Download Present and Future trends in Paediatric Cardiology Dr Oliver

Present and Future trends in Paediatric Cardiology
Dr Oliver Stumper , MD,PhD
Birmingham Children’s Hospital
Birmingham, UK
Paediatric Cardiology has developed dramatically over the past 50 years in the diagnosis and
understanding of congenitally malformed hearts and their treatment. The past two decades
have seen emerging treatment opportunities for the entire range of congenital heart
disease. The major emphasis at present is to define the best investigative and therapeutic
management approaches to these lesions in order to achieve best possible long-term
outcome at the lowest morbidity and mortality.
The diagnosis of congenital heart disease is shifting towards the antenatal period with
routine screening programs being implemented before 20 weeks gestation. Detection rates
still vary considerably throughout the UK and Europe. However, in the context of readily
available postnatal (surgical) management with very low mortality rates and generally good
outcomes there has not been a decline in the incidence of complex congenital heart disease
requiring treatment. Certain lesions would ultimately benefit from fetal catheter or surgical
interventions, but, at present, this approach remains experimental.
Imaging the diseased heart by cardiac ultrasound has scaled new heights with the
introduction of 3 and 4 dimensional imaging and functional assessment of myocardial
performance. Cardiac MRI and CT scanning has become common-place offering detailed
information and increasingly low radiation exposure. These trends in imaging have made
cardiac catheterisation an almost exclusive interventional tool.
Cardiac catheter interventional techniques have secured a firm and growing place in the
treatment of so called simple lesions such as patent ductus arteriosus, atrial and ventricular
septal defects, and pulmonary or aortic valve stenosis. But, increasingly, catheter techniques
are being used and developed to replace initial palliative cardiac surgical intervention such
as systemic-to-pulmonary artery shunts (stenting the right ventricular outflow tract or
stenting the ductus arteriosus), or Norwood stage I procedure for hypoplastic left heart
syndrome (hybrid stage 1 procedure). The treatment of adult coarctation or severe aortic
stenosis in the elderly is about to become completely catheter based. Right ventricle to
pulmonary artery conduit replacement will become a catheter rather than a surgical
intervention. Transcatheter Fontan completion is further area which will become reality
within the next 5 years or so. There will be further development of interventional techniques
and materials, the most significant one being the development of custom-shaped
biodegradable devices which will take account of the specific needs of a growing child into
adulthood.
These trends in the treatment of even complex congenital cardiac lesions, demand greater
cooperation and integration of paediatric cardiology, surgical and anaesthetic teams to
establish the facilities and clinical protocols that allow for this to happen. It is likely that all
paediatric cardiac catheterisation theatres will be kitted out to also accommodate cardiac
surgical intervention and an increasing number of cardiac surgical theatres will incorporate a
angio system to aid in certain steps of combined interventions.
The last decade has also seen an explosion of knowledge and understanding of the genetic
basics of cardiovascular development and adaptation and the experimental use of stem cell
therapy. These developments will, in time, lead to the development of targeted drug or cell
therapy, possibly aided by specific interventional catheter techniques.
Due to the ongoing shortage of donor hearts for paediatric cardiac transplantation there will
be a dramatic improvement and pick-up of medium to long-term vascular and cardiac
support devices, with percutaneously implanted impeller pumps being the most promising
approach.
At the same time, paediatric cardiologists and all other professionals involved in the care of
patients with congenital heart disease will have to realize that the major part of their patient
population has by now grown up. The biggest challenge for the next three decades will be to
provide specialist care for the large number of adult patients with palliated congenital heart
disease or those with significant haemodynamic lesions.