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Cardiac Surgery at Arkansas Children’s Hospital, 2006 Robert D.B. "Jake" Jaquiss, M.D., Professor, Department of Surgery, University of Arkansas for Medical Sciences College of Medicine; Chief, Pediatric and Congenital Cardiothoracic Surgery, Arkansas Children’s Hospital Since the inception of the specialty of pediatric cardiac surgery in 1938 when Dr. Robert Gross performed the first ligation of a patent ductus arteriosus, there have been several distinct eras of advancement, each building on the prior era and heralding improvements in the care of children with congenital heart disease. In this article, I will briefly describe these eras, highlighting some of the seminal developments in each and conclude with my impression of the current state of affairs in pediatric cardiac surgery, as it is practiced at Arkansas Children’s Hospital, with some comments about what the future may hold. The earliest era, which might be termed the “Time of the Pioneers,” was when Gross began the specialty and proved false the formerly held view that the cardiovascular system could not safely be operated upon. Indeed, Gross himself was actually forbidden by his chief to perform the ductal ligation, an admonition he boldly ignored to the benefit of untold thousands of children with congenital heart disease. Other notable surgical visionaries in this era include Dr. Clarence Craaford of the Karolinska Institute in Stockholm who performed the first repair of coarctation of the aorta, Dr. Harold Blalock of the Johns Hopkins Hospital who developed, along with Drs. Helen Taussig and Vivien Thomas, a shunt to provide pulmonary blood flow for “blue babies,” and Dr. John Gibbon of Philadelphia, who along with his wife and engineers whose services were donated by the IBM company, developed a workable heart-lung machine. This latter development, subsequently improved by many other investigators, allowed for the heart to be incised, permitting access for intra-cardiac repairs (so-called “open heart surgery”). With the taboo against operating on the heart and blood vessels of children effectively shattered, and even the interior of the heart itself accessible to surgeons, the next era was one of application of innovative surgical techniques to “cure” or palliate children with virtually all forms of congenital heart disease. Some of these procedures were fairly simple conceptually, such as patching a single hole in the septum separating the right and left ventricles. Others, such as the Mustard and Senning procedures, and more recently the arterial switch operation, are incredibly imaginative, complex operations that provide effective and durable surgical treatment for children with even very complex heart disease. During this time, operations were developed to replace a malformed or diseased heart valve with a man-made prosthetic valve. Later, animal and even human valves were used instead of man-made valves, thus avoiding the need for the patient to take a powerful anti-coagulant medication. Perhaps the most ingenious example of the latter type of valve operation was developed by Sir Donald Ross in London and involves the translocation of a valve from one location in a patient’s heart to another. Another notable advance in this era was the proof of the hypothesis that blood would flow through the lungs without having to be pumped by a ventricle, thus allowing the potential for palliative reconstructive operations in children born with hearts with only one functional ventricle. Although operations were developed for virtually all cardiac malformations during this time, there remained a few children for whom no good surgical option existed. For them, cardiac transplantation was also shown to be a potentially successful option. With at least one, and sometimes several, surgical options thus available for children with virtually any form of congenital heart disease, the recognition that early results were still unacceptably poor in many children ushered in the next era, which was predominantly focused on improving operative survival. Led particularly by groups at Boston Children’s Hospital, Children’s Hospital in Philadelphia and the Royal Children’s Hospital in Melbourne, as well as several other centers across the world, physicians and surgeons caring for children in this time period began to alter peri-operative care so as to account for the unique physiology of neonates. The success that followed this approach supported the concept of early complete repair of congenital heart disease, avoiding initial palliative surgery, particularly championed by Dr. Aldo Casteñeda at Boston Children’s Hospital. Recognition and prevention of many of the harmful effects of cardiopulmonary bypass, miniaturization of the heart-lung apparatus, more accurate and exact pre-operative diagnosis and simple iterative improvement in the conduct of operations all provided additive improvements in early outcomes for children undergoing reparative cardiac surgery. Just as the invention of cardiac operations led to the observation of attendant complication of morbidity and mortality, so the dramatic reduction in early mortality (along with better follow-up) led to the observation of important late morbidity. The current era of cardiac surgery, at Arkansas Children’s Hospital and other leading institutions, is focused to a large extent on the minimization or even elimination of the long-term negative sequelae that may result from reparative cardiac surgery. Some of the late morbidity, such as re-operation because of imperfectly durable biologic valve replacements for example, is minor in relative terms, and manageable. Other morbidity, such as subtle or not-so-subtle impairment in neuro-cognitive function may be much less easily managed. A first part of the effort to address neurologic morbidity in particular will involve what might be termed apportionment of blame, based on the recognition that abnormalities diagnosed after heart surgery may have in fact been present before surgery. The overall effort will involve a series of steps: the magnitude of the problem has to be defined, the responsible culprits must next be identified and finally solutions must be proposed, tested and put into practice. At Arkansas Children’s Hospital we have begun already to institute strategies that we believe will “protect” the brain during open heart surgery. Furthermore, we have a meticulous protocol of surveillance, both before and after surgery, to detect any neurologic abnormality so that we may institute early and appropriate therapy. This is truly a team effort, involving the cooperation of nurses, cardiologists, anesthesiologists, surgeons, intensive care unit physicians and parents. Likewise, all operations are considered by the entire Heart Center Team, from the important perspective of minimizing early risk, but also from the perspective of the long-term impact of decisions made early in life. We have learned and continue to emphasize that even the smallest decision, the tiniest alteration in where a stitch is placed for example, may have far-reaching consequences long after our patients have left the hospital. This is an exciting time to practice cardiac surgery at Arkansas Children’s Hospital. We have a superb team assembled and believe we can offer the promise of outcomes for our patients that are unsurpassed anywhere in the world. Further, building on the bold, innovative and courageous work of our medical and surgical forbears, we believe that each year we will provide better and better care, based on our commitment to continuous improvement and advancement of the state-of-the-art in pediatric cardiac surgery. Pediatric Cardiothoracic Anesthesiologists in the Most Unlikely Places Michael L. Schmitz, M.D., Professor, Anesthesiology & Pediatrics, University of Arkansas for Medical Sciences College of Medicine; Chief, Pediatric and Congenital Cardiothoracic Anesthesiology, Arkansas Children's Hospital At one time, the most likely place to find pediatric cardiothoracic anesthesiologists was in the pediatric cardiothoracic operating room. Although we still spend a lot of time in the cardiothoracic operating room, more than 70 percent of anesthetics presently provided by the cardiothoracic anesthesiologists at Arkansas Children's Hospital (ACH) are elsewhere in the hospital. While any well-trained pediatric anesthesiologist is capable of caring for a child with congenital heart disease, we specialize in such care and are especially available to care for those with cyanotic heart disease and dysrythmias. The pediatric cardiothoracic operating team mobilizes to the neonatal intensive care unit one to two times a week to operate on the tiniest infants, some weighing less than a pound, by ligating a patent ductus arteriosus through a small left chest incision. Many of these infants either have failed medical management or have contraindications for such treatment. The infant receives intravenous anesthetics and close monitoring, and the entire operation takes less than 30 minutes from start to finish. But, the largest proportion of anesthetics for children with heart disease is given in the cath lab, the main operating rooms and in the CT and MRI suites of radiology. In fact, the need for cardiothoracic anesthesiologist care has increased by 10 percent per year for the past several years in these areas. Why? Well, there are a couple reasons… First, more infants and children now survive to adulthood due to steady improvements in surgical repair and palliation of congenital defects and to advances in medical care provided by their cardiologists. Thus, the population of children with congenital heart disease has increased, and these children require follow-up heart-related procedures requiring anesthesia as well as the usual occasional pediatric surgical care such as tonsillectomies and myringotomies (ear tubes). Second, remarkable advancements have evolved in computed tomography (CT) and magnetic resonance angiograms (MRA). Such new technology is available at ACH and put to full use by our pediatric radiologists for tasks such as measuring cardiac parameters like valve regurgitation, ejection fractions and flow through blood vessels as well as constructing 3-D images of the heart and great vessels to show their overall relationship prior to operating in the chest. So yes, while one may almost always find a pediatric cardiothoracic anesthesiologist in or near the cardiothoracic operating room at ACH, we also go wherever children are who need our care – even in the most unlikely places. Success Through
Teamwork: All For One, One For All
I remember the first time I attended the Catherization (Cath) Conference at Arkansas Children’s Hospital. I had just arrived as the new chief of pediatric cardiology and had resolved not to change anything, at least for a while. Cath Conference was a bit of a surprise, however. Sure, the cardiologists and surgeons were there, but I wondered why there were so many others; specialty nurses, anesthesiologists, operating room scrub nurses, child life specialists and social work. What were they doing at Cath Conference? I didn’t know then what I know now and that is, I had stepped into the middle of a different model for success. Cath Conference, now called Surgical Conference, was probably the most notable of many examples of how a tradition of teamwork has been at the core of the effectiveness of the cardiac program at Arkansas Children’s Hospital. Now, there is standing room only with everyone in attendance who has anything to do with the patient and family’s experience with cardiac surgery. The forum is open, anyone can contribute and the contributions of all are respected and encouraged. Although Surgical Conference is the most notable example, the teamwork mentality in the Heart Center at Arkansas Children’s Hospital is pervasive. In the cardiovascular intensive care unit (CVICU), morning rounds are conducted, again, with the whole team in attendance. We take the crowd for granted, but we forget that everyone participating in morning rounds plays an essential role in the care of our precious charges. Key to the success of the CVICU team is the advanced practice nurses who function as the backbone of the team. But after rounds, other team members go about getting the work done and in a crisis, everyone responds. Anesthesia, cardiology, critical care, surgery, nursing and social services function seamlessly. It’s “all for one” for our patients and families. From cardiology’s perspective our situation is ideal. With the evolution of interventional catheterization, ablation procedures, device insertions in the Cath Lab and the need for semi-invasive echocardiography (TEE), success absolutely hinges on collaboration between anesthesiologists, surgeons, cardiologists and the technical and nursing staff of the Cath Lab. Some would call having expert cardiac anesthesia coverage of the Catheterization Laboratory a luxury. I call it a necessity for doing the best for our patients. But to have a team that models collegiality and excellence is something money can’t buy. Add to that expert interventionalists and electrophysiology and a Cath Lab technical and nursing team that never says no…“One for all” for our patients and families. I could mention the “one for all” attitude in our ACH outpatient clinic, in our Heart Station and in our cardiac transplant program, our collaboration with cardiovascular radiology and more. But perhaps one of the best examples of commitment to teamwork can be found outside the hospital, even outside Little Rock. Regional clinics have always been part of the program here having been started by the founder of our program, Dr. W. Thompson Dungan. Over time, with the increasingly technical standard of care in cardiology, services have had to be added to our regional clinic effort. With the addition first of ECG, then echocardiography, it became necessary to bring ECG and echo technicians along to clinic. We’ve added members of the cardiology office staff as well to handle the heavy burden of paper work needed to provide care. And where would this effort be without our specialty nurse coordinator? Now, all this might seem to be a routine expectation, but consider that each clinic requires staff to travel for two to over three hours, one way, starting in the early morning hours. Consider also that the regional clinic team, like the CVICU team and the Cath Lab teams, represent a perfect model of collaboration between ACH and faculty and staff of The University of Arkansas for Medical Sciences. Our program has always led the way in collaboration and thankfully, we can continue to say we model success through teamwork. “All for one, one for all” for our patients and families! Cardiovascular
Intensive Care Unit at ACH Adnan Bhutta, MBBS, FAAP, Instructor, Pedatric Critical Care Medicine and Cardiology, University of Arkansas for Medical Sciences College of Medicine; Co-Medical Director, Cardiovascular Intensive Care Unit, Arkansas Children’s Hospital The cardiovascular intensive care unit (CVICU) at Arkansas
Children’s Hospital was founded in 1981 and was one
of the first dedicated ICU’s in the region to provide
care to neonates, children and adolescents with congenital
or acquired heart disease. We moved to our current location
in the hospital in 1999 and presently have 12 ICU beds. Another
10 monitored beds are available for hospitalized patients
who are less critically ill. We provide specialized inpatient
care to more than 600 patients annually.
The CVICU is equipped to provide the most advanced invasive and non-invasive hemodynamic and respiratory monitoring including the ability to monitor regional blood supply using non-invasive NIRS monitoring at every bedside. We have a vast experience in the use of therapeutic and supportive therapies such as Nitric Oxide therapy and Extracorporeal Life Support (ECLS- also known as extracorporeal membrane oxygenation or ECMO) and we are one of a few facilities who can transport patients on ECLS by air. Our team was the first in the country to successfully use the DeBakey ventricular assist device (VAD) to transition a patient to cardiac transplant and have also successfully used the Berlin Heart ventricular assist device for the same purpose. Patient safety is an important aspect of ICU care and the staff of the CVICU is fully cognizant of this. Our rates of hospital-acquired infections are well below the national average and are similar to the national benchmark rates in the Pediatric Intensive Care Unit (PICU) at Arkansas Children’s Hospital. Staff education for both the medical and nursing staff is carried out through regularly scheduled conferences. We strive to provide family-centered and patient-focused care to all our patients. Families are free to visit patients at all times and are encouraged to stay for as long as they wish. For the comfort of our families, there is a large waiting area available for them. Additionally, we have two family rooms available for use by families whose child is having surgery on a particular day. Social workers, chaplains and child life specialists are available to assist patients and families during their hospital stay. For additional information on our unit, contact Trenda Ray at (501) 364-5864. Pediatric Perfusion: “A Child is Just a Small Adult” Chuck Johnson, R.N. Chief of Perfusion, Arkansas Children's Hospital Although this statement is one of the most overused clichés to express the medical care of children by adult-oriented health care workers, it reflects a sarcastic inaccuracy. In the field of perfusion, there are many different considerations between adult and pediatric perfusion. Perfusion schools concentrate on adult cases, since less than 10 percent of all open heart procedures are on children under the age of sixteen. The lack of training experience contrasts with the mortality for pediatric cardiac procedures with cardiopulmonary bypass (CPB) of three to five percent in most centers specializing in the care of children with congenital heart disease. CPB has evolved from futuristic visions of the surgical pioneers to safe and efficient means of support for those children undergoing repair of complex congenital heart defects. The application of CPB in the pediatric population is very demanding. Infants and children present a multitude of variables affecting hemodilution, hypothermia and flow rate restrictions of the arterial and venous cannulaes The pediatric perfusionist must be knowledgeable about the pathophysiology of the heart defect. For example, the presence of real or potential intracardiac shunts could place a patient at risk for air embolism if proper procedure and monitoring are not applied. Careful observation for rapid changes in the hemodynamics, temperature and lab data is vital for all cardiac cases with congenital heart disease. Much preparation is required to assess and accommodate basal metabolic demands of the anesthetized patient during CPB. Hemodilution, oxygen consumption, blood flow rates, blood and chemistry data are critical in decreasing the morbidity. Continued research in pediatric perfusion has dramatically furthered the field. Myocardial and cerebral protection has been greatly improved with such techniques as blood cardioplegia and regional low flow cerebral protection (RLFCP). RLFCP is a methodology of CPB used for selective cerebral perfusion undergoing reconstruction of the native aorta. Modified ultarfiltration (MUF) has emerged. MUF takes place in the immediate post-CPB period and utilizes the extracorporeal circuit in such a way as to allow both the ultrafiltration of the patient and the reinfusion of concentrated circuit contents. Advantages are decreasing the total body water, inflammatory mediators and pulmonary vascular resistance while increasing the hematocrit, colloid oncotic pressure, blood pressure and the lung compliance. Finally, there are ventricular devices available for the smallest of patients, such as the Berlin Heart. Miniaturization of the bypass circuitry, modulation of the inflammatory response and continued improvement in techniques of perfusion will maximize the safety and efficiency of CPB. New Visitor Policies at the Heart Center The Heart Center at Arkansas Children's Hospital is composed of two different units under one roof. One side is the CVICU, or cardiovascular intensive care unit. This is where children will stay immediately after surgery, and for some children before surgery as well. Across the hall is CV East, or the step-down unit. This unit is staffed by ICU nurses as well. Patients move to CV East after the ICU until they are ready to go home. Visiting Your Child in the CVICU
Visiting Your Child in CV East How You Can Help Us To Help Your Child On CV East Once your child has been transferred to East, your participation in your child’s care is very important. We will teach you everything you need to know to care for your child while he or she is a patient of East, so that when you are discharged you will be very comfortable going home. Please ask as many questions as you want to. Please ask questions as often as you need to. Don’t ever be afraid to write down your questions so that you don’t forget them. Some faces you may see on the unit participating in your child’s care are the doctors, residents, nurses, patient care technicians and the secretary. Each plays a vital role; please feel free to ask them for help whenever you need it. Your responsibilities will include the following; but remember that the nurse will teach you how to do each of these before you have to do them on your own: Please remember to keep your child’s room clean and tidy. Do not leave food or drinks lying around. You will be given a tour of the unit so that you can help yourself to the clean linens, clean pajamas for your child, the nutrition room and the playroom. Spotlight On Tonia
Cox What is your role at ACH and how long have you worked here? Currently, I am employed in the Heart Center as a Level III RN. My hours are split between bedside nursing (Friday nights) and coordinating (Sunday nights). I work extra in the Cardiovascular Intensive Care Unit (CVICU), Neonatal Intensive Care Unit (NICU), Pediatric Intensive Care Unit (PICU) and the Burn Unit. Why is your job rewarding? My job is rewarding for several reasons. I am proud to work with the weekend night staff. I appreciate their dedication, knowledge and skills. I also appreciate their ability to work together as a team. They are a responsible and independent group and they make my job as a coordinator much easier. I also enjoy working with the neonates in CV. It is rewarding to be able to anticipate and meet their needs, since they are unable to speak for themselves. I enjoy working toward positive outcomes for them. How did you become interested in pediatric
cardiology or cardiovascular surgery? What do you want people to know about the Heart Center at Arkansas Children's Hospital? I want them to know that we have a group of dedicated and talented professionals who will give the best care possible. No matter how busy or stressful things are in the unit, everyone works together to get the job done. I especially appreciate the “off shifts” for getting things done with less support/ancillary staff. What do you enjoy most about working with children? I enjoy doing my part to give them a chance for a healthy future. They are young and innocent, and they have their whole lives ahead of them. What has been your most memorable moment working in the Heart Center at Arkansas Children's Hospital? Several years ago I was caring for a patient in ECMO who suddenly decannulated. I quickly yelled for help. Charles, Karen and Julie came running, and Dr. Fontenot responded as well. Jay Avant and David Webb took care of the pump side of things, while we pushed blood and medication until surgical help arrived. It was a scary event, but everyone worked together, did their part and the patient survived. What is your greatest professional achievement? I have maintained my certification in neonatal intensive care nursing since 1990. I still enjoy working in the NICU occasionally, and I also try to be a resource to CV nurses in the area of neonatal care. Spotlight On
Adriane Lewis What is your role at ACH and how long have you worked here? RN in the Cardiology Clinic for 11 years. Why is your job rewarding? I have the opportunity to work with some of the finest heart doctors, co-workers and the strongest and bravest patients I have ever seen. How did you become interested in pediatric
cardiology or cardiovascular surgery? What do you want people to know about the Heart Center at Arkansas Children's Hospital? They will be taken care of by professional, compassionate and dedicated staff. What do you enjoy most about working with
children? What has been your most memorable moment working in the Heart Center at Arkansas Children's Hospital? Getting my RN.
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