Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 253--259

Pediatric cardiology: Is India self-reliant?


Sivasubramanian Ramakrishnan 
 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Prof. Sivasubramanian Ramakrishnan
Department of Cardiology, All India Institute of Medical Sciences, New Delhi
India




How to cite this article:
Ramakrishnan S. Pediatric cardiology: Is India self-reliant?.Ann Pediatr Card 2021;14:253-259


How to cite this URL:
Ramakrishnan S. Pediatric cardiology: Is India self-reliant?. Ann Pediatr Card [serial online] 2021 [cited 2021 Dec 3 ];14:253-259
Available from: https://www.annalspc.com/text.asp?2021/14/3/253/323817


Full Text



Annals of Pediatric Cardiology (APC) is a global journal and has a vision to further expand its footprint across the world.[1] Indian health care has seen unprecedented growth in the last few decades, which has further received a great boost with the announcement of “Make in India” and “Atmanirbhar Bharat Abhiyan (self-reliant India program)” by the Government of India. The editorial board of APC has decided to dedicate the current issue to “Research Made in India,” an attempt to highlight the progress of pediatric cardiology in India. Besides, this editorial tries to address a few critical questions: “Has India become self-reliant in the field of pediatric cardiology in terms of delivering clinical care, in training health professionals, and in addressing research questions relevant to India?”

 Self-Reliance in the Delivery of Patient Care



The first pediatric cardiac surgery was performed in India way back in 1949 and the first Indian center that sought to deliver pediatric cardiac care was established in the 1960s.[2] After considerable hiatus until the mid to late 90s, multiple pediatric cardiac centers were established. Many of these are now offering high-quality pediatric cardiac and surgical services. In the current scenario, we need to address issues related to availability, accessibility, and affordability of pediatric cardiac care in India.

A status report in 2005 estimated the number of pediatric cardiac centers in India at 14,[3] and the number stands now at 90 based on an inquiry done among the members of Pediatric Cardiac Society of India (PCSI). It only seems that pediatric cardiac care in India has grown from its infancy to childhood. The rate of increase in the number of hospitals is particularly steep in the past two decades with newer cities such as Jaipur, Raipur, Coimbatore, Bhubaneshwar, Palwal, and a few more added to the map of pediatric cardiac care in India. Despite this, patients face a variety of challenges in accessing standard pediatric cardiac care. Most of the pediatric cardiac centers are concentrated in major cities, and most of them are privately run. The distribution of pediatric cardiac centers is also not uniform across the country. For instance, Kerala has eight centers offering neonatal cardiac surgeries for an estimated 4.5 lakh annual childbirths. In stark contrast, the most populous states of India, namely Uttar Pradesh and Bihar, with estimated annual childbirth of 48 and 27 lakhs, respectively (Census of India, 2012), do not have a center capable of performing neonatal cardiac surgery. Hence, all sick neonates born in these states who need emergency cardiac surgery have to be transported, often by trains, buses, or occasionally private ambulances to the nearest cardiac centers, which are usually hundreds of kilometers away.

Many Indian pediatric cardiac programs have shown the way in terms of cost-efficiency. Most of the cardiac procedures are performed at a fraction of the cost compared to Western countries. For instance, an arterial switch surgery costs anywhere between 800 and 6000 USD in India, depending on the nature of the hospital, while the approximate cost for the same procedure exceeds 50,000 USD in the United States.[4] However, lack of insurance and dependency on out-of-pocket expenses have remained major hindrances, making pediatric cardiac care largely unaffordable for the average Indian family. Fortunately, several funding opportunities have emerged for children needing a cardiac surgery over the past decades. Janani Shishu Suraksha Karyakaram (JSSK), a program under the National Health Mission, intends to eliminate the out-of-pocket expenses incurred by families toward the treatment of infants in public health facilities. Ayushman Bharat, other state government insurance schemes for the underprivileged, and funding from nongovernmental organizations have made financial assistance for pediatric cardiac procedures available for most Indians. However, a lack of awareness about these schemes among parents remains a major constraint.

Developing subspecialties of pediatric cardiac care in India is the need of the hour. Whereas interventional and surgical pediatric cardiology services are reasonably well established, especially in the Southern and Western parts of India, the rest of subspecialties lack an organized structure. Even in these parts, the rates of antenatal diagnosis of congenital heart disease (CHD) are dismal. Some specialized services such as inherited cardiovascular disease clinics[5] and pediatric heart transplant programs are getting established. However, organized adult CHD and pediatric electrophysiology services are almost nonexistent. There are no dedicated care providers for adults with CHD, with both trained adult cardiologists who lack CHD knowledge and pediatric cardiologists who lack expertise in managing adults, ultimately ending up caring for these patients. There are no dedicated pediatric electrophysiologists, and electrophysiology services for children with CHD are provided by adult electrophysiologists only. There are very few personnel qualified as pediatric cardiac intensivists, and there is really no system to train them.

In delivering pediatric cardiac care, India has taken the first steps toward being self-sufficient. There is a lot that needs to be done for improving the access and the quality of care. The available resources, though limited, are to be utilized judiciously. Every state should establish enough pediatric cardiac centers to cater to their local needs and develop an integrated model of care for children with heart diseases. Lessons should be learned from programs like the Hridyam, a unique initiative by the Government of Kerala, aimed toward early detection and management of critical CHDs. At the hospital level, quality and outcomes are variable across India. Nationwide audits and quality control initiatives are needed. We need to set up centers of national excellence for uncommon pediatric cardiac conditions such as cardiomyopathies, inherited cardiovascular diseases, and pulmonary hypertension.

 Self-Reliance in Training of Personnel



The US had 2966 pediatric cardiologists in 2019, with a ratio of one pediatric cardiologist per 29,196 population.[6] In contrast, India has only 300 pediatric cardiologists for a population of 1.39 billion with a ratio of one per 4,500,000 population. The comparison is even more dismal for pediatric cardiac surgeons, though accurate numbers are not available. An additional challenge is to motivate younger generation cardiovascular surgeons to take up the subspecialty of pediatric cardiac surgery. The number of centers offering pediatric cardiology fellowship programs has increased over the years. Yet, the total number of fellows trained (Doctorate in Medicine and Diplomate of National Board) is around 35 per year only. Unlike the Western world, where most fellows (59%) pursue advanced fellowships after their pediatric cardiology fellowship,[7] such opportunities are seldom available in India. To bridge the gap, PCSI has instituted fellowship programs in selected subspecialties of fetal cardiology, electrophysiology, and pediatric cardiac intensive care involving centers of excellence across the country. India needs to invest in training specialized nurses to provide critical care for children with CHD, a neglected field. The number of training centers, quality of training, and availability of advanced subspecialty training must further improve in India.

 Self-Reliance in Research



In contrast to patient care and education, we are a lot less self-sufficient in terms of research in pediatric cardiology. India is a net consumer than the producer of original research in the field. In recent years, the major Indian contributions to pediatric cardiac surgery include two-stage arterial switch surgery,[8] delayed primary arterial switch surgery,[9] and an innovative approach of integrated extracorporeal membrane oxygenation circuit[10] for late presenters with transposition of great arteries (TGA) and intact ventricular septum. In the field of noninterventional pediatric cardiology, noteworthy Indian contributions include echocardiographic screening for rheumatic heart disease,[11] drug therapy for children with idiopathic pulmonary hypertension[12] and adolescents with Eisenmenger syndrome,[13] use of thiamine to reverse infantile pulmonary hypertension,[14] management of nonspecific aortoarteritis,[15] and lifestyle diseases in children.[16,17] Off-label use of devices for perimembranous ventricular septal defects[18] and Gerbode defect,[19] ductal stenting in late presenters with TGA,[20,21] and balloon-assisted atrial septal defect device deployment technique[22] are some of the major contributions to the field of interventional pediatric cardiology. Truly Indian innovations include a percutaneous transvenous aortic valve technology (MyVal; Meril Life Sciences Pvt. Ltd, India) and a multifunctional occluder device known as Lifetech™ Konar-MF.[23]

Indian contributions to pediatric cardiac research could have been a lot better, considering the number of patients and the quality of expertise. It is unfortunate that none of the Indian articles featured among the most influential 100 articles compiled by Eynde et al.[24] in the field of CHD published between 2000 and 2020. This is despite the fact that research activity in Indian pediatric centers has increased exponentially, and the total number of articles published from India is at its peak in recent years. One of the main reasons for this paradox is that the research performed in India is not focused on areas that interest the Western world.

For this editorial, the most cited Indian articles published over 30 years between 1991 and 2020 were compiled [Table 1]. The methodology used for compiling the list and relevant references is outlined in Supplementary Appendix 1 and 2 [SUPPORTING:1]. Such an approach focusing on citations, especially in a field known for low citation scores, has an inherent bias toward older articles and articles focusing on popular areas. Yet, this exercise presents some important learnings. Most of the impactful Indian researches in pediatric cardiology over the past three decades have come from only a few select institutions involving a group of dedicated clinical researchers. Furthermore, most of these articles concentrated on relevant Indian issues, prevalent tropical diseases, or introduced niche ideas. They offer the young Indian pediatric cardiac specialists an inspiration and motivation to aim higher and encourage them to focus on issues that are pertinent to Indian patients.{Table 1}

Focused issue on research “Made in India”

In this issue of Annals, we decided to focus on Indian research articles, and it reflected a lot of our strengths. All the major Indian pediatric cardiac centers are represented, covering various aspects of pediatric cardiology including intensive care,[25] anesthesia,[26] fetal cardiology,[27] electrophysiology,[28] and heart transplantation,[29] fields in which articles published from India are limited.

The PCSI COVID-19 registry[30,31] is the first major collective effort from 24 pediatric cardiac centers across India. The first of the two papers offers a bird's eye view of what happened to pediatric cardiac care in India during the COVID-19 pandemic. It is heartening to see that emergent cases received appropriate care despite mounting challenges.[30] The second paper confirms the popular belief that the outcome of unoperated children with serious CHD could be compromised when they acquire a COVID-19 infection.[31] The accompanying editorial proposes a call for action and describes how we can prevent the situation in future in India and other low- and middle-income countries.[32] We sincerely hope that this first collaborative registry is the beginning of brighter things to come and not a one-time affair. To make this a reality, we need strong leadership, wider participation, and persistence.

Successful percutaneous pulmonary valve implantation (PPVI) using three different percutaneous valve systems is presented[33],[34],[35] and includes the first Indian multicenter experience of Melody valve implantation.[33] These articles raise the uncomfortable question that why Indian patients should wait for 20 years to get these newer and expensive technologies. The successful off-label use of relatively cheaper Indian MyVal system in pulmonary position could help us in making the therapy more affordable.[34] However, at current costs, these therapies are out of full insurance coverage by governmental and private insurance schemes. The editorial by Kothari[36] presents a critical appraisal of follow-up of operated patients with Tetralogy of Fallot and the thoughtful application of these expensive PPVI technologies in Indian patients. Considering the various concerns with PPVI in India, a strategy to reduce the subsequent requirement for pulmonary valve replacement during the primary surgery assumes greater importance, which was the focus of two different surgical approaches described from India in the current issue.[37,38]

Randomized controlled trials, especially drug trials, are a rarity among children with CHD. A randomized study of propranolol for heart failure in infants with ventricular septal defect demonstrated reduced hospitalizations and improved outcomes.[39] Exploring novel medical therapies is important for India, as many children diagnosed with critical heart disease do not receive timely interventions. Even though definitive evidence is lacking, the importance of beta-blockers for heart failure in children is highlighted in the editorial by Buchhorn.[40] He argues for a more widespread use of beta-blockers for heart failure in children, while more evidence becomes available.

 Research in Pediatric Cardiology in India: Problems and Prospects



The major reasons for the current state of pediatric cardiac research in India include lack of manpower, overwhelming patient load and clinical care, lack of dedicated time for research, lesser funding opportunities, and limited collaborative multicenter research. Research in pediatric cardiac surgery is even less compared to the field of interventional cardiology, and so is research in the fields of pediatric cardiac anesthesia and intensive care. Rarely, various subspecialties come together to perform high-quality research. The status of medical research and the reasons for it are the same across various medical fields in India and are not unique to pediatric cardiology.

Pediatric cardiac research in India is limited to a select few individuals of limited centers as stated earlier. Some of them excel in their fields and are world leaders. However, the number of such leaders is small for a country of the size of India. The most critical and urgent step needed is to increase the critical mass of persons involved in pediatric cardiac research. In this regard, it is heartening to see a few small centers thinking beyond anecdotal or uncommon case reports and coming up with innovative original research work. Importance of having our outcome data could not be overemphasized as it would help us realize how far and how fast we need to go before we could achieve self-reliance. We need to move beyond intervention-dominated research. Challenges in resource-limited settings are unique, and we need to focus on our own problems and innovate methods to resolve them. Long-term follow-up studies are difficult in the Indian system, but increased mobile phone penetration and advancements in telemedicine services provide good opportunities.

Western medical curricula have integrated research as a core activity of academic training. Basics of research methodology are systematically taught, and pathways for becoming a physician–scientist are well established. Those in academic positions are periodically evaluated on the merits of projects and research output. Such systems are nonexistent in India even in academic institutions. Then, why do Indian physicians indulge in research? either due to compulsion to fulfill criteria for promotions or thesis requirements for their academic degrees. Only a handful are self-motivated and carry out research with an itch to solve an important problem. We need to make clinical research attractive in India by introducing both financial and nonfinancial incentives. Mentoring is another hurdle as the number of good quality mentors is limited in India. Often, mentoring is limited within the boundaries of catheterization laboratories and operating rooms in India. The pediatric cardiac community in India is witnessing a generational change. Those who are about to graduate to leadership positions need to have a futuristic vision and make a difference in research while maintaining the standards set in clinical care. In recent times, several youngsters are coming through and are importantly focused on a particular field. Many of them are inducted into the revamped editorial board of APC. Some institutions collaborate with foreign institutions and encourage young fellows and faculty, especially in their formative years, to take part in collaborative clinical work and research.

In a nutshell, critical appraisal of pediatric cardiac research in India may identify a lot of missed opportunities. However, what is already achieved is commendable considering the dismal physician per patient ratios and workload. Each missed opportunity is a chance to learn and strategize a plan. We need to concentrate on collaborative research, high-quality randomized controlled studies, meta-analysis, and systematic reviews focusing on areas relevant to India. An increase in the critical number of clinicians involved in research, motivating the younger generation, and incentivizing research activities may be the first steps ahead.

“You are what your deep, driving desire is. As your desire is, so is your will. As your will is, so is your deed. As your deed is, so is your destiny.”

–Anonymous, Brihadaranyaka Upanishad

Let's change our driving desires to change the destiny of children born with heart diseases in India.

Happy Independence Day 2021!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Ramakrishnan S. Annals of pediatric cardiology: A glorious journey and a vision for the future. Ann Pediatr Cardiol 2021;14:135-8.
2Saxena A. History of pediatric cardiology in India. J Pract Cardiovasc Sci 2015;1:203-5.
3Saxena A. Congenital heart disease in India: A status report. Indian J Pediatr 2005;72:595-8.
4Faraoni D, Nasr VG, DiNardo JA. Overall hospital cost estimates in children with congenital heart disease: Analysis of the 2012 kid's inpatient database. Pediatr Cardiol 2016;37:37-43.
5Rajan S, Chockalingam P, Koneti NR, Geetha TS, Mishra S, Narasimhan C, et al. Initial experience and results of a cardiogenetic clinic in a tertiary cardiac care centre in India. Ann Pediatr Cardiol 2021;14:443-8..
62020 Physician Specialty Data Report. Number of People Per Active Physician by Specialty, 2019. Association of American Medical Colleges. Available from: https://www.aamc.org/what-we-do/mission-areas/health-care/workforce-studies. [Last accessed on 2021 Jul 27].
7Ross RD, Srivastava S, Cabrera AG, Ruch-Ross HS, Radabaugh CL, Minich LL, et al. The United States Pediatric Cardiology 2015 workforce assessment: A survey of current training and employment patterns: A report of the American College of Cardiology, American Heart Association, American Academy of Pediatrics Section on Cardiology and Cardiac Surgery, and Society for Pediatric Cardiology Training Program Directors. J Am Coll Cardiol 2017;69:1347-52.
8Iyer KS, Sharma R, Kumar K, Bhan A, Kothari SS, Saxena A, et al. Serial echocardiography for decision making in rapid two-stage arterial switch operation. Ann Thorac Surg 1995;60:658-64.
9Bisoi AK, Sharma P, Chauhan S, Reddy SM, Das S, Saxena A, et al. Primary arterial switch operation in children presenting late with d-transposition of great arteries and intact ventricular septum. When is it too late for a primary arterial switch operation? Eur J Cardiothorac Surg 2010;38:707-13.
10Bisoi AK, Ahmed T, Malankar DP, Chauhan S, Das S, Sharma P, et al. Midterm outcome of primary arterial switch operation beyond six weeks of life in children with transposition of great arteries and intact ventricular septum. World J Pediatr Congenit Heart Surg 2014;5:219-25.
11Saxena A, Desai A, Narvencar K, Ramakrishnan S, Thangjam RS, Kulkarni S, et al. Echocardiographic prevalence of rheumatic heart disease in Indian school children using World Heart Federation criteria-A multi site extension of RHEUMATIC study (the e-RHEUMATIC study). Int J Cardiol 2017;249:438-42.
12Kothari SS, Duggal B. Chronic oral sildenafil therapy in severe pulmonary artery hypertension. Indian Heart J 2002;54:404-9.
13Mukhopadhyay S, Sharma M, Ramakrishnan S, Yusuf J, Gupta MD, Bhamri N, et al. Phosphodiesterase-5 inhibitor in Eisenmenger syndrome: A preliminary observational study. Circulation 2006;114:1807-10.
14Sastry UM, Jayranganath M, Kumar RK, Ghosh S, Bharath AP, Subramanian A, et al. Thiamine-responsive acute severe pulmonary hypertension in exclusively breastfeeding infants: A prospective observational study. Arch Dis Child 2021;106:241-6.
15Tyagi S, Khan AA, Kaul UA, Arora R. Percutaneous transluminal angioplasty for stenosis of the aorta due to aortic arteritis in children. Pediatr Cardiol 1999;20:404-10.
16Raj M, Sundaram KR, Paul M, Deepa AS, Kumar RK. Obesity in Indian children: Time trends and relationship with hypertension. Natl Med J India 2007;20:288-93.
17Narang R, Saxena A, Desai A, Ramakrishnan S, Thangjam RS, Kulkarni S, et al. Prevalence and determinants of hypertension in apparently healthy schoolchildren in India: A multi-center study. Eur J Prev Cardiol 2018;25:1775-84.
18Udink Ten Cate FE, Sobhy R, Kalantre A, Sachdev S, Subramanian A, Koneti NR, et al. Off-label use of duct occluder devices to close hemodynamically significant perimembranous ventricular septal defects: A multicenter experience. Catheter Cardiovasc Interv 2019;93:82-8.
19Trehan V, Ramakrishnan S, Goyal NK. Successful device closure of an acquired Gerbode defect. Catheter Cardiovasc Interv 2006;68:942-5.
20Sivakumar K, Francis E, Krishnan P, Shahani J. Ductal stenting retrains the left ventricle in transposition of great arteries with intact ventricular septum. J Thorac Cardiovasc Surg 2006;132:1081-6.
21Kothari SS, Ramakrishnan S, Senguttuvan NB, Gupta SK, Bisoi AK. Ductal recanalization and stenting for late presenters with TGA intact ventricular septum. Ann Pediatr Cardiol 2011;4:135-8.
22Dalvi BV, Pinto RJ, Gupta A. New technique for device closure of large atrial septal defects. Catheter Cardiovasc Interv 2005;64:102-7.
23Tanidir IC, Baspinar O, Saygi M, Kervancioglu M, Guzeltas A, Odemis E. Use of Lifetech™ Konar-MF, a device for both perimembranous and muscular ventricular septal defects: A multicentre study. Int J Cardiol 2020;310:43-50.
24Van den Eynde J, Franchi T, Foo YC, Mills B, Ali S, Doulamis IP, et al. The 100 most influential articles in congenital heart disease in 2000–2020: A bibliometric analysis. Int J Cardiol Congenit Heart Dis 2021;4:100156.
25Pathak P, Das S, Gupta SK, Hasija S, Choudhury A, Gharde P, et al. Effect of change in tidal volume on left to right shunt across ventricular septal defect in children – A pilot study. Ann Pediatr Cardiol 2021;14:350-5.
26Joshi R, Aggarwal N, Agarwal M, Joshi R. Anaesthesia protocols for “bedside” preterm patent ductus arteriosus ligation: Single institutional experience. Ann Pediatr Cardiol 2021;14:343-9.
27Bakhru S, Koneti NR, Patil S, Dhulipudi B, Dash T, Kolar G, et al. Prenatal diagnosis of vascular rings and outcome. Ann Pediatr Cardiol 2021;14:359-65.
28Rasal G, Deshpande M, Mumtaz Z, Phadke M, Mahajan A, Nathani P, et al. Arrhythmia spectrum and outcome in children with myocarditis. Ann Pediatr Cardiol 2021;14:366-71.
29Ramaswamy RK, Marimuthu SK, Ramarathnam KK, Vijayasekharan S, Rao KG, Balakrishnan KR. Virtual reality guided LVAD implantation in pediatric patient: Valuable pre surgical tool. Ann Pediatr Cardiol 2021;14:388-92.
30Choubey M, Ramakrishnan S, Sachdeva S, Mani K, Gangopadhyay D, Sivakumar K, et al. Impact of COVID-19 pandemic on pediatric cardiac services in India. Ann Pediatr Cardiol 2021;14:260-8.
31Sachdeva S, Ramakrishnan S, Choubey M, Koneti NR, Mani K, Bakhru S, et al. Outcome of COVID-19 positive children with heart disease and grown-ups with congenital heart disease: A multicentre study from India. Ann Pediatr Cardiol 2021;14:269-77.
32Shivaprakasha K. Getting around the pandemic – Lessons from the PCSI COVID-19 study. Ann Pediatr Cardiol 2021;14:278-80.
33Sheth K, Azad S, Dalvi B, Parekh M, Sagar P, Anantharaman R, et al. Early multicentre experience of Melody valve implantation in India. Ann Pediatr Cardiol 2021;14:302-9.
34Sivaprakasam MC, Reddy RV, Sengottuvelu G, Sivakumar K, Pavithran S, Rohitraj GR, et al. Early multicentre experience of a new balloon expandable MyVal Transcatheter Heart Valve in dysfunctional stenosed right ventricular outflow tract conduits. Ann Pediatr Cardiol 2021;14:293-301.
35Sivakumar K, Sagar P, Qureshi S, Promphan W, Sasidharan B, Awasthy N, et al. Outcomes of venus-P valve for dysfunctional right ventricular outflow tracts from Indian Venus-P valve registry. Ann Pediatr Cardiol 2021;14:281-92.
36Kothari SS. Percutaneous pulmonary valve implantation in India – Quo Vadis? Ann Pediatr Cardiol 2021;14:310-4.
37Dharmapuram AK, Ramadoss N, Goutami V, Verma S, Pande S, Devalaraja S. Early experience with surgical strategies aimed at preserving the pulmonary valve and annulus during repair of tetralogy of Fallot. Ann Pediatr Cardiol 2021;14:315-22.
38Jain A, Rajan SK, Patel K, Garg P, Agrawal V, Kakkar D, et al. Concomitant pulmonary valve replacement with intracardiac repair for adult tetralogy of Fallot. Ann Pediatr Cardiol 2021;14:323-30.
39Ramakrishnan S, Ghati N, Ahuja R, Bhatt KN, Sati HC, Saxena A, et al. Efficacy and safety of propranolol in infants with heart failure due to moderate to large Ventricular Septal Defect (VSD-PHF study)-A prospective randomized trial. Ann Pediatr Cardiol 2021;14:331-40.
40Buchhorn R. Betablocker therapy in pediatric heart failure: 50 years lost to improve pharmacotherapy of a deadly disease. Ann Pediatr Cardiol 2021;14:341-2.