Insights in Pediatric Cardiology

Introduction

Congenital heart disease (CHD) is defined as structural malformation of the heart or great vessels that is present at birth. Whatever may be the time of diagnosis CHD is the single most common malformation which constitute about 30% of the total [1-5]. Congenital heart defect may occur as an isolated form or in combination with others. Some of the defects are simple and some are complex. Major congenital heart defects (MCHD) are those of the heart or great vessels which necessitate surgical on catheter intervention in first six months of life. Pediatric cardiology was started as a subspecialty in Bangladesh in 1998 and initially pediatricians and public were not aware about existence of such a harmful disease in our community. Later, all concerned were educated by continuous medical education. A study conducted in Combined Military Hospital, Dhaka showed an incidence of 25/1000 live births in our country [4]. The Baltimore Washington infant study reported the rate as 4/1000 live births [5]. Less incidence in western country is contributed by fetal screening of heart in early pregnancy and abortion of diseased fetus play thereafter. Maternal health and nutritional status are also better in developed countries. Many hospital-based studies are conducted in many regions of the world but study in South Asia is limited. In this study, regional experience was highlighted [1,3,5]. This study has taken a cross section of patient for survey from a single day arrival in a tertiary care busy pediatric cardiac outpatient clinic of Bangladesh.

Methods

All the patient who reported as a referred case to a pediatric cardiologist of a tertiary care hospital on a busy day, 6 March 2017, was selected randomly. All the cases were seen by the paediatric cardiologist after a healthcare assistant measured the body weight and oxygen saturation of the patients. The cardiovascular system of every patient was examined thoroughly, and a provisional diagnosis was made. Chest x-ray and electrocardiogram (ECG) were advised in some of the cases and Echocardiography was advised for all cases for anatomical diagnosis of new cases or follow up of previous diseases or postintervention and post-surgery follow up. Patients were documented in a non-invasive laboratory in database. Adults with chest pain who reported to the paediatric cardiologist were excluded from enrollment.

Data were analyzed in Microsoft Excel. Numerical data were expressed in frequency and categorical data as percentage. Comparative analysis was not required it is a single variant observational study.

Permission of ethical committee of the hospital was taken accordingly.

Results

Out of 66 cases, 46 (69.70%) were male and 20 (30.31%) were female (Fig 1). Fig 2 showed age distribution of the subjects. Seven (11.66%) cases were in 0- 01 month age group, 25 (41.66%) were in more than one month to one year age group, 21 (35%) cases were in more than one year to 5 years age group and 13(21.66%) cases were in more than five years age group. Fig- 3 showed general distribution of cases reported on that day. Fiftyeight (87.88%) cases had congenital heart diseases of various types, five (7.57%) cases had normal heart and three (4.51%) cases had spontaneously closed simple CHD. Fig-4 showed 21% patient reported from greater Capital city and rest 79% from peripheral and rural area. Table 1 showed pattern of disease in studied cases. Ventricular Septal defect (VSD) was found in nine (13.63%) cases, Atrial Septal defect (ASD) in ten(15.16%) cases, Patent ductus arteriosus (PDA) in eight (12.13%) cases, Patent foramen ovale (PFO) in three (4.56%) cases. One VSD and two ASD secundum cases were cured spontaneously. Among combination form of simple congenital heart diseases, VSD with pulmonary stenosis (PS) was commonest (6.06%). Amongst cyanotic CHD variety, Tetralogy of Fallot (TOF) was commonest (3.03%) followed by transposition of great arteries (TGA) in 1.51% Pulmonary Atresia (PA) in 1.51%, double outlet right ventricle (DORV) in 1.51%, Truncus Arteriosus (TrA) in 1.51% and so on. Among Neonatal special situations, persistence pulmonary hypertension of newborn was seen in five (7.57%) patients. Fetal Echo and adult congenital Echo cases were not reported on that day. Table 2 showed association of syndromes in study cases. Down syndrome was seen in two (3.03%) cases, congenital Rubella syndrome in 1(1.51%) case and Curzon syndrome in one (1.51%) case. Table 3 showed position of the heart in cases analyzed. Levocardia was seen in 65(98.48%) cases and Dextrocardia in one (1.51%) case. Table 4 showed post interventional follow up cases in study group. PDA device closure was found in five (7.57%) cases, PDA stenting in one (1.51%) case, pulmonary balloon valvuloplasty in 1(1.51%) case and medical intervention following a 3 days protocol for persistent pulmonary hypertension (PPHN) in 3(4.56%) cases. Table 5 showed surgical interventions in follow up cases. VSD closure and PDA ligation was performed in two (3.03%) cases, TOF repair, PDA ligation, Septal myomectomy, bidirectional glen shunt (BDG) for mitral Atresia and DORV were performed in one (1.51%) cases each. Table 6 showed instant management plan provided after Echocardiographic diagnosis of patient. Medical management was offered in eleven (16.67%) cases, twenty nine (43.93%) cases were placed on follow up, trans catheter interventions were planned for eight (12.13%) cases, surgical intervention was planned for nine (13.63%) cases, eight (12.13%) cases were discharged as their Echo were normal or they cured spontaneously from simple diseases. One (1.51%) patient was found inoperable (AP window).

Discussion

Congenital heart disease is the commonest of all congenital malformation and accounts for highest morbidity. Incidence of congenital heart disease was studied amongst hospital live birth of Bangladesh and it was 25/1000 live birth [4]. In India, one study showed 3.9/1000 live birth are suffering from CHD [1,6-8]. In Pakistan the incidence is 4/1000 live birth [9]. Worldwide analysis of incidence study had a consensus of 8-10/1000 live birth. In our study male preponderance was noticed (Fig-1) which was also observed in other studies [1-4,10]. Most of the cases in this study fall in more than 1 month to 1 year age group (Fig-2). In other studies, most of the cases made their first visit to doctors in their first year of life. Studies by Nazma et al., Burki et al., Khalil et al. showed similar results [2,11-12]. About the pattern of disease (Table- 1), the most common disease was ASD (15.16%), followed by VSD (13.63%) and PDA (12.13%). In Bangladesh ASD was found as the commonest acyanotic lesion in other studies also13. Among cyanotic heart diseases, TOF (3.03%) was the most common even on that single day which correlates with other studies in India, Pakistan and other countries [1-2,4,13- 14]. Most common combined lesion in this single day data analysis showed VSD and PS as commonest (6.06%) combination. Similar patterns were noticed in other studies [14]. Down syndrome was found as commonest syndrome in this study which correlates with others study also [15-18]. Medical and catheter intervention was performed in 10 (15.16%) cases (Table 4) and surgical interventions were performed in six (9.06%) cases. Other study also showed more interventions than surgery in current scenario [14]. Reason is most interventions are now coming up with good outcome and guardians of children always prefer non operative procedures on their children. Management plan (VI) was decided as per requirement of specific disease of the patient. Most of the cases were placed in follow up as they were mainly neonates and infants and time was given for spontaneous cure for simple lesions. Medical management was offered to patient with heart failure, pulmonary hypertension, and associated chest infection cases. Cases who were cured from previous simple CHD were discharged from follow up. Surgery was offered in some critical and complex cases and interventions were offered in feasible cases.

Single day experience in a busy Echocardiography laboratory of a tertiary care hospital reflects the scenario which has been observed over the years in countries. Varieties of cases representing the whole country give an information about how the cases are managed in a country like Bangladesh. Though complex and neonatal surgeries are referred to neighboring countries, all kind of medical and catheter interventions are performed in our setup.