• Cases: We performed a total of 4 cases this week, supported by GOLI. Two were from Burundi and two were local. I have participated in all 4; personally performed the most difficult and guided Dr Kapadia through the other 3.

• Advocacy: I was invited to a symposium with the local secretary of health on “Medical Tourism” and asked to comment on what must be done to improve the local health care system from the perspective of our GOLI experience. I offered three points:

1. Infrastructure and trash collection
2. Hygiene
3. Education and retention of health care workers

• Thank You Note:   The Hospital CEO will deliver a written note acknowledge what GOLI has been done for them since 2009. Click Here to view
•  Lecture:  (10/1 I delivered a lecture )summarizing all the work that GOLI has done since 1993 around the world. The lecture was given to physicians in the local community and potential local donors. The slides are attached in PDF format. The presentation was extremely well received and it was one of my best in terms of message. Click Here to view PDF presentation.

Sir,

I am just receiving your Certificate of my scholarship requested during my training.

I am very happy and full of joy because you respond to my regarding.

I think Sir, you will stay with me during my training and also after training when i will go back as you’ve promised.

Thank you again.
Be blessed!

Emmanuel

Sincerely,
Kapadia

Leading Cardiologist Dr.K R Balakrishnan,Director-Cardiac Sciences, Dr.Nandkishore Kapadia, Senior Cardio Thoracic Surgeon & Dr.Suresh Rao

As Rabindranath Tagore said, “Every child comes with the message that God is not yet discouraged of humanity” and Baby Afifa stands as a testimony to just that. Baby Afifa, a 20 old baby had a very large tumour in one of the chambers of the heart and Fortis Malar hospital today announced the successful removal of the tumour in this new born.Leading Cardiologist Dr.K R Balakrishnan,Director-Cardiac Sciences, Dr. Nandkishore Kapadia, Senior Cardio Thoracic Surgeon & Dr.Suresh Rao,HOD – Cardiac Anesthesia & Cardiac Critical Care performed this rare surgery.

On becoming blue and breathless, 4 day old Baby Afifa was rushed to Fortis Malar hospital where she was diagnosed with a tumour in the heart.The child collapsed since the tumour blocking the right side of the heart led to dangerously low oxygen levels.The procedure involved administering anesthesia which was critical as the baby was just a few days old.

The baby’s body temperature was cooled to 15 degree Celsius and the circulation was stopped and under sus
pended animation the tumour was completely removed.The tumour was a leiomyoma- a benign tumour (commonly found in the uterus of a woman)

For the first time in the world a leiomyoma of the heart has been reported in a newborn.Rightly said,All is well that ends well – the rare surgery that was performed was a success and Baby Afifa has recovered well and is expected to lead a normal life.

Monday. C. Rajendran, Vellore Collector, Kapadia of Vision Save Heart Foundation (second from right) and

VELLORE: A foetal echocardiography machine, costing Rs.12 lakh, was installed at the Primary Health Centre (PHC) in Poigai near Vellore under the mode of Public-Private Partnership (PPP) between the Department of Public Health and Preventive Medicine (DPH) and Vision Save Heart Foundation.

Vellore Collector C. Rajendran installed it on Monday. This is the first time that such a machine is being installed at a PHC in India, according to K.S.T. Suresh, Deputy Director of Health Services (DDHS), Vellore Health Unit District (HUD).

Thanking Nandkishore Kapadia of the Vision Save Heart Foundation on behalf of the district administration for his gesture of installing the machine free, the Collector said that the apparatus would be of immense help in detecting cardiac problems in the foetus of pregnant women and making timely medical interventions to save the child from the physical hardships likely to be caused by the problem after the birth of the child, and the risk of the child losing its life.

It was a boon for pregnant women hailing from economically backward families, he said.

The Collector also inaugurated on the occasion a medicinal herbal park, set up on the premises of the PHC under a PPP between the DPH and the Tamil Nadu Parambariya Siddha Vaidhya Maha Sangam.

Dr. Suresh and Dr. Kapadia signed a Memorandum of Understanding for the PPP and exchanged documents.

Dr. Suresh said that the foetal echocardiography equipment would detect functional and structural anomalies in the heart of the foetus. Women in Anaicut block who have completed 16 to 18 weeks of pregnancy in Vellore would be called to the PHC on a particular day every month and subjected to tests through the foetal echo cardiography machine. The Vision Save Heart Foundation would provide free follow-up treatment for those whose foetuses were found to have heart problems.

The DDHS said that as per the MoU signed with Tamil Nadu Parambariya Siddha Vaidhya Maha Sangam, the latter would maintain the herbal park. It has also agreed to set up similar medicinal herbal parks at the remaining 36 PHCs in Vellore HUD, he said.

A.V. Venkatachalam, Conservator of Forests, Vellore Circle presided.

T. Sivakumar, Field Publicity Officer, Vellore, said that wrong food habits were responsible for heart problems.

About 40 million children below the age of 14 throughout the world suffered from obesity problems. Awareness of the link between obesity and heart problems should be created among children. He said that the Medicinal Plants Development Board of the Union Government had launched a scheme for developing medicinal herbal gardens in schools. The park in the PHC in Poigai had 83 herbs, he said.

Kailasam, Block Medical Officer, Anaicut, and K.P. Arjunan, State President, Tamil Nadu Parambariya Siddha Vaidhya Maha Sangam, spoke. Mangayarkarasi, Medical Officer, PHC, Poigai, proposed a vote of thanks.

Cardiac tumors are rare, although they were first described in the 18th century. Benign tumors occur more often than malignant tumors. The most common type of tumors in children is rhabdomyoma. Other benign tumors are  fibroma, myxoma, and teratoma. The most common

malignant tumors are sarcomas, particularly angiosarcomas.

Because of the interference with cardiac function, and invasion of the cardiac chambers, even benign cardiac tumors may induce severe symptoms, particularly in children.Tumors on the right side of the heart may cause heart failure with swelling, ascites (fluid in the abdomen), fluid around the heart  shortness of breath,  cough and collapse. Tumors located  on the left side of the heart may also cause fever, chills, seizures, and stroke. All cardiac tumors may also induce irregular heart beat.

As indicated, rhabdomyomas are the most common tumors in children. They are associated with tuberous sclerosis  They are rarely excised because they tend to regress. However, surgical removal is indicated when they present with obstruction of the cardiac chambers or intractable irregular heart beat. Fibromas, are found mostly in the left ventricle and frequently occurr in infants younger than 1 year

Myxomas are usually seen in adults but can appear in children as part of the syndrome myxoma or Carney syndrome, which includes  tumors in other organs, and skin. This condition runs in families (familial syndrome). Myxomas may embolize to the brain and other organs and can also be found in fetus in utero.

Teratomas and  develop in the right atrium, right ventricle, and septum of the heart.

Angiomas are a benign vascular tumors. They can occur in any part of the heart and can form blood vessels (hemangiomas) or lymph vessels sometimes associated with bloody fluid accumulated around the heart.

Sarcomas are rare in children but rhabdomyosarcomas is invasive, and tend to produce metastases.

Other rare tumors in children include lipomas, and, leiomyomas. Lipomas are nodules of fat. Leiomyomas are made of  smooth muscle cell and can invade the large vains entering the heart, like the superior and inferior caval veins. They cause obstruction of these veins and of the cardiac chambers.

Recently, our associates in Chennai, Dr Kapadia and Dr Bala, operated on a small baby who was critically ill with a  leiomyoma that occupied the inferior vena cava and the right atrium, preventing the heart from filling and causing peripheral congestion and collapse. The operation consisted of removing the tumor and  went well.

The operation, the baby and our colleagues in Chennai are featured in the articles below from the local press. Please join me in congratulating the team, of which we at GOLI are all very proud.

Additional Articles

The Hindu News

The New Indian Press

T.Gowri.

SRM Hospital & Research Centre, Potheri, Chennai

Introduction:With improvements in  intraoperative surgical techniques for congenital heart disease and advances in  postoperative expertise, there has been a move to “fast track” approach with  extubation in opertating room.  These changes  in approach has resulted  decline in  perioperative morbidity and mortality, Less  ICCU  Stay,  and  cost reduction to   Hospital  and patient.

Method: Between    February  2008  and  November  2009,  121   children underwent open  or  closed  heart  surgery,  Age  ranged  from  10  months  to  18  years, All surgical procedures were performed by One  Cardiac surgeon and all anesthetic care was provided by one pediatric anesthesiologist.  Postoperative care was provided directly by attending-level Pediatric ICU physicians or the pediatric CT surgeon.

Results: Ninety  seven  of 112  patients  ,( 67  had  open  and 30  had  closed  heart  surgery) were extubated in operating room ( 86 % ) , 5 were   extubated within 4 hours of completion of  surgical procedure . One Patient was  reintubated  . Of   10 patients   left intubated  ,  Two were extubated in  next 18 hours, Prolonged ventilation >24 hours required in 5 patients. There were  4 deaths  ( 3.5 %).Mean  surgical time 97 ,Cardiopulmonary Bypass Time 47 minutes, cross clamp time  26 minutes, duration of ICU stay 1.88  days, duration of hospital stay  5.6 days were  reasonable for fast tracking.

Conclusion:With experienced Cardiothoracic Surgeons, Pediatric Anesthesiologist, Paediatric Cardiologist  along  with well  trained perfusionist ,nursing personnel, a fast track pediatric cardiac  Surgical  program is feasible  in a moderate-sized  Department . offering surgical care to all types of patients with Congenital Heart  Diseases including neonates.

GOLI SUPPORT MAKES POSSIBLE NEW LIFE SAVING PROGRAM IN CHENNAI

Recently GOLI has donated two pumps to our colleagues in Chennai so as to facilitate the establishment of a program of mechanical support of the circulation or ECLS (extracorporeal life support) in children and adult patients. Two children have benefited already from the new program. The new program relies on GOLI’s continuous mentorship in order to thrive and mature.

Extracorporeal Life Support-ECMO

Extracorporeal life support refers to a medical therapy used to deliver oxygen through an artificial lung, also called oxygenator, and to support the circulation mechanically through a special pump. The pump and the artificial lung represent a miniaturized form of the heart and lung machine used in open heart surgery operations. Various systems are used to achieve ECLS, but in general, the equipment is not only smaller than that used for open heart
surgery, but it is also transportable in various areas of the hospital, including the emergency room and intensive care unit. The patient is connected to the pump and oxygenator through tubes inserted in an artery and in a vein of the patient (see pictures).

ECMO (extracorporeal membrane oxygenation) is the original form of ECLS, and it used for newborns with respiratory failure that fails to respond to medications. like surfactant, gas therapy, like Nitric Oxide, and artificial breathing with mechanical ventilation. Some of these newborns have other congenital anomalies like diaphragmatic hernia and underdeveloped lungs. In diaphragmatic hernia, some of the baby’s bowels are dislodged in the chest because of lack of a portion of the diaphragm, the muscle that normally separates the chest cavity
from the abdomen. In these babies, one of the lungs is usually underdeveloped, frequently requiring ECMO.

Other indications for ECMO/ECLS are heart failure in children and adults, acute lung infection, H1N1 flu, and keeping the patient alive while waiting for a heart or lung transplant. For all these conditions, the pump maintains adequate circulation and blood pressure. The artificial lung replaces the respiration; meaning that it adds oxygen to the blood and it removes carbon dioxide. The patient is supported mechanically until his/her own heart and/or lungs recover.

ECLS and ECMO are lifesaving procedures, but they are associated with complications, like infection, bleeding and stroke. Depending on the patient’s diagnosis and physiologic conditions, survival varies from 30% to 85%. In other words, not all patients will survive. However, historically, without ECLS and ECMO, nearly 100% of patients with conditions now treated with mechanical circulation and ventilation would die. With the refinement of equipment and techniques, it is likely that the outcomes will continue to improve in the years to come.

Following is an informational brochure prepared by our nurse specialist, Joanne Russo, RN and used to educate parents and families of Dr Russo’s patients here in the US. GOLI has provided the brochure to Dr Kapadia as well. The brief educational document describes the procedure, its indications, and its risks.

To: Family and Patients, by Joanne Russo, RN
RE: Extracorporeal Life Support (ECLS)

ECLS is a form of therapy that can keep a very ill patient alive, by supporting the heart and/or lung function when a patient’s own heart and/or lung function is inadequate.

The technology of ECLS is similar to the heart-lung bypass techniques used in cardiovascular surgery. Blood drains from the patient through a tube (catheter) placed in a large vein. This blood passes through a circuit and then is pumped through the membrane oxygenator that serves as an artificial lung, putting oxygen into the blood and removing carbon dioxide.

The blood then passes through a heat exchanger that maintains the blood at normal body temperature. Finally, the blood re-enters the body through a large catheter placed in an artery in the neck or other part of the body. Our team uses centrifugal pumps, closed circuits, and special new oxygenators, which we believe provide several advantages over the traditional neonatal ECLS system, called ECMO (extracorporeal membrane oxygenator).

To place someone on ECLS, the surgeon inserts the catheters into the vein and artery through a small incision made in the neck, groin or chest. This procedure is done in the Intensive Care Unit or the OR. At the same time, perfusionists set up the ECLS circuit, priming it with blood that is carefully tested and cross-matched for compatibility with the patient’s blood type. When the patient and the ECLS circuit are connected, the blood must be thinned with heparin, a drug that prevents the formation of clots. Also, during ECLS support the patient’s lungs continue to be ventilated, but with “lung rest settings”. Often, we use special oxygenators and circuit requiring
low heparin levels.

ECLS does not cure lung or heart disease; it merely supports the patient to allow time for the organs to heal.

ECLS course of treatment can extend from three up 30 days depending upon the severity of the patient’s condition. ECLS is discontinued when careful evaluation of lung and /or heart functions shows that oxygenation and carbon dioxide elimination can be supported with a conventional ventilator, and/or cardiovascular function is adequate by clinical observation and echocardiogram.

Bleeding is the most common complication of ECLS. This problem is associated with the use of heparin, a blood thinner, which must be used. Bleeding is most serious when it occurs in the brain as this can cause brain damage or death. If the patient does experience a brain hemorrhage, or stroke, ECLS may have to be discontinued because the continued use of heparin increases the risk of further bleeding in the brain.

Mechanical failure or equipment malfunction is also possible. The ECLS circuit is composed of many components. If the equipment malfunctions, there is the risk of blood loss or the introduction of air into the system, which could cause death or damage to any of the organs, including the brain.

Chances of patient’s survival depend on the cause of the lung/heart disease, the hospital course before ECLS support, and the patient’s condition while on ECLS.

ECLS is started only on patients who have a chance for a healthy survival, but there are several potential long term problems that can occur. These include chronic lung disease and neurological problems. The neurological problems are usually secondary to bleeding complications during ECLS therapy, to low levels of oxygen to the brain during the time prior to ECLS or during ECLS, or to ligation of the major blood vessels to the brain on the right side of the neck. The lung problems and heart problems are usually the result of the initial lung or heart disease or the lung injury associated with mechanical ventilation.