A few months back, we received a referral call for a 40-day old baby from a peripheral hospital with very low body weight in critical condition. The child was diagnosed with Patent Ductus Arteriosus or PDA, a common condition detected in premature babies. Doctors performed a minimally invasive treatment procedure using a wire mesh device to close the PDA and successfully treated the infant.
In India, eight out of every 1000 newborn babies suffer from heart defects which accounts for approximately 1.5 lakh infants born with congenital heart disease per year. About 10% of the infant mortality rate can be attributed to congenital heart disease alone. These defects range from simple to complex. Certain problems can be examined by the doctor and managed with medicines, others require surgery, at times as soon as in the first few hours of the child’s birth.
Understanding heart defects in newborns
It is critical to know how the heart works to understand congenital heart disease. The heart is divided into chambers – two upper chambers (atria) and two lower chambers (ventricles). The right side of the heart transfers blood to the lungs through blood vessels known as pulmonary arteries. Oxygen-rich blood in the lungs then returns to the left side of the heart. The left side of the heart then pumps blood to the rest of the body through a blood vessel known as the aorta. When an individual suffers from congenital heart disease, any of their heart structure can get affected including valves, chambers, arteries, and the wall of tissue that separates the upper and lower chambers called the septum.
Congenital heart defects can be broadly classified into three categories viz. one with the increased flow to the lungs which includes Patent ductus arteriosus (PDA), Atrial septal defect (ASD), Ventricular septal defect (VSD), and Atrioventricular canal (AVC or AV canal) Coarctation of the aorta (CoA), pulmonary stenosis and Aortic stenosis (AS).
Congenital heart defects can be detected during pregnancy using an ultrasound (Foetal echocardiography or anomaly scan). After birth, the defects are diagnosed using echocardiography on suspicion at a physical examination in the form of abnormal pulses or abnormal heart sounds. Other clues that point towards the presence of congenital heart disease are low oxygen levels, recurrent pneumonia, poor weight gain, persistent feeding and breathing difficulty, or with history of previous sicking affected with heart disease.
PDA occurs commonly in preterm infants, especially in those with respiratory distress syndrome. In mature full-term neonates incidence of PDA is 1 in 2000 births accounting for 5-10% of CHD while in premature neonates, the incidence ranges from 20-60%. PDA occurs when a blood vessel called the ductus arteriosus that connects the pulmonary artery directly to the aorta (which is supposed to close after birth), remains open. This leads to extra blood flow from the aorta to the lungs and is often seen in premature infants. Normally PDA gets closed within 72 hours of birth. But in case PDA persists, it can often result in heart failure, kidney failure, brain hemorrhage, poor weight gain, or lung congestion that can result in death, prolonged hospital stay, or dependency on the ventilator or CPAP. In such a scenario, it is important to close the PDA.
How can this condition be treated?
There are three types of treatment options available for this condition namely, medical management, surgical management, and non-surgical procedure. Paracetamol, Ibuprofen, and Indomethacin are three drugs that are widely used in closing the PDA. So, normally medical treatment is the first choice of treating this condition in newly born babies. If this fails and the condition of the baby deteriorates, there are two options – surgical and non-surgical. The surgical repair is performed under general anesthesia and involves closing the open PDA by surgical incision through the side of the chest using clips or stitches to prevent the surplus blood from entering the child’s lungs. The third and advanced option to treat this condition by transcatheter route using wire mesh occluder device closure. This is a minimally invasive (non-surgical) procedure to close the ductus arteriosus.
Specialized heart doctors called pediatric cardiac interventionists use a minimally invasive procedure to close the PDA. Medical technology has given way to an advanced pea-sized device that can help treat even the tiniest of babies as low as 500 grams. This medically advanced wire mesh device is self-expanding and is inserted through a puncture in the leg vein and guided through vessels to the heart, where it is placed to seal the opening in the heart. It is designed to allow the physician to insert it through the aortic or pulmonary artery, as well as to retrieve and redeploy the device for optimal placement, the release.
Due to the minimally invasive nature of this procedure, many of the premature babies who are critically ill in the neonatal intensive care unit can be weaned from artificial respiratory support soon after the procedure with less risk in comparison to surgery.
For years, congenital heart defects were repaired with open-heart surgeries that included risks like blood transfusion, blood infections, and longer hospital stays. Credit it to advanced technologies, we now have minimally invasive procedures for selected cardiac conditions to treat infants with fewer complications and short hospital stays.
Though technological advancement has given a certain edge in saving a million lives with CHD, parents or pregnant parents should keep certain things in mind. Young women should seek early prenatal care, even before they are pregnant. Quitting smoking, reducing stress, taking folic acid supplementation, maintaining their blood sugars would be key towards maintaining health and wellness. It is advisable to discuss any medication that you may be consuming with the doctor. Eating a healthy diet, regular exercise, and working closely with the doctor to develop a customized plan will help in maintaining a healthy body.
By Dr. Sudeep Verma, Paediatric Cardiologist, KIMS Hospital, Secunderabad – Hyderabad
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