Paediatric Cardiology- A sub-specialty

Paediatric Cardiology is a well-establishedsub-specialty in the western countries, dating back as far as the early 1960s. The evolution of paediatric cardiology is the result of identifying the fact that the mortality in the neonatal period resulting from congenital heart diseases was alarmingly high and therefore, the need for paediatricians trained in managing these children from the time of their birth, right through their childhood and beyond. Initially, diagnosing a congenital heart disease (CHD) was dependant solely on the paediatric cardiologist`s skills with the stethoscope and correlating the auscultatory findings with the child’s signs and symptoms. Later developments like echocardiography including colour doppler, cardiac catheter studies and angiocardiography have formed an impressive armamentarium of tools for the paediatric cardiologist, leaving little room for error in accurately diagnosing and managing children with CHD over their life time. Predeterming the exact anatomical nature of the heart defect helps the paediatric cardiothoracic surgeon plan the correction/palliation prior to the surgery, thus greatly improving the end result and the long-term prognosis for the child.

Recent advances in the field of therapeutic interventional paediatric cardiology has added great impetus to the medical management of children with heart defects like Atrial Septal Defect (ASD), Patent Ductus Arteriosus (PDA), Ventricular Septal Defects (VSD) and various valvular narrowing. Occluding devices are now available which can be inserted percutaneously from the groin and directed to the heart where the defects can be successfully plugged. Narrow valves could be stretched with a balloon using the same technique to enter the heart, thus either totally avoiding heart surgery or buying valuable time until the surgery could be done when the child is older. This is important as operating on an older child is significantly less risky than operating on a younger child. Avoidance of the surgical scar, especially in the case of female children, plays a major role in the preference for closure of holes in the heart by device occlussion, the other advantages being a low intra-operative risk, significantly reduced hospital stay, and no known long-term problems.

With the technological advances in recent years equipment for echocardiography have improved tremendously. As a direct result of this it is now possible to image a foetal heart with enough clarity to make a diagnosis or predict malformations in the heart early on in the gestation, the success rate, however, being highest around the 20 weeks period. This helps the obstetrician and the paediatric cardiologist to counsel the parents, plan the management of pregnancy and for appropriate measures to be taken well in advance by the paediatric cardiologist to receive the baby immediately post delivery, should the heart condition be com pat ible with life after birth. The diagnostic and legal implications of identifying CHD in foetus is such that it should be done by qualified persons trained in interpretation of the foetal cardiac images. Therefore, foetal cardiology is gaining recognition as a sub-specialty in its own rights.

Cardiac rhythm disturbances (arrhythmias) have been a significant portion of paediatric cardiology practice. Children with arrhythmias may present with symptoms such as unexplained loss of consciousness, chest/abdominal pain or sensation of tightness, unexplained irritability or lethargy with refusal to feed. Recent strides in better understanding of the electro-physiological conduction pat hways within the heart and the ability to modify the conduction characteristics by radio-frequency waves have resulted in alleviating the life-style of many a children whose arrhythmias have not responded to medical management.

In the current global setting, more than 95% of infants born with congenital heart disease are amenable to some form of medical or surgical correction. Therefore, every effort must be made to ensure that the quality of care available to children with heart defects is universally of the same standard. It is also important to raise awareness amongst the public about the outcome of children with congenital heart disease and dispel any myths associated with all such heart defects in children.