|LESSONS FROM HISTORY
|Year : 2015 | Volume
| Issue : 2 | Page : 203-205
History of pediatric cardiology in India
Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||30-Sep-2015|
Dr. Anita Saxena
Department of Cardiology, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
In India, the discipline of cardiology started in the late 1950s and at that time pediatric cardiology was practiced as a part of cardiology specialty. This article traces the history of pediatric cardiology in India. Dr. S. Padmawati and Dr. Kamala Vytilingam underwent training in pediatric cardiology at international centers in the early 1950s and early 1960s. Dr. N. Gopinath successfully closed a ventricular septal defect using a pump oxygenator at Christian Medical College, Vellore. Open heart surgery program kicked off in the 1960s with the tireless efforts of many other surgeons. Dr. Rajendra Tandon, trained for 2 years at Boston Children Hospital under Dr. Alexander Nadas, joined the Department of Cardiology at the All India Institute of Medical Sciences, New Delhi in 1963. This and many other stories are described.
Keywords: History, pediatric cardiology, India
|How to cite this article:|
Saxena A. History of pediatric cardiology in India. J Pract Cardiovasc Sci 2015;1:203-5
| Introduction|| |
Heart disease in children found its place for the 1st time in a book on pediatrics, written by Thomas Morgan Rotch in 1896. This book had seven pages devoted to congenital heart disease. Thirty years later, in 1926, Dr. John Morse penned a textbook of pediatrics, in which 42 pages were on cardiovascular disease, but only five of these 42 pages were on congenital anomalies. The landscape for treatment of congenital cardiac anomalies was quite bleak in those days as is evident from Dr. Morse's writings. He wrote, “Fortunately the diagnosis of the exact lesion ___ is not of great importance in either prognosis or treatment ___. There is no curative treatment and nothing, which will either diminish the deformities or favor the closure of abnormal openings. The treatment must, therefore, be hygienic and symptomatic.” Since then a lot of water has flown down many rivers as the field has advanced immensely. Dr. Robert Gross, a chief resident at Harvard Medical School and Peter Bent of Brigham Hospital performed the first operation for a congenital defect. He closed a patent ductus arteriosus in a 7-year-old girl on August 26, 1938. Dr. Alfred Blalock, a surgeon at Baltimore performed the first aortopulmonary shunt (Blalock–Taussig shunt) on November 29, 1944. In fact the first book which was totally devoted to congenital heart disease was written by Dr. Helen B. Taussig, an American cardiologist working in Baltimore. This magnum opus was published in 1947 as congenital malformations of the heart. A comprehensive textbook in pediatric cardiology was first published by Dr. Alexander Nadas in 1956. By then the specialty of pediatric cardiology had found its place in the Western world.
In India, the discipline of cardiology started in the late 1950s and at that time pediatric cardiology was practiced as a part of cardiology specialty. Some of the world renowned Indian cardiologists today such as Dr. S. Padmawati and Dr. Kamala Vytilingam underwent training in pediatric cardiology at international centers in the early 1950s and early 1960s, respectively. However, due to the paucity of surgical expertise and facilities, they practiced both adult and pediatric cardiology. The first Cardiothoracic Surgery Department was started at Vellore in 1949. Ligation of patent ductus arteriosus was the first surgery for congenital heart disease. It was performed by Dr. B. R. Billimoria at Masina Hospital in Bombay in the early 1950s. A Pott's shunt in a patient with tetralogy of Fallot was first performed in 1951 by Dr. Reeve H. Betts at Christian Medical College (CMC), Vellore. Dr. P. K. Sen performed the first repair of coarctation of Aorta in 1953 in Bombay. He also performed the first successful closure of atrial septal defect under hypothermia and inflow occlusion in 1956. The first open heart surgery using cardiopulmonary bypass was an atrial septal defect closure by Dr. K. N. Dastur at BYL Nair Hospital, Bombay on February 16, 1961. In May 1961, Dr. N. Gopinath successfully closed a ventricular septal defect using a pump oxygenator at CMC, Vellore. Open heart surgery program kicked off in the 1960s with the tireless efforts of many other surgeons.
Dr. Rajendra Tandon, trained for 2 years at Boston Children Hospital under Dr. Alexander Nadas, joined the Department of Cardiology at the All India Institute of Medical Sciences, New Delhi in 1963. He devoted himself almost entirely to the discipline of pediatric cardiology. [Figure 1] shows some of the pioneers.
A few other trained doctors returned to India after training at good centers abroad. Such was the state, due to paucity of good pediatric cardiology services then available in India that they either went back or started to practice general pediatrics. After spending 2 years at Toronto with Dr. John Keith, Dr. I. P. Sukumar established pediatric cardiology at Vellore in the early 1970s.
Pediatric cardiology, although developed as an independent specialty, mainly consisted of clinical diagnosis of the defect, diagnosis supported by an X-ray, and an electrocardiogram. The diagnosis remained provisional in most cases unless confirmed by cardiac catheterization. With the advent of echocardiography or ultrasound, a sea change took place, and a precise noninvasive diagnosis became possible. Cardiac catheterization for making a diagnosis was no longer required in a majority of cases. Echocardiography, during 1980's was in a developing phase in India, and only a few people were actively involved in this field. However, by 1985 or so, it became very popular and widely available. Another exciting development happened in the year 1982 when first mitral valve balloon dilatation was performed in India. This opened a huge potential for interventional cardiology in pediatric patients. Dr. S. Shrivastava, who was a professor at the All India Institute of Medical Sciences, New Delhi, is credited for advancing the subspecialty of pediatric cardiac interventions in India. By 1990 or so a majority of children with obstructive lesions of the valves or vessels were undergoing balloon dilatations for relief. Interventions were very attractive to patients as well as cardiologists as defects could be treated without the need for cardiopulmonary bypass and with no scar on the chest. Later devices were developed that helped to close left to right shunts such as atrial septal defects, patent ductus arteriosus and some ventricular septal defects in cath lab. These interventions have made the specialty of pediatric cardiology more attractive for enterprising and challenge seeking professionals, something that did not exist two decades ago.
Pediatric cardiology is growing at a rapid pace, and a significant number of trained pediatric cardiologists, pediatric cardiac surgeons, pediatric cardiac anesthesiologists, intensivists, and others involved in the care of pediatric patients have joined this specialty. More than 25 centers caring for cardiac patients have been established in India, most in the last decade and a half. A large number of peer-reviewed papers are published every year in national and international journals.
A national level society, namely Pediatric Cardiac Society of India was established in 1999 to bring all specialists caring for pediatric cardiac patients under one umbrella. The major goals of the society were to promote the growth and development of pediatric cardiac care in India and to improve awareness about diagnosis and management of heart disease in children among pediatricians. This society has been very active on the academic front, holding regular academic meetings, CMEs, workshops, etc. Development of guidelines for the management of congenital heart disease in India by expert groups is one of the several examples; these have been published for widespread circulation. Some of the founder members of the society are leading practitioners and well-known international figures. In the year 2014, a pediatric cardiac society of India hosted the first even international conference at New Delhi, India in the specialty of pediatric cardiology.
The focus of pediatric cardiology practice has also undergone a sea change over the last three decades or so. With advancements in technology worldwide, including India, the specialists are further specializing in certain specific areas of pediatric cardiology. Some are excelling in noninvasive cardiology, others in therapeutic interventions and a few in pediatric cardiac electrophysiology. This subdivision within the discipline of pediatric cardiology is becoming more and more attractive to the new entrants and is enriching this specialty. For diseases such as valvular and vascular obstructions, patent ductus arteriosus, and other selected left to right shunts, the pediatric cardiologist is less dependent on his/her surgical colleagues as these can be managed much less invasively in the cardiac cath lab as mentioned earlier. However, it is important to appreciate that the cardiologists and surgeons play a complementary role to each other. A very close synergy needs to exist between the cardiology and surgical teams for the best outcome of the patient. Since the stakes are high, especially in small babies, even a small complication can be life-threatening, and management strategy has to be decided by a conjunctive opinion by both teams. Perhaps no other area of medicine needs such a close cooperation between the team members as is required in the care of children with heart disease.
Over the years, pediatricians and other caregivers have become more aware of heart diseases in children. Most are well versed with therapeutic options available for such children and importance of timely referral for a good outcome. This has been possible as the task has been done on a war footing with conduct of symposia, CMEs, workshops, e-learning modules, etc., by various expert groups and teams, very enthusiastically supported by the philanthropic organizations as well as by industry. Most of the specialists are now being trained in good, high volume centers, located in India itself. A formal 3 years training program, recognized by National Board of Examination (Diplomate of National Board in pediatric cardiology) is already in place at more than 5 centers. Doctorate of Medicine (DM) in pediatric cardiology is also being offered in some centers and is on the anvil in many more. With increasing workforces, there has been a substantial increase in the number of operations and interventional procedures being performed for children with congenital heart disease.
Despite this expansion over the last 15 years or so, the specialty of pediatric cardiology has a long way to go for providing optimal care to children with heart disease. It is estimated that more than 150,000 children are born with congenital heart disease every year in India; about 25% of these have a critical lesion. Added to this burden is a significant number of children affected by rheumatic heart disease. With the centers available today, not more than 10% of children with heart disease are getting the care they need. Although several new centers are opening up, the gap between the required number of centers and the number of patients needing treatment is very wide. There is the inequitable distribution of available resources with some of the most populous states of India having no facility for treatment of these children. The government of India and several state governments are initiating health programs for children. National schemes such as Janani Shishu Suraksha Karyakram, Rashtriya Bal Swasthya Karyakram are designed to care for the health of neonates, infants children for multiple diseases including congenital and rheumatic heart diseases. Major challenges include improvement in access to health care in vast rural and semi-urban areas of Eastern, Central and Northeastern parts of India, better quality of care and more pediatric cardiac care specialists. Pediatric cardiology community is looking forward to far greater level of involvement and participation from the government in its endeavor to improve outlook for children with heart diseases.
| Conclusion|| |
The specialty of pediatric cardiology has come a long way. It is growing in India, albeit slowly. The awareness is increasing; more centers are opening up. The field is becoming very exciting and is attracting young and enterprising minds.
“To climb steep hills requires a slow pace at first” by William Shakespeare.
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