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| Sunday, 26 September 2004 |
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Features |  |
| News Business Features Editorial
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Compiled by Carol Aloysius Is surgery for heart defects a safe option?
Surgery is now a standard procedure for treating heart defects in young and old. Dr. Prasad Krishnan Consultant Cardiac Surgeon at the Apollo Hospital discusses the latest techniques in treating heart defects, in an interview with Carol Aloysius. Q: How safe is heart surgery ? A: Coronary Artery Bypass Grafting (CABG) has become a routine, standard, very safe, reproducible, good operation with a less than 1 per cent mortality. The key thing is to restore blood flow before muscle damage occurs. Heart muscle is very valuable and man has yet to find a suitable alternative.
The extent and severity of coronary artery disease varies from patient to patient and it is important to individualize treatment for every patient. Multiple blocks, especially in diabetics are best treated by surgery. Q: What is the age range of patients and what are the types of heart disease, that can be treated with surgery ? A: We have operated on patients ranging in age from six days to 85 years and weighing 2.1 kg to 110 kg. The types of heart diseases treated with surgery, fall into three groups. They are : Coronary Artery Disease (Disease of the vessels that supply blood to the heart); Disease of the heart valves; Congenital Heart Disease - Birth defects of the heart. Our heart develops during the first 60 days of fetal life in the womb. Many things can go wrong during this complex process of development which can give rise to a wide variety of congenital heart diseases. Q: Are congenital heart defects very common in new borns ? What causes them ? A: Congenital cardiovascular defects are present in about 1 percent of live births. They're the most common congenital malformations in newborns. In most children we don't know why they occur. Sometimes a viral infection causes serious problems. German measles (rubella) is an example. If a woman contracts German measles while pregnant, it can interfere with how her baby's heart develops or produce other malformations. Other viral diseases also may cause congenital defects. Heredity sometimes plays a role in congenital cardiovascular defects. Q: What effect does a heart defect have on a child ? A: While we are in the womb (uterus) of the mother, we get our oxygen from the mother. The moment we are born, we need to be able to get oxygen from the air. Depending on the type of defect, their effects on the child can vary from being incompatible with survival outside the womb, to survival with a widely variable life span. Q: What does Transposition of the Great Arteries (TGA) mean ? A: It is a condition where all the individual components of the heart are well formed, but are connected wrongly. As can be seen from the diagram, this makes it impossible for body to get oxygenated (red) blood. Many of these children die in the first month of life without urgent intervention. Certain heart defects can have a profound effect on the growth and development of the child and various other organ systems, like the lungs, brain and kidneys. Q: What is a 'blue baby'? A: In Tetralogy of Fallot there is mixing of the red and blue blood, because of the hole in the heart and narrowing of the pipe going to the lungs. This is one of the causes of a 'blue baby'. Some children have an obstruction to the flow of blood from the pump, like Subaortic Stenosis. This can damage the pump, (left ventricle) upstream and the aortic valve downstream. It is important to remove this obstruction, before severe damage. If the aortic valve gets severely damaged, we do not have a substitute nearly as good as only a natural valve will grow in a child. Q: What is the role of surgery in the treatment of birth defects of the heart in children? Is it a safe procedure ? A: There have been numerous recent advances that have made open heart surgery very safe and successful in small infants, even in the first few weeks of life. Some of these are fast accurate diagnosis using altrasound, (echocardiography); advances in anaesthesia, perfusion technology, surgical expertise and post operative ICU care. Multiple heart defects can be corrected with one operation and it is not necessary to wait for the child to grow up to a certain size, if the risks of waiting are high. Q: What are the limitations if any of cardiac surgery ? A: We are limited by the fact that we can only modify what nature has provided and cannot remake the heart, the way nature should have, with artificial valves and pacemakers. For the heart muscle, there is no long-term substitute. Q: What are the problems with artificial valves ? A: Blood clots whenever it comes in contact, with foreign material, like an artificial valve. This necessitates taking anti clotting drugs that have side effects like bleeding. To overcome this problem, valves made from animal or cadaver tissue have been used, but these valves seldom last a lifetime. Further artificial valves will never grow, which is very important in a child. For these reasons it is always better to repair a valve if it can be done successfully and the results are long lasting. Q: When can a valve be repaired? What are the advantages of repairing a valve? A: With presently available techniques, almost all patients with severe mitral regurgitation caused by mitral valve prolapse, can have a good long lasting repair, for upto 20 years. The mitral valve in addition to functioning as a valve is very important in preserving the shape and function of the ventricle or pump. It has been seen that those who have had a successful valve repair therefore live much longer than those with a valve replacement. They can lead a normal life and need not have to take anti clotting medicines as in the case of a valve replacement. Q: What about non surgical methods of treatment of heart disease ? A: The last decade has seen tremendous progress in the non surgical treatment of heart disease, in the cardiac catheterization lab, for all the disease groups mentioned before. Some of the narrowings in coronary arteries are best treated with angioplasty/stenting. Some narrowed valves are best treated by opening them with a balloon. Some holes in the heart, are best closed with devices in the cath lab. These techniques are complementary to surgery. However not all defects can be best treated in the cath lab and surgery does have its place. Q: What do you have to say about the present status of cardiac care in Sri Lanka ? A: There are many excellent centres offering very good Cardiac care, in Sri Lanka. They can do all types of cardiac surgery, in all age groups with excellent results and much lesser cost. ********************* Communicating with the autistic child - a real life story by Florica Stone I first came across the word 'Autism' or Autism Spectrum Disorders' in 1992 in a paediatrician's surgery. She asked "What do you think that is wrong with your son?"
My husband replied "We don't know but my mother thinks that he is autistic." The paediatrician replied "I am afraid it is autism." Her words sounded like a death sentence. I did not know what the word meant and she wasn't able to explain it to me in simple English. At the age of 3 years and 6 months, Alexander did not know who I was. He did not know that I was his mum, he did not call me mum; he did not kiss me and avoided hugs as if hugs were stinging nettles. I felt rejected and inadequate. His 'diet' consisted of earth, grated cheese, orange juice, milk and chocolate biscuits. He spent his waking hours inspecting his toys, dust particles or repetitively placed a toy car on the top of a ramp and watched it coming down. Alexander was fascinated with water and could spend 2 hours watching the water running out the tap and flooding the bathroom floor. He did not talk to me and he did not play with his brother. Instead he wrote on the walls or painted numbers from 1 to 1000. We could not go out for a walk because as soon as we stepped outside the house Alexander ran ahead, crossing roads with no fear or sense of danger. If I asked him to stop or wait, he ignored me. We became prisoners in our home. Alexander never shared his toys, and he did not respond to his name. If I shouted out his name he walked past me as if he did not hear me, yet if his favourite cartoon was on TV he ran into the room and stood mesmerised in front of the TV until his cartoon was finished. These are just a few behaviours that set Alexander apart from other children of the same age. I knew that I had to act. I knew that I had to do something to teach him to talk but I did not know how to go about it. Like every parent in the world, I found myself wanting a cure for my child and the doctors told me that there isn't one. Cure 13 years later I can say without fear or heartache that, 'There is no 'cure' for autism and yes my son is just as autistic today as he was on the day he was born.' This means that the doctor's statement 'there is no known cure for autism' was correct. Parents of any race or religious beliefs around the world feel the same fear and desperation that I used to feel when I was told that there is no cure for autism. If your child is different, if you cannot communicate with him and don't know how to go about teaching him to communicate I hope my story can help. You the non-autistic can teach yourself to understand how your child's mind works and then you can teach him to communicate with you. If the autistic child is not talking with you it is because he doesn't know why we are talking. You can teach him the role of language. If the child avoids playing with other children of his own age it is because he finds them too unpredictable and scary. You can become his best friend, mentor and protector. Play with him, have fun with him, observe him, nurture him and bring fun into his life. Help him feel loved even though he behaves differently. These guidelines should help towards meaningful communication Step 1 Help him to acquire words Hello mirror, hello wall, goodbye mirror goodbye wall. Alexander 4 years old I know and you know that we don't say hello to mirrors. But if Alexander decided to say hello to each object in the house we did too. We walked around the house and said Hello to everything. This way he was given the opportunity to expand his vocabulary. If your child is 3, 4 or 5 years old and if he is not talking with you, it is highly likely that you have stopped talking with him as well. Start talking with him again. If the child covers his ears when he hears loud sounds whisper your words. Covering ears means that the child has hypersensitive hearing. As you are whispering words encourage him to repeat them. The child doesn't need to see you or look at you during this exercise. He needs to hear you and he needs to repeat the word after you. Step 2: Help him see that each word has an exact meaning This was done by labelling every object that we gave him (glass, cup, ball, car, train) or labelling each action as we were performing it (open door, close box, tickle, run, spin). You can ensure that your child learns meaningful words by being precise. For example if the child likes a drink of milk in a plastic cup, when you give him milk in a plastic cup say 'milk in plastic cup' not 'drink in plastic cup.' Why you might ask. The word drink can mean 'milk, water, juice' You want the child to taste and see and learn all three words, milk, juice, water. Another example: If the child likes a tickle and a massage, if you are giving a tickle use the word tickle as you are tickling him. Do not give him a massage when you use the word tickle. This is because you want him to experience and associate the word tickle with the action. If he can say the word 'tickle'! and if when he says the word he is expecting you to do it, then engage into this game wholeheartedly. You want him to see that words are powerful. They make things happen. If he calls out 'stop!' you must freeze in an instant. If you stop as soon as he asks, the child once again can experience the power of words. These experiences will motivate the child to learn more words. Step 3: Use words to make meaningful sentences "No look at me. Mummy draw red railway line." Alexander 5 year old. To reach this stage we encouraged him to add on to single verbs. Take the tickle game. Once Alexander knew that if he called out 'tickle!' I would tickle him I started to play the 'fool'. I would say 'tickle the floor?' or 'tickle Alex?' Invariably Alexander replied 'Tickle Alex!' The next step was to have two people ready to tickle Alex. This was I could ask "Mummy tickle Alex?" or "Sebastian tickle Alex?" so Alex would say "Mummy tickle Alex". The first sentence was formed. This is a gradual process, which happens as the child's understanding of language grows. Step 4 Enunciation "Mum can I nook it?" Alexander 5 years old Alexander wanted to look through the camera. Instead of using the word 'look' Alexander used the word 'nook'. It is common for children not to pronounce the words properly. Each time Alexander said 'Can I nook it?' I said 'Yes you can look at it.' With the passing of time he did pronounce the words correctly. Step 5: Using intonation to convey your intention The simple advice is do not use intonation to convey your message. Use precise words that you know your child understands. Intonation makes little sense to a non-verbal autistic child. You can begin teaching the meaning of intonation after the child is actively interested in interacting with people. A child will show an active interest in interacting with other people when he is allowed to be himself. In other words if the people surround him tell him all day "Don't do this, stop it, come here, sit still, don't touch that" the child is less likely to want to learn from others. If on the other hand the adult approaches the child with curiosity and patience, if the adult is a source of fun, the child will learn from the adult. Your child is in front of you, ready to be discovered, waiting to be interacted with, ready to become a learner ready to be loved. Teach him to communicate your way so that you can find out how he feels and that he can find out how you feel. Do not be afraid of his age, and do not be conned by miraculous cure claims. For individualised help you can contact the writer on her e-mail: ********************* Journalist award for excellence on health - 2004 Sri Lanka Medical Association has called for entries from those who have contributed to the print media on Health issues from July 1st 2003 to June 30, 2004, for the "Annual Journalist Award for excellence on health issues". The scheme is open to journalists, including free-lancers, from newspapers and health magazines of all three languages in Sri Lanka. Medical Doctors registered with the Sri Lanka Medical Council are not eligible for this award. The following criteria should be adhered to by all entrants: * Contestant should apply personally with the endorsement of the relevant institution he/she is working for, to certify that he/she is a professional journalist (either fulltime parttime or free-lance) * Contestant should submit not more than three (03) articles of his/her choice) * Contestant should certify that the articles are his/her own, and that they were published during the period July 01, 2003 to June 30, 2004. He/She should also name the date and source of the article. * Entries should be accompanied with certification from the institution he works for, that it is his/her own work. * Completed entries should be sent to by registered post to reach The Chairman, Media Committee, Sri Lanka Medical Association, No. 6, Wijerama Mawatha, Colombo 7 before 12 noon, on October 15 2004. Recipient of the award will be selected by an independent panel of judges from among eminent health and media personnel. For further information please contact: The Chairman, Media Committee, Sri Lanka Medical Association, 6, Wijerama Mawatha. |
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