Editorial : Pediatric Cardiology
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《美国医学杂志》
Division of Pediatric Cardiology, University of Texas-Houston Medical School, Medical Director, Children's Heart Institute, Memorial Hermann Children's Hospital Houston, Texax, USA
I have the distinct pleasure and honor to serve as a Guest Editor and organize pediatric cardiology symposia of the Indian Journal of Pediatrics virtually for the last 20 years, initially by myself and more recently with the able help of Dr. Anita Saxena. Initially the focus was to educate the practicing pediatrician regarding the general issues of congenital and acquired heart disease, scientific basis of the management approaches and updating recent advances. As the technology advanced world-wide, some of these advances were imported to India, but initially the availability of these methods was limited to a very few institutions. As time progressed, the new treatment modes have become available at increasing number of institutions in the country. Although there is an inequitable distribution of the availability of these resources to some groups of populations, none-the-less they are available locally. Therefore, it has become important to discuss, in the current symposium, not just the general principles as in the past, but to focus on specific disease entities and their management such that the practicing pediatrician may actively get involved and participate in the care of children with heart disease.
The current symposium is divided into two parts, the first part published in this issue of the Journal and the second part in the next issue. In the first paper of the current issue, Dr. Lantin from the University of Texas/Houston Medical School, Houston, TX presents a lucid discussion outlining what a primary care physician should do to take care of his/her patients with cardiac defects. She discusses the role of primary care physician in taking care of milder forms heart defects that do not require transcatheter or surgical intervention as well as those that need rapid intervention. Particularly useful are her recommendations regarding anticipated problems of patients who had undergone cardiac surgery and the emphasis she places on the team approach in collaborative management of the patients along with pediatric cardiologists and cardiac surgeons. In the next two papers of this issue, I discuss the clinical features of the most common types of acyanotic heart defects, both obstructive and left to right shunt lesions, followed by commonly used laboratory studies which confirm the diagnosis and quantify the severity of the problem; the latter will help on deciding the need for catheter or surgical intervention. Transcatheter therapy may be successfully applied for most obstructive lesions and a large number of left to right shunt lesions. The few who are not candidates for transcatheter intervention may require surgical intervention. As the technology gets better, more and more of these defects will become amenable to transcatheter treatment. In the final paper of this issue, Dr. Krishnan from the New York Medical College, Valhalla, NY discusses management options for patients with the so called single ventricle which, by the way, constitutes a variety of complex congenital heart defects, including tricuspid atresia, double inlet left ventricle, hypoplastic left heart syndrome, heterotaxy syndromes and many other defects in which one of the ventricles is too small to support the pulmonary circulation. The management, as the author rightly points out, is by a multi stage Fontan approach, necessarily required because of the fact that the pulmonary artery pressures and sometime their size are not suited for single stage correction at presentation. Untreated, the prognosis of patients with functionally single ventricle is poor. Recent advances in medical and surgical therapy, particularly the application of "Fontan" principle, have markedly improved the long-term outlook of these children. Palliative procedures to normalize the pulmonary blood flow (Blalock-Taussig or similar aorta-pulmonary shunt for patients with pulmonary oligemia and pulmonary artery banding for patients with pulmonary plethora) and to relieve interatrial and/or interventricular obstruction should be undertaken promptly. Norwood procedure is required for patients with hypoplastic left heart syndrome. Staged total cavo-pulmonary connection (modified Fontan) to bypass the right atrium and right ventricle by bi-directional Glenn procedure initially followed by extracardiac conduit diversion of inferior vena caval flow into the pulmonary arteries appears to be the current procedure of choice in the surgical management of single ventricle lesions. Total cavo-pulmonary diversion appears to be superior to conventional Fontan-Kreutzer operations, but long-term follow-up results than are currently available are needed to confirm this impression. There is an attempt to undertake some of these Fonatan steps with transcatheter means; this technique is evolving.
These discussions along with those that will be presented in the next issue, I hope, will give a fund of information to the practicing pediatrician which may help them provide better care for their patients.(Syamasundar Rao P)
I have the distinct pleasure and honor to serve as a Guest Editor and organize pediatric cardiology symposia of the Indian Journal of Pediatrics virtually for the last 20 years, initially by myself and more recently with the able help of Dr. Anita Saxena. Initially the focus was to educate the practicing pediatrician regarding the general issues of congenital and acquired heart disease, scientific basis of the management approaches and updating recent advances. As the technology advanced world-wide, some of these advances were imported to India, but initially the availability of these methods was limited to a very few institutions. As time progressed, the new treatment modes have become available at increasing number of institutions in the country. Although there is an inequitable distribution of the availability of these resources to some groups of populations, none-the-less they are available locally. Therefore, it has become important to discuss, in the current symposium, not just the general principles as in the past, but to focus on specific disease entities and their management such that the practicing pediatrician may actively get involved and participate in the care of children with heart disease.
The current symposium is divided into two parts, the first part published in this issue of the Journal and the second part in the next issue. In the first paper of the current issue, Dr. Lantin from the University of Texas/Houston Medical School, Houston, TX presents a lucid discussion outlining what a primary care physician should do to take care of his/her patients with cardiac defects. She discusses the role of primary care physician in taking care of milder forms heart defects that do not require transcatheter or surgical intervention as well as those that need rapid intervention. Particularly useful are her recommendations regarding anticipated problems of patients who had undergone cardiac surgery and the emphasis she places on the team approach in collaborative management of the patients along with pediatric cardiologists and cardiac surgeons. In the next two papers of this issue, I discuss the clinical features of the most common types of acyanotic heart defects, both obstructive and left to right shunt lesions, followed by commonly used laboratory studies which confirm the diagnosis and quantify the severity of the problem; the latter will help on deciding the need for catheter or surgical intervention. Transcatheter therapy may be successfully applied for most obstructive lesions and a large number of left to right shunt lesions. The few who are not candidates for transcatheter intervention may require surgical intervention. As the technology gets better, more and more of these defects will become amenable to transcatheter treatment. In the final paper of this issue, Dr. Krishnan from the New York Medical College, Valhalla, NY discusses management options for patients with the so called single ventricle which, by the way, constitutes a variety of complex congenital heart defects, including tricuspid atresia, double inlet left ventricle, hypoplastic left heart syndrome, heterotaxy syndromes and many other defects in which one of the ventricles is too small to support the pulmonary circulation. The management, as the author rightly points out, is by a multi stage Fontan approach, necessarily required because of the fact that the pulmonary artery pressures and sometime their size are not suited for single stage correction at presentation. Untreated, the prognosis of patients with functionally single ventricle is poor. Recent advances in medical and surgical therapy, particularly the application of "Fontan" principle, have markedly improved the long-term outlook of these children. Palliative procedures to normalize the pulmonary blood flow (Blalock-Taussig or similar aorta-pulmonary shunt for patients with pulmonary oligemia and pulmonary artery banding for patients with pulmonary plethora) and to relieve interatrial and/or interventricular obstruction should be undertaken promptly. Norwood procedure is required for patients with hypoplastic left heart syndrome. Staged total cavo-pulmonary connection (modified Fontan) to bypass the right atrium and right ventricle by bi-directional Glenn procedure initially followed by extracardiac conduit diversion of inferior vena caval flow into the pulmonary arteries appears to be the current procedure of choice in the surgical management of single ventricle lesions. Total cavo-pulmonary diversion appears to be superior to conventional Fontan-Kreutzer operations, but long-term follow-up results than are currently available are needed to confirm this impression. There is an attempt to undertake some of these Fonatan steps with transcatheter means; this technique is evolving.
These discussions along with those that will be presented in the next issue, I hope, will give a fund of information to the practicing pediatrician which may help them provide better care for their patients.(Syamasundar Rao P)