Finally, shementioned that studies involving combination therapies arecurrently underway. The second lecture was by Dr. BrianReemtsen (USC), who discussed live donor lung transplant forpulmonary arterial hypertension. He stated that lung trans-plantation should not be considered the futile therapy it hasbeen in the past. At USC, 88 bilateral lung transplants havebeen performed, with a 5-year survival of 58%. Interestingly,there is virtually no difference in survival between living donorand cadaveric transplants. Dr. Reemtsen reiterated the factthat many lung transplant recipients can live a good quality oflife. The last talk of the early morning session was by Dr.Jane Somerville (Royal Brompton Hospital, London), who pro-vided a fascinating fifty-year historical account of the many For information, please call 1-800-BRAUN2 (227-2862) w ww .b b rau nu sa. co m Working Together to Develop a Better Tomorrow w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 11. JULY 2007 12 CONGENITAL CARDIOLOGY TODAY pioneering congenital heart surgeons defects and recommended that all first with whom she has interacted. degree relatives of patients with HLHS have screening echocardiograms. Attention The late morning session led off with a talk by Dr. Ian Adatia (UCSF), on Beta- Lastly, he gave an update on the genet- ics of Marfan Syndrome, and mentioned Pediatric Cardiology Naturetic peptide in congenital heart that there is a new study through the disease. First, he provided an historical Fellows account of how BNP was identified. He pediatric heart group that is testing the possibility that Losartan, an AT1 recep- then discussed how BNP levels can be tor antagonist, may prevent the develop- used to predict post-operative outcomes. ment of cardiovascular problems in Just finishing your fellowship In neonates, he cited that high post/pre these patients. and looking for a great job surgical BNP ratios are predictive of poor outcomes. He also stated that data The first talk of the third session, Sur- opportunity? indicated that BNP cannot be used to gery II, was a brief overview by Dr. predict when a patient can be weaned Masato Takahashi (CHLA) on the new off of ECMO. However, the level of BNP guidelines published electronically inWe are looking for a non-invasive in patients on ECMO during a trial off, Circulation (April 19, 2007) for the Pre-Pediatric Cardiologist (BC/BE) with compared to the pre-trial off level, was vention of Infective Endocarditis. Nextexperience in Pediatric and Fetal predictive of the need for surgery and was an interesting talk by Dr. FrancoisEchocardiography to join our death within three months of being on Lacour-Gayet (U. of Colorado), who dis-established Pediatric Cardiology ECMO. The second talk was by Dr. Amy cussed the history of the Aristotle Scor-Private Practice Group. We have Sehnert (Stanford). Dr. Sehnert provided ing System for measuring surgical out-offices located in the suburbs of a comprehensive overview of current come of patients with congenital heart genetic testing for the following disor- disease. One of the ongoing challengesa major metropolitan area in the ders/lesions: W illiams Syndrom e that he described is how surgical mor-Midwest. (Elastin), TOF/PA/MAPCAS (22q11), bidities are defined and quantified. An-This position offers the opportunity Long QT Syndrome, Preexcitation other limitation is that these statisticsto admit and manage your own (PRKAG2), Pulmonary hypertension have not predicted mortality, but only (BMPR2), Atrial septal defects (NKX2.5), evaluated performance. There are cur-patients in a large Pediatric Noonan Syndrome (PTPN11, KRAS, rently 47 participating centers fromCardiology Center with participa- SOS1), and Pompe Disease. She cited around the world. More recently, a newtion in weekly Cardiovascular a very useful website which lists all labo- score factors in mortality and morbidityConferences among Cardiac ratories worldwide that perform genetic index, which gives a so-called technicalSurgeons, Pediatric Interventionists testing: www.genetests.org. The last difficulty score. The next talk was by Dr.and Pediatric Cardiologists. talk of the session was by Dr. Paul Norman Silverman (Stanford), who gave Grossfeld (UCSD), who presented real a comprehensive presentation on how cases that demonstrated how under- echocardiography can be used to em-Attractive salary and benefits. standing the genetic basis of specific ploy a segmental approach for identifica- congenital heart defects can be trans- tion of the anatomy and physiology of lated into improved clinical care. He single ventricle patients. The last talk of described a family with multiple affected the session was by Dr. John Nigro (SaintIf you are interested, please email members with atrial septal defects, and Joseph’s Hospital, Arizona), on the man-your CV to: PC1@CCT.bz one with HLHS that has a mutation in agement of pulmonary blood flow in the NKX2.5, and how there is a subset of univentricular heart. He reviewed how, patients with these lesions that are ge- for single ventricles like tricuspid atresia, netically predisposed to the develop- HLHS, and double inlet left ventricle, ment of progressive heartblock. He also there is a balance between pulmonary discussed how 30% of siblings of pa- and systemic blood flow. This, in turn, is tients with HLHS have congenital heart determined by the relative pulmonary Share your Interesting Stories or Research in Congenital Cardiology Submit a brief summery of your proposed article to Congenital Cardiology Today at: Article@CCT.bz. The final manuscript may be between 400-3,500 words, contain pictures, graphs, charts and tables. w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 12. CONGENITAL CARDIOLOGY TODAY 13 JULY 2007 Clinical Fellowships Greenlane Paediatric & Congeni- tal Cardiac Service at Starship Children’s Hospital, Auckland District Health Board is the national provider for Paediatric Cardiology and Cardiac Surgery in New Zealand. There are two positions for one year, fixed term, Clinical Fellow- ships in Paediatric CardiologyDebate audience. commencing in December 2007 and January 2008. One of these is for a more senior trainee.and systemic vascular resistances. He jection. The second fellows’ talk was bybriefly discussed the advantages and Dr. Rabih Hamzeh (UCSD). Dr. There is provision for a seconddisadvantages of pulmonary artery Hamzeh described a new technique that year’s appointment by mutualbanding, and how early DKS can be has been developed to obtain percuta- agreement.safe for a subset of patients. He con- neous vascular access for catheteriza- Both positions offer an opportu-cluded by discussing the need for early tion when a standard approach is unsuc- nity for specialised training incontrol of pulmonary bloodflow for a cessful. The technique is a modification Paediatric Cardiology and willsuccessful Fontan outcome. of the Seldinger technique and is per- also involve clinical research formed using a targeting wire under fluo-The last session consisted of two talks within the department. roscopy. He stated that this techniqueby current fellows. The first talk, by Dr. was successful in all 14 patients in For further enquiries please con-Miwa Geiger (UCLA), discussed the which standard techniques for obtaining tact: Sally Adams onutility of monitoring B-type natriuretic access were unsuccessful, and that sallya@adhb.govt.nzpeptide levels for predicting rejection in there were no significant complications.heart transplant patients. She statedthat all patients with levels >700pg/ml The final day of the conference con-were rejecting. She stated that BNP sisted of a single session entitled Car- To apply, please visitlevels cannot distinguish between acute diac Cath Intervention and the Future. www.aucklandhealthcareers.co.nzrejection and chronic graft failure or The first talk was by Dr. Robert Boucek and submit an online applicationallograft vasculopathy. She suggested (U. of Washington). Dr. Boucek stated quoting reference number 012799that the results from her study could that there is the need for cardiac myo-help to avoid unnecessary hospital ad- cyte regeneration in the pediatric popu-missions for patients suspected of re- lation, as exemplified by a patient with Would You Like to Receive Your Issue of CONGENITAL CARDIOLOGY TODAY on your computer in a PDF file? If Yes, then simply send an email to us at ONLINE@CCT.bz w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 13. JULY 2007 14 CONGENITAL CARDIOLOGY TODAY Director of Pediatric Cardiovascular Critical Care Major Medical Center in Dallas seeks a Pediatric Cardio- vascular Critical Care Director. Preferred candidate will possess a charismatic personality, leadership attributes with evidenced experience, strong clinical skill set for a complex patient population and board certification in Pe- diatric Cardiology and Critical Care. Candidates with board certification in one discipline and solid experience in the alternate subspecialty should also apply. The in- coming Director will serve as the Medical Director of the existing 10 bed Pediatric Cardiovascular ICU and the new, state-of-the-art unit due for completion in late 2008. Additional responsibility includes coordinating a collegial collaboration with pediatric cardiology physicians/ subspecialists and nursing staff. Incoming physician will Dr. Jacqueline Szmuszkovicz’s lecture. be provided an outstanding financial package and the opportunity to advance their medical and/or research ca- reer. The Congenital Heart Surgery program performs more than 300 surgeries each year. Two thirds of the surgeries are pump cases. The program provides care to neonates (approximately 30%) and children under 2 yrs of age (approximately 70%). A team of nine pediatric intensivists and eleven pediatric cardiologists cover the congenital heart surgery unit. A dedicated 10-bed pediatric cardiovascular intensive care unit opened in 2004. Construction has begun on a newer unit with a completion date in late 2008. The program participates extensively in research initia- tives and i-Rounds, a web based informatics system al- lowing second to second tracking of clinical data and shares information with outside referring physicians. The center employs all of the latest technologies for monitor- Drs. Carl Owada, William Evans and Jane Sommerville (left to right) ing patients and performing point of care testing. The Medical Center operates a very busy research entity in HLHS who has a failing systemic right ventricle. He cited one which the Pediatric Cardiovascular Surgery Director, ac- of the greatest challenges in the stem field is to determine tively participates. what is the best population of stem cells to be used for trans- Contact plantation. He described several studies in adults in which Charles J. Humes bone marrow-derived stem cells are being transplanted into (800) 338-7107 patients who have suffered myocardial infarction. In some cases, this seems to result in an increase in left ventricular c hum es@f ox hilla ss oci ate s.com systolic function. Although these kinds of studies raise great hope for the pediatric population, many obstacles remain w ww .Co nge n ita lCa rd io log yTod a y.c om
  • 14. CONGENITAL CARDIOLOGY TODAY 15 CONGENITAL CARDIOLOGY TODAY © 2007 by Congenital Cardiology Today (ISSN 1554-7787-print; ISSN 1554-0499-online) Published monthly. All rights reserved(such as determining which stem cell strain is a much more accurate predictor Headquarterspopulation is optimal, and how to deliver of diastolic dysfunction than tissue Dop- 9008 Copenhaver Dr. Ste. M Potomac, MD 20854 USAthem to the proper location and achieve pler. He also discussed how intracar-long-lasting results). The next presenta- diac imaging can facilitate performing Publishing Management Tony Carlson, Founder & Editortion was by Dr. William Berman (New ablations in the EP laboratory. Finally, T C arls o n m d @gmail .c omMexico) on future cardiac catheterization Dr. Sahn discussed how new kinds of Richard Koulbanis, Publisher & Editor-in-Chiefprocedures. Dr. Berman described the transducers, using matrix arrays, should R ic ha r d K@C CT . b znumerous challenges for improving pal- improve our current imaging capabilities. John W. Moore, MD, MPH, Medical Editor/ Editorial Boardliative catheterization procedures, in- Real time 3D echocardiography will J Moor e@R C H SD . or gcluding the development of stents that bring about a paradigm shift and bring Jeffrey Green, Contributing Editorare bioabsorable, sequentially expand- major improvements in qualitative and Editorial Board Teiji Akagi, MDable, have decreased risk of restenosis, quantitative diagnosis to echocardiogra- Zohair Al Halees, MDcan be used for maintaining patency of phy. Mazeni Alwi, MDthe ductus arteriosus, and for creating Felix Berger, MD To summarize, this year’s conference Fadi Bitar, MDsystemic to pulmonary shunts. He also was a smashing success. The diversity Jacek Bialkowski, MDdiscussed the development of a hybrid Philipp Bonhoeffer, MD of the talks is a testimony to the growingprocedure for the bidirectional Glenn, Mario Carminati, MD complexity of pediatric cardiology and Anthony C. Chang, MD, MBAVSD closure devices, and the need for the ever-expanding fund of knowledge. John P. Cheatham, MDnew and better valves that can be deliv- Bharat Dalvi, MD, MBBS, DM Clearly, the best pediatric cardiologyered through catheter techniques into Horacio Faella, MD programs must incorporate this rapidlythe right ventricular outflow tract. The Yun-Ching Fu, MD evolving knowledge from all aspects of Felipe Heusser, MDnext talk was by Dr. Carl Owada pediatric cardiology in order to optimize Ziyad M. Hijazi, MD, MPH(UCSD), on when to resort to surgery for Ralf Holzer, MD patient care. Conferences like this year’satrial septal defects. He reiterated the Marshall Jacobs, MD WSOPC are a valuable tool for helping R. Krishna Kumar, MD, DM, MBBSimportance of having sufficient rim tis- to convey the newest advances in pedi- Gerald Ross Marx, MDsue as a requirement for performing Tarek S. Momenah, MBBS, DCH atric cardiology. Next year’s conferencedevice closure of ASDs. He recom- Toshio Nakanishi, MD, PhD is tentatively scheduled to take place inmended that most ASDs that have a Carlos A. C. Pedra, MD Northern California. Daniel Penny, MDminimum of 5-7mm of rim tissue in all James C. Perry, MDdimensions should be amenable to de- ~CCT~ P. Syamasundar Rao, MDvice closure. If the dimensions of the Shakeel A. Qureshi, MDrim tissue are uncertain, then a TEE Andrew Redington, MD Carlos E. Ruiz, MD, PhDshould be performed to determine anat- Girish S. Shirali, MDomic suitability. If there is insufficient Paul D. Grossfeld, MD Horst Sievert, MDrim tissue, then the patient should be Assistant Adjunct Professor Hideshi Tomita, MDreferred for surgical closure. If the total Gil Wernovsky, MD Division of Pediatric Cardiology Zhuoming Xu, MD, PhDseptal length is less than the left atrial University of California William C. L. Yip, MDdisc diameter, these patients should be San Diego School of Medicine Carlos Zabal, MDreferred for surgery. In his experience, 3020 Children’s Way, MC 5004 FREE Subscription Congenital Cardiology Today is available free toeight of 180 patients with ASDs were San Diego, CA 92123 USA qualified professionals worldwide in pediatricreferred for surgical closure. The re- and congenital cardiology. International editions Telephone: 858-966-5855mainder were closed by catheter tech- available in electronic PDF file only; Northniques. The last lecture was by Dr. Telefax: 858-571-7903 American edition available in print. Send an email to Subs @CC T.bz. Include your name,David Sahn (Oregon Health and Sci- pgrossfeld@ucsd.edu title, organization, address, phone and email.ences U.), who gave an in depth discus- Contacts and Other Informationsion on new echocardiographic and MRI For detailed information on author submission, sponsorships, editorial, production and salestechniques that are being developed. contact, current and back issues, see website:He discussed how measurement of wall www.CongenitalCardiologyToday.com Do You Want to Recruit a Pediatric Cardiologist? Advertise in the only monthly publication totally dedicated to pediatric and congenital cardiology. For more information: call +1.301.279.2005, or send an email to: TCarlson md@ g mail.co m w ww .Co nge n ita lCa rd io log yTod a y.c om

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