Children born with heart diseases is an emerging critical public health issue which paediatric heart specialists are currently facing in Sri Lanka.
Consultant Paediatric Cardiologist, Lady Ridgeway Hospital(LRH), Dr. Duminda Samarasinghe tells the Sunday Observer, however critical, no child with CHD is beyond hope due to advanced diagnoses and treatment measures now in place. With the Little Hearts Project underway at the LRH he assures parents all facilities will be available to help their children lead normal lives and appeals for more support to this worthy initiative.
Excerpts…
Q. Congenital Heart disease (CHD) is a critical public health issue in many countries. Would you tell us what CHD is.
A. A heart disease prevalent from birth is called a congenital heart disease. It is also called structural heart disease. It may be a hole in the heart, a narrow valve or a blood vessel or a combination of lesions leading to a more complex disease.
Q. What is the prevalent incidence of CHD in Sri Lanka?
A. An estimated 3,000 children with CHD are born every year in Sri Lanka – figures are based on incidence of CHD and number of live births in Sri Lanka which match the number of patients that we see every year at Lady Ridgeway Hospital.
Q. Are there different types of congenital heart defects?
A. Congenital heart defects can be broadly categorised into cyanotic (heart diseases that cause bluish discolouration of the baby) and acyanotic (those that do not cause bluish discolouration). As a rule of thumb, acyanotic lesions are less complex than cyanotic lesions. Hole in the heart and narrowing of a valve or a blood vessel, fall under acyanotic lesion.
Q. How are they diagnosed ?
A. First, you need to suspect that something is wrong with the baby. If he is not gaining weight, sweats a lot, becomes breathless and fatigues easily, has a high heart rate or if there is bluish discolouration of hands, feet and tongue you can suspect a heart lesion.
In addition to these symptoms if a child gets recurrent respiratory infections like pneumonia, you can suspect a congenital heart disease.
If the heart sounds are abnormal when a doctor listens to the heart using a stethoscope he can suspect a heart disease.
In all these situations the child will be subjected to an Echocardiogram by a paediatric cardiologist.
Q. What does this test involve?
A. It is a harmless test which uses ultrasound waves to visualise the heart. An echocardiogram can confidently and accurately diagnose over 99% of congenital heart diseases.
Q. Is CHD preventable?
A. A majority of CHDs are not preventable. However, a mother to be can take certain measures to minimise the chances of CHD.
Q. How?
A. By avoiding drugs, smoking and alcohol during pregnancy. Completing family before she turns 30 years would also reduce the risks of having a Down Syndrome baby. This in turn would reduce CHD as around 40% of Down Syndrome babies have CHD. Other risk factors for CHD are, viral infection, diabetes mellitus and some drugs like Lithium taken for psychiatric disorders during pregnancy.
Q. Is it curable?
A. Yes, most CHDs can be treated effectively to lead a normal life. Treated at the appropriate age they can become productive citizens.
Q. What is the most common CHD in Sri Lanka?
A. ASDs are the commonest in Sri Lanka. Before the echo era, it was thought that VSDs are the commonest CHD. But with good quality echocardiography machines we can now diagnose relatively silent lesions like ASDs which can be easily treated if detected early in life.
Q. How does congenital heart disease occur?
A. The formation of the heart is a very complex process and is completed within the first few weeks in the womb. It starts as a tube and ultimately transforms into a complex heart with valves and chambers. Any deviation during this process can lead to a congenital heart lesion.
Q. How do congenital heart defects impact on the child’s development?
A. Children with lesions which cause high blood flow to the lungs would have recurrent pneumonia and poor weight gain. They will have recurrent hospital admissions due to this. Children with bluish discolouration can have a life threatening drop in their oxygen content needing emergency care. These lesions make them more prone to develop infection within the heart itself called endocarditis, which needs long term hospital stay and treatment with IV antibiotics for over 4-6 weeks.
Q. Which of these defects do you consider as the most critical in saving the life of an infant?
A. Some defects like PDAs, VSDs are simple and have effective methods of treatment. If not treated in a timely and appropriate manner it could lead to grave consequences. Lesions such as Hypoplastic left heart syndrome and complex cyanotic lesions need multiple surgeries and are more critical as a lesion itself. So, the decision on which one is important and more critical is difficult.
Q. Treatment- Do all children with heart defects require surgery?
A. No. It is estimated that approximately 2/3 of patients with CHD would need some form of treatment. The balance 1/3 are either insignificant or too complex for treatment. There are two options for those who need treatment; surgical or interventional. Some lesions can be treated in the catheterisation laboratory under X-ray guidance without opening the chest. The lesions that are not suitable for such treatment should go for surgery.
Q. How soon should an infant with CHD undergo surgery?
A. A majority of CHD which need surgery should undergo surgery within the first year of life. However, all patients should be assessed individually, and timing of surgery decided on individual patient and lesion characteristics.
Q. Are there alternative methods of treatment?
A. Catheter based intervention is an alternative to surgery. It is done under X ray guidance without opening the chest. Catheters and devices are passed through a small opening in to a blood vessel in the groin and guided into various parts of the heart under X-ray guidance. Certain holes in the heart can be closed using devices and narrow valves and blood vessels can be opened up using balloons. There are many more options as well.
Most of the treatment options are available in Sri Lanka but as the demand is high there is an issue in delivering timely care.
Q. Mothers attending prenatal clinics are screened for various NCDs. Is screening for CHD also included in this?
A. It happens in a stepwise manner at the moment. If the VOG who does the fetal scan suspects a CHD, he would refer the patient for a fetal echocardiogram to the Paediatric Cardiologist. However it is not mandatory to do this in all pregnancies. After birth, the newborn will be examined by a neonatologist or a paediatrician and if they suspect, send for an echocardiographic evaluation. Echocardiogram can diagnose almost 99% of heart lesions but unfortunately, not all newborns are subjected to an echocardiogram due to our limited resources. It is not practical aswell and the lesions that can be missed during this process of clinical screening, are the simple lesions like ASDs which can be treated easily and if not operated, may become inoperable due to severe lung damage.
Q. What happens to a child with CHD who is not treated?
A. Holes in the heart, like ASD, VSD and PDAs, depending on the size of the lesion would lead to high blood flow to the lungs. This can lead to recurrent pneumonia and lung damage in the long run and after a certain limit, become inoperable. Some other lesions like narrow valves and blood vessels would lead to thickening of cardiac muscle and ultimately heart failure. Other lesions which can cause bluish discolouration could lead to issues in oxygen delivery to tissue. Therefore, all children with CHD, should be assessed by a paediatric cardiologist early to see if they need treatment.
Q. Do Lankan babies with CHD today have better chances of survival. Why?
A. Definitely we have improved from what we were but there is a long way to go. In 2005, there was no cardiac surgery or catheter interventions at LRH. Therefore, most of the babies diagnosed with a CHD, succumbed to their illness. Today we do around 700 catheter based interventions and 900 cardiac surgeries per year at LRH. But to treat all children with heart disease in an appropriate manner, we need to target 2,000 surgeries per year in Sri Lanka. To achieve this target, we have started the Little Hearts project.
Q. Your message to women on avoiding having babies with heart defects?
A. Complete your family early at least before 30-35 years of age. Avoid drugs, unnecessary medication and contracting viral illnesses during pregnancy. Even if you have a baby with CHD, you don’t have to worry too much as we have facilities to treat them.