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Events
Lecture of Dr B Soma Raju, Chairman CARE
Hospital, delivered at Jubilee Hills Public School, Hyderabad on
Tuesday, 1 March 2005
Scenario
Each newborn is a responsibility of the immediate family, the society
and finally, the nation.
During a lifetime and even during the months prior to birth, any
individual may develop heart disease, or acquire a lifestyle pattern or
environment that fast-tracks him/her to develop heart disease.
35% of Indian population is < 15 years of age.
India is in the phase of "epidemiological transition". On the one hand,
there is a substantial burden due to rheumatic fever, infection and
malnutrition and, on the other hand, there are a vast number of cases of
obesity and diabetes which represent the degenerative and man-made
diseases.
Heart Abnormalities at Birth
A foetus may be affected during cardiac development by intrauterine
infection e.g. rubella, or drugs and toxins, such as tobacco and
alcohol, taken by the mother.
Some genetic conditions are also associated with a higher incidence of
abnormal heart development e.g. Down’s syndrome and Turner’s syndrome.
Some maternal chronic diseases such as Diabetes are also associated with
an increased incidence of babies having abnormal hearts.
Lack of folic acid during the first trimester may also predispose the
foetus to heart defects.
CHD
Congenital heart disease (CHD) is the most common birth defect and
affects a large number of children.
The incidence of CHD in various countries and different ethnic groups is
about the same. The incidence of CHD in infancy varies from 4 to 12 per
1000 live-births.
The number of cases of CHD recognized in the first year of life is only
about two-thirds the number of cases recognized in a population of
children followed up till their teens.
In India, every year, about 121 000 children with CHD reach the age of
15 years. Of these, one-third would require long-term follow-up in adult
life.
As children with CHD are now surviving to have children of their own,
the incidence of mothers with CHD having affected children is 2.5-18%,
and the incidence of fathers with CHD having affected children is
1.5-3.0%, both figures are higher than for the general population.
About 45% of CHD cases require some form of intervention or surgery
during childhood.
Thus, every year, nearly 50 000 children require surgery or care at an
advanced infant cardiac centre. However, in our country every child who
needs surgery does not get operated.
Taking the number of paediatric oxygenators used as an indirect measure
of paediatric cardiac surgeries performed for children below 1 year of
age, the number for India is <1000.
The gap is therefore enormous.
RHD
Rheumatic heart disease is a condition in which permanent damage to
heart valves is caused by rheumatic fever. The heart valve is damaged by
a disease process that generally begins with a sore throat caused by
bacteria called Streptococcus, and may eventually cause rheumatic fever.
The prevalence of RHD has declined in the West but continues to be an
important cause of cardiovascular morbidity and mortality in India. The
prevalence of RHD varies from 1.0 to 5.4 per 1000 schoolchildren.
A prevalence of 21/10,000 schoolchildren is the best estimate we have.
That means in your school we are most likely to have at least I child
with RHD.
The incidence of rheumatic fever (RF) varies from 0.2 to 0.75 per 1000
per year in schoolchildren 5–15 years of age. On an average, one-third
of patients with a possible first attack of rheumatic fever develop
chronic valvular lesions.
The younger age of onset of RHD seen in India is a special feature of
both public health and clinical importance.
Juvenile RHD is a more severe and rapidly progressive disease. It is
associated with significant mitral stenosis, organic tricuspid valve
disease, severe pulmonary artery hypertension and congestive heart
failure.
It is the commonest heart disease associated with pregnancy and is found
in about 1% of pregnant women.
The most and dominant valvular lesion is mitral stenosis (72%), which
leads to significant maternal and foetal morbidity and mortality. These
patients require either balloon mitral valvuloplasty or surgical mitral
commissurotomy. Both procedures are available only at limited centres in
India.
Surgeries on Children
Valvular surgery in India is performed mostly for RHD. Every year about
8,000 valve replacements are done. Of these, about 5,000 are mitral
valve replacements, about 2,000 aortic valve replacements, and about
1,000 repair/ replacement of other valves.
These operations cover only a fraction of the very large number of
patients who need them. The high cost of prosthetic valves and
inadequate facilities for operative management of these patients are
hindrances to valve replacement surgery.
Valve replacement surgery costs approximately 10 times the average
annual income of a person.
Prevention
Prevention is an established and cost-effective strategy for RHD.
Dissemination of education can assimilate this into routine health care
practice.
For CHD, early detection and awareness of known antenatal risk factors
can probably reduce the incidence.
Little Hearts
At CARE Hospital, we have set up a Little Heart Foundation. So far we
have received more than 2 croes from more than 6000 donors. The first
donor was our President Dr APJ Abdul Kalam who gave Rs. 100,000 of his
personal money to start this fund. So far more than 150 surgerirs have
been done on children and more than 500 children are given dates for
surgeries.
We are now planning to set up an adolescent heart disease clinic. This,
we hope, can significantly reduce morbidity.
Future
Advances in biogenetics (such as the rheumatic fever vaccine) will
probably end these diseases in next ten to fifteen years.
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