Health planners should provide more funding to develop, strengthen paediatric cardiology, surgery facilities - Prof. Masood Hameed Khan


9th International Paediatric Cardiology Symposium
Health planners should provide more funding
to develop, strengthen paediatric cardiology,
surgery facilities - Prof. Masood Hameed Khan

Institute of Paediatric Cardiology should be
established & we need to concentrate
prevention & curative services in all
sub-specialties-Prof. Kalimuddin Aziz

KARACHI: There is no dearth of talent in the country and paediatric cardiologists and surgeons are doing a commendable job looking after these patients. Health planners need to provide more funding to develop and strengthen these facilities in Pakistan. This was stated by Prof. Masood Hameed Khan Vice Chancellor of Dow University of Health Sciences. He was speaking at the inaugural session of 9th International symposium of Pakistan Paediatric Cardiology Society held here from September 26-28th 2012. The symposium attracted a large number of cardiac surgeons, paediatric cardiologists from all over the country besides many eminent delegates from overseas who spoke on many important issues in paediatric cardiology to brief the participants of developments taking place in this super specialty.

 Prof. Masood Hameed Khan VC DUHS presenting a mementoe to Prof. Kalimuddin
Aziz at the inaugural session of Paediatric Cardiology Symposium held recently.
Picture also shows from (L to R) Dr. Najma Patel, Prof. Khan Shah Zaman Khan
and Prof. Masood Sadiq.

Continuing Prof. Masood Hameed said that we not only have to control the communicable diseases but also the non-communicable diseases like heart diseases and diabetes. Hence we need to give importance to preventive measures to prevent these diseases as curative services are very expensive. Paediatric cardiologists and surgeons are doing a commendable job and they need to be encouraged. It is very embarrassing to see when some odd patients are reported to be going to India to seek treatment. The media need to highlight the services being provided within the country despite financial constraints. Public need to be educated as there is no dearth of expertise within the country. Our paediatric cardiologists and surgeons are performing an excellent job saving many precious lives. Members of healthcare profession also need to be informed of what they are doing as the people doing good job should be known to all.

Human Resource development, Prof. Masood Hameed Khan opined was extremely important. We need more trained people in paediatric cardiology, paediatric cardiac surgery. We need to set target and then make efforts to achieve that. Pakistanis are a hard working Nation. We must learn to respect humanity. We must remember that we all got medical education almost free with the poor tax payers’ money. We must now repay back something to the Nation
Prof. Kalimuddin Aziz President of Pakistan Paediatric Cardiology Society in his speech said that we started our academic activities with one day symposium many years ago but now it has been expanded to three days. Paediatric cardiologists are now practicing in all the provinces of Pakistan. Progress in medicine in the countries is recognized by the number of sub-specialties they create and that is how medical progress is measured. Sub-specialties will further increase in Pakistan in the days to come but there is always a tussle between the old guards who do not want to give up and the young enthusiasts in sub-specialty. The change itself changes the attitude of people. At present we have thirty two paediatric cardiologists including paedatric cardiac surgeons. We need to address the problems as to how much basic training is required and how examinations in these sub-specialties should be conducted. At present the exam pattern is the same and we need to modify these things which we have been discussing with the CPSP authorities.

Mementoes being presented to some of the foreign delegates during the recently held
Paediatric Cardiology symposium at Karachi.

Convener of the symposium Dr. Najma Patel in her welcome address pointed out that almost sixty thousand children with congenital heart diseases are born in Pakistan every year and there is already a large group of patients with rheumatic heart disease and rheumatic fever. Twenty five thousand children develop Rheumatic Heart Disease. Many of these patients are not diagnosed and majority comes to attention when they have already developed some complications. Quality of life can be good if these patients are diagnosed early and provided appropriate treatment. We need to decrease the incidence of rheumatic heart disease and provide treatment to these children, she added. Later the chief guest Prof. Hameed Khan presented mementoes to Prof. Shaukat Ali Syed former Director of NICVD, Prof. M.Rehman former Prof. of Cardiac Surgery at NICVD and Prof. Kalimuddin Aziz the noted paediatric cardiologist in recognition of their services and contributions to promote the discipline of paediatric cardiology and paediatric cardiac surgery. Dr. Nadir Ali Syed son of Prof. Shaukat Ali Syed received the mementoe on his behalf while a participant from Khyber PK received the mementoes on behalf of Prof. Surgeon M.Rehman who also could not come.

Some members of Pakistan Society of Paediatric Cardiology photographed along with some foreign delegates during the paediatric cardiology symposium held recently.

The first scientific session was jointly chaired by Prof Nizamul Hassan, Prof. Azhar Farooqui and Prof. Mehnaz Atiq. Prof. Kalimuddin Aziz was the first speaker who talked about arrival of paediatric cardiology in Pakistan. Tracing the historical background he commended the contributions of Muslim physicians to medicine like Razi and Ibne Sina. He then talked about close heart surgery for PDA and mentioned the contributions of Dr.Charles who helped establish the specialty of paediatric cardiology all over the world. Open heart surgery became possible in Pakistan with the availability of CPB machine. Dr.Shakeel Qureshi from UK helped open the door of interventional cardiology in Pakistan while Prof.Surgeon M.Rehman initiated paediatric cardiac surgery doing many complex cases. Tremendous work was carried out at NICVD and later we started organizing workshops in Pakistan training the juniors. Now interventional paediatric cardiology procedures are being routinely performed at NICVD, AKUH, AFIC, Cardiac Institute at Multan, PIC and Children Hospital at Lahore. At the NICVD now paediatric cardiology services are maturing and paediatric cardiac surgery is taking off. He suggested that an Institute of Paediatric Cardiology should be established and we need to concentrate on prevention and curative services in all the sub-specialties.
Prof. Masood Sadiq informed the participants that the government of Punjab has already approved setting up of an institute of paediatric cardiology at Children Hospital and PCI Form will be submitted shortly.
Prof. Masood Sadiq from Children Hospital Lahore discussed how to improve diagnosis of congenital heart diseases in newborns. Highly specialized infant care, he said, is available in developed world and they have excellent neonatal transport system to the tertiary care centers providing specialized services. On the contrary in developing countries most of the children with congenital heart disease do not survive because of hypoxia, congestive cardiac failure, infections including sepsis. Referring to the Human Development Index, he said, Pakistan has 145thplace in the world as regards HDI. Over forty thousand children with congenital heart disease are born in Pakistan every year; fifteen thousand of them require intervention during their first year of life. Delay in diagnosis and management increases infant morbidity and mortality. We have limited number of surgeons who are performing these procedures. There is very little critical care for babies and most of them are not managed in Pakistan. He then referred to mixed diagnosis. There is no index of suspicion as we have an impression that congenital heart diseases are very rare. Hence, CHDs are just picked up by chance in most cases. If we create awareness, improve resources allocation, set up tertiary care centers, majority of these children with congenital heart diseases can live normal life. Anatomical screening, foetal diagnosis is very difficult and we need to improve teaching and training at rural health centers, Tehsil and DHQ Hospital. Pediatricians and GPs can play a vital role in diagnoses of these children and they can be transported to regional centers. We need to develop telemedicine linkage, development of congenital heart diseases services at divisional level. We need to improve antenatal diagnosis and screening of newborns before they are discharged. Train people in prenatal diagnosis and see structural abnormalities in fetus. He emphasized the importune of early management and timely referral and long term management. Prof. Masood Sadiq further stated that we must manage these children as a whole. It is the paediatric cardiologists who can make the diagnosis by using echocardiography machines but many of these machines are available at DHQ hospitals where those using it do not understand what it is at the time of presentation. History and physical examination along with pulse oximetry at DHQ Hospitals can pick up many patients with congenital heart diseases. He was of the view that Echo should be left for experts. Provide management facilities at some centers and develop paediatric cardiac services. Detection and management of maternal infections, early screening by paediatricians and refer the patients in time. Ensure that the first discharge visit is within three to five days, he added.
During the discussion it was emphasized that we must train our paeditatricians to pick up more cases and detect them early. Since we do not have enough paediatricians, we need to train our GPs so that they can refer these children in time. Prof. M. Afzal felt that it should be taught at undergraduate level and postgraduates must have some rotation in paediatric cardiology departments. Early referral is essential for successful treatment, he remarked.
Dr. Najma Patel talked about acute myocarditis and said that its incidence was increasing. Diagnosis is difficult. High index of suspicion is a must. Speaking about its clinical presentations she mentioned abdominal pain, irritability, lethargy, early fatigue. Treatment of non-specifics can reduce cardiac failure. Manage normal blood oxygen levels. ACEIs, diuretics, digoxin, dopamine and beta blockers are useful in managing heart failure. However, in acute decompensating phase beta blockers should be avoided.
Dr. Hasina Changani from DUHS spoke on prevention of rheumatic fever while Dr.Zahid Jamal from NICVD discussed sudden cardiac death in the young. He discussed at length about mitral valve prolapsed, LV outflow, obstruction while syncope may also present with serious cardiac problems. It is very common in advanced lesions. He also referred to risk factors for serious cause of syncope. Explore for family history of sudden death, recurrent episode, look for chest pain, palpations. If the patient is on certain drugs it may also alter cardiac conduction. Look for cardiac disease and ask for any exertion preceding event. Check for valvular disease, pulmonary hypertension, dilated cardiomyopathies. Children who survive must be stabilized. Sudden cardiac death, he said, is very common in sportsmen. He also discussed the patho physiology of sudden death.
Prof. Zeenat Isani along with Prof. Shakeel Qureshi chaired the next session. Prof. Shakeel Qureshi from UK was the first speaker who made a presentation on heart failure in children. Its pathophysiology and new approaches in management. Heart Failure in children, he said, is different than adults. Diastolic and systolic dysfunction can co-exist. There is a 15-40% chance of inherited DCM. He also referred to family screening and clinical management of CCF with ACEIs. All diuretics work on adult heart. He laid emphasis on risk factor reduction. ACEIs and Beta Blockers can be used. Advise the patient on sodium restriction. Diuretics, he said, can be used for long periods in adults but not in children as there is no evidence. ACEIs improve survival and ARBs are good alternatives to ACEIs. Beta blockers fail in reducing mortality and hospitalization. Digoxin does lead to reduced mortality and hospitalization despite controversy. After paediatric heart transplant, twenty years survival is about 40% but there is high mortality. He also talked about circulatory failure in infants and children.
Prof. Shakeel Qureshi then talked about future of mechanical cardiac support, improvement of primary care measures, prevention and reduction of obesity in children. In UK one out of ten children are obese. Stem cells therapy and regeneration therapy has a role. There is lot of work in progress as regards delivery of stem cells directly in the heart through injections. Cell therapy for heart is also being looked into. He disclosed that one third of heart failure patients who require heart transplant die within one year. Extent of the disease, choice and timing of cell delivery is crucial.
Dr. Mazeni Alvi from Heart Institute in UKL Malaysia made a presentation on manifestations of PDA in neonates. He first talked about clinical settings of Patent Ductus Arteriosus (PDA). Patients with large PDA, he said, have significant heart failure symptoms, they suffer from failure to thrive. These days’ coils are being used for large PDAs. In large shunts, there are technical problems of remobilization. Transcatheter occlusion has now increased the surgeon’s domain. Then we have small patients with large PDA. Putting the device deep into the PDA can be difficult in small children. He then talked about Patent Ductus Arteriosus. Pre term infants with large PDA will have severe cardiac failure. Large PDA in infants, he said, are feasible to close in cath lab with Amplatzer Device and one needs to use large sheaths. Newer devices can be more useful, he stated..
Dr. Asif Hassan from UK made a presentation on Left Ventricular Outflow and treatment options. He was of the view that one will see more of these patients in Pakistan in NICVD. He then presented a few case histories the first one of which was a case of partial arterio ventricular septal defect. At nine years of age the patient had severe LVH. Treatment options in such cases are limited. At five years 50% of these children will require operation and at ten years of age all will require re-operation. Results of resection of residual are not good. He discussed many surgical options like mini Ross operation, Redo surgery for auto graft regurgitation and modified Kono operation. He then discussed the management of another case of aortic atresia and demonstrated the procedure in detail. He also discussed stenting of arterial ductus at six days with good results.
In the cardiac surgery session Dr. Asif Hassan from UK gave a plenary lecture on surgical correction of CHD- is it the end of the Game. He pointed out that it was often said that now interventional cardiologists will take care of most of the problems and the cardiac surgeons will be resting but it is not the case as both are interdependent. He commended the interventional cardiologist’s vision and courage. They started by dong simple things but now they are doing complex procedures. They can do Transcatheter Fontan which we all have been doing. After fifteen years, 30% of patients would die after Fontan operation. Outcome has been excellent after revision of fontan operation. Recurrent arrthymias is a problem of heart failure. Some of these patients may develop stroke, ascites, oedema. This particular patient about which he was discussing was put on inotropic support and required reoperation after twenty years. His chances of being alive were quite slim. But one year later he was back on his motorbike after he was transplanted. Congenital surgery had to be done to make him transplantable. We have done twenty nine cases with 90% survival. Many people have done this procedure with excellent results. Very few heart transplants, he said, are done outside North America and Europe. Iran has done many cases of heart transplant with good results. He then discussed the Berlin Heart and Mitral Valve replacement. Stress test showed good function, he added.
He was of the view that efforts should be made to support heart with some device instead of going for heart transplant. There are over two million patients with heart failure in USA alone and various heart support devices are now available. He then referred to various generations of devices. Subsequently some of these patients are also transplanted. He then talked about postpartum heart failure after cesarean section. This patient was put on inotropic support. Later LVAD and tricuspid valve replacement was done in this case. She remained in ICU for five days and in the hospital for another three weeks and then discharged. He opined that I do not think it is the beginning of the end but end of beginning and in the days to come you will hear more from the surgeons, he remarked.
Dr. Dawood Kamal from AFIC Rawalpindi presented their experience of Fontan surgery which is a gold standard for palliative procedure. He discussed in detail the pathophysiology of single ventricle, palliation of stage one and stage two. In third stage we do Fontan Surgery. He described Fontan circulation and said that make sure that the patient has no loss of energy, age of patient and good pulmonary hemodynamic, good single ventricle function, competent AV valve. These are some of the guidelines which we judge in patients less than fifteen years of age before undertaking any surgical procedures.
The scientific programme also included special sessions on cyanotic heart diseases, pulmonary hypertension, post operative care where in speakers discussed many important issues like Tetralogy of fallots, corrected TGA double switch, how to diagnose and investigate pulmonary hypertension, management of arrhythmias, early detection of low cardiac output syndrome and fluid therapy in paediatric cardiac patients. On the last day of the symposium there was live transmission of percutaneous intervention procedures along with invited talks on what have we cured with interventions, intervention in new born vs surgery.

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