Annex A > Chapter 3 - Developments in the UK, in the Diagnosis and Treatment of Congenital Heart Abnormalities in Children, 1984-1995 > Management strategies

Management strategies

22 All members of the cardiac team, including paediatric cardiologists, cardiac surgeons, anaesthetists, intensivists (doctors who specialise in intensive care), nurses and perfusion technicians, must work closely together in caring for each patient. There is an important reliance on the cardiologist for an accurate clinical assessment and detailed diagnosis of the abnormalities. Common practice during the period 1984-1995 was that discussions between cardiologists and surgeons took place on a formal basis at least once a week in conferences concerning groups of patients, and more frequently on an informal basis concerning individual patients. The decision concerning an operation depended upon open discussions and teamwork, especially when existing techniques were modified or when new methods were introduced. As indicated above, the decision to proceed with cardiac surgery was a decision made between the family, the cardiologist, the cardiac surgeon and of course the patient where able.

23 Emergency management of a baby with a cardiac abnormality is primarily undertaken by the paediatric cardiologist. There is usually a telephone discussion between the paediatric cardiologist and the referring paediatrician in order that appropriate initial treatment can be instituted both before and during the transfer to the cardiac unit. Depending on the condition of the baby, the cardiologist might also discuss the case with an intensivist or anaesthetist and arrangements might be made for admission to the ICU. The cardiologist and the intensivist together will then administer appropriate drugs to support the baby's heart, lungs and other organs while further investigations and discussions are undertaken. Throughout this period, support from nursing staff will be given together with the necessary counselling. All aspects of the baby's care and their impact on all members of the family will be considered.

24 From the 1980s onwards, the trends towards the use of newer technologies and towards earlier surgery for certain cardiac abnormalities created increased demands on paediatric cardiologists. These demands include diagnostic accuracy, intra-operative support by means of echocardiography in theatre, and also the diagnostic assessment of the post-operative result.

25 At the appropriate time, the surgeon will undertake either an `open' or a `closed' operation. Closed-heart surgery is mostly concerned with operating on structures close to the heart, without the need to stop the heart from beating and open the heart itself. Examples include: creating connections between blood vessels in order to promote an increased flow of blood to the lungs (shunt operations); relieving or removing narrowed areas of blood vessels (e.g. repair of Coarctation of the Aorta); creating a narrowing of the main artery to the lungs in order to reduce the blood flow (pulmonary artery banding); and tying off abnormal blood vessels (e.g. ligation of a Patent Arterial Duct). Open-heart surgery usually involves opening the heart. It thus requires the heart to be stopped after blood flow has been diverted from the heart and lungs though a heart-lung bypass machine which, as the name suggests, takes over the role of the heart and lungs in providing oxygen to, and removing carbon dioxide from, the blood. The particular advantages to the surgeon are that there is a clear field of vision, and that the necessary valuable time is available for the repair in question to be undertaken.

26 Surgical techniques constantly evolved during the 1980s and 1990s. Important new operations were more widely undertaken in the UK including, for example, the Arterial Switch and the Fontan procedure. There were trends towards earlier surgery for specific lesions (e.g. Truncus Arteriosus and CAVSD) and towards primary correction rather than interim procedures (e.g. for VSD). Many of these trends were made possible by improvements in equipment and technology. Some of the more important of these were improvements in the cannulae [7] used for heart-lung bypass and in improved design of the heart-lung bypass machine used to support children who had open-heart surgery. There were also significant improvements in control and correction of clotting defects resulting in the shorter duration of operation and less bleeding post-operatively. In addition, there were improvements in illumination (surgical headlights) and magnification (surgical glasses).

27 It is not only the surgeon who performs interventions on the cardiovascular structures. It was during the mid-1960s that cardiologists first created a hole in the wall between the two upper chambers of the heart (the atriums) in babies with TGA. From about 1982 cardiologists began to undertake more interventions by means of cardiac catheterisation within the heart using newer technology. This meant that some operations which involved opening the chest, and which previously would have been done by a surgeon, were no longer necessary. Examples include: the stretching of narrow valves by means of an inflated balloon at the tip of the catheter; inserting devices into the heart or blood vessels in order to close holes or block off blood vessels; and inserting devices (known as `stents') into the heart or blood vessels in order to open up narrowed areas.

28 A child who undergoes a surgical procedure, or a diagnostic procedure such as cardiac catheterisation, requires an anaesthetic. Anaesthetists have expertise in the various techniques and treatments needed to maintain patients in a state whereby the necessary surgical procedures can be carried out in a safe manner. They are responsible for determining whether a patient is in a condition to be safely anaesthetised and undergo an operation. They are important members of the team during cardiac operations, especially during open-heart procedures. Together with the perfusionists they monitor the condition of the patient and advise on the use of drugs to maintain the stability of the patient. They maintain observation of the monitors that are attached to the patient, recording the electrocardiogram (electrical heart tracing), blood pressure in different parts of the body, blood oxygen values, inhaled and exhaled gases and other measurements.

<< previous | next >> | back to top

Footnotes

[7] For the purpose of cardiopulmonary bypass, a cannula is a plastic or metal tube connected to tubing that leads to the heart-lung bypass machine. It is inserted into the aorta, or the right atrium, or the great veins. Blood is pumped through the tubing and the cannula into the aorta, and is drained from the right atrium or great veins through a cannula and tubing back to the heart-lung bypass machine