HISTORICAL REVIEW OF PAED. CARDIOLOGY & CARDIOTHORACIC SURGERY IN SOUTH AFRICA

1. HISTORICAL REVIEW OF PAED. CARDIOLOGY & CARDIOTHORACIC SURGERY IN SOUTH AFRICA PROF. SOLLY LEVIN November 2007

2. HISTORICAL REVIEW • AIM: A comparison of our achievements with those attained in overseas centres. • Paediatric Cardiology Workshop: Sept. 2002 “ It is not possible to consider Paed Cardiology as a discipline totally separate from Paed Cardiothoracic Surgery”. • Certain Milestones will be considered.

3. Historical Review • HISTORICAL INTRODUCTION 1938 - PDA ligation: Robert E Gross ( USA ) 1944 - Coarctation repair: Clarence Crafoord ( Sweden ) 1944/5 - Subclavian to Pulmonary artery shunt: Alfred Blalock & Helen Taussig ( USA ) 1950 - Creation of an ASD ( in children with TGA ): Alfred Blalock & Rollins Hanlon ( USA ) 1955 - Repair of tetralogy of Fallot using extracorporeal circulation: C. Walton Lillehei ( USA ) 1957 - Atrial switch repair (using autogenous atrial tissue) for TGA: Ake Senning ( Sweden ) 1964 - Atrial switch repair (using a pericardial baffle): W.T. Mustard (Canada ) 1965 - Balloon atrial septostomy (BAS) for TGA: William Rashkind ( USA )

4. 1945: Work of HELEN TAUSSIG at Johns Hopkins – Baltimore. Brought together clinical, X-Ray & ECG findings in the diagnosis of various types of cong. heart disease. Published 2 volumes in 1947 – entitled “ Congenital Malformations of the Heart”. Co-operation between paed. cardiologist & surgeon resulted in the BLALOCK – TAUSSIG operation with improvement in the oxygenation of cyanotic children. HISTORICAL REVIEW

5. HISTORICAL REVIEW H. Taussig et al. - 1970

7. HISTORICAL REVIEW Alfred Blalock (1866 - 1965)

8. HISTORICAL REVIEW • 1949: Alex Nadas appointed as cardiologist – Children’s Hospital, Boston. Cardiac catheterisation extended to infants & neonates by Abe Rudolph. 1958 – Pediat. Clin.N. Amer. 5: 907. • 1955: Cardiopulm, by-pass machines used by Gibbon and Walt Lillehei ( DE WALL – LILLEHEI Bubble Oxygenator ). Successful correction of VSDs & tetralogy of Fallot. • 1958: Chris Barnard starts open-heart surgery in CT. Chris Rainier-Pope cardiac surgery technician at 1st operation ( VSD ).

9. HISTORICAL REVIEW

10. TETRALOGY OF FALLOT • HISTORY 1673 - Neils Stensen. First anatomical description. 1888 - Arthur Louis Etienne Fallot. Made a precise anatomic diagnosis at the bedside & was proved right at postmortem. (1) VSD; (2) Subpulmonary stenosis; (3) Deviation of origin of the aorta to the right; (4) RV hypertrophy. 1945 - Blalock-Taussig Anastomosis of left subclavian artery to LPA. 1955 - C. Walton Lillehei. Total repair of tetralogy with extracorporeal circulation. LOCAL EXPERIENCE: 1961 - C.N. Barnard. Surgery on 42 patients; 7 deaths. 1975 - T.G. O’Donovan et al. Surgery on 40 patients; 1 late death. 2 patients at each centre required re-op for residual VSDs.

13. HISTORICAL REVIEW • 1965: Balloon atrial septostomy – RASHKIND First performed in S. Africa by Ronnie v.d. Horst et al. in Durban. Subsequently reported from JHB by G.E. Gale et al. in SAMJ, Sept. 1971. 10 of 12 successful from Sept. 1967 onwards. • 1967: ECHOCARDIOGRAPHY in Cong. Heart Disease In Nov. 1971, Pediatr. Clin. Of N.Amer. 18: 1163 – 1190. Article by Ellie Chesler, Hymie Joffe, Wally Beck and Velva Schrire from Cape Town. Later contributions by Norman Silverman from SanFrancisco.

14. TRANSPOSITION OF THE GREAT ARTERIES( TGA ) • 1999 - LONG TERM FOLLOW-UP AFTER MUSTARD REPAIR BY DR. THAMI TSHIGABE ( Jhb. Hospital ) • 1972 - 1988 86 PTS underwent Mustard (intra-atrial) repair. 57 MALE & 29 FEMALE. Simple TGA - 46 & Complex TGA - 40 Median follow-up: 15 years. • DEATHS Early - <30 days : 9/86 (10.4%) Late - >30 days : 13/86 (15.1%) Sudden - 8/77 (10.4%) cf: 7-15% in the literature. • ARRHYTHMIAS Supraventricular 23/77 (30%) PAT or Atrial Flutter - 13; Nodal rhythm - 10; Cor. Sinus rhythm - 4; Ventr fibrillation 1; Complete heart block - 1. Persistence of sinus rhythm: See Kaplan-Meier graph

15. TGA ( contd ) • SURVIVALBetter for Simple TGA than Complex TGA. See Kaplan-Meier survival curve. • RV DYSFUNCTION 13/77 (17%) ; Overt RV failure - 6 pts. • BAFFLE OBSTRUCTION 31 (40%) SITE NO. RE-OP. SVC 19 3 PV 8 5 IVC 4 0 • NEURO MORBIDITY 15 PTS Hydrocephalus - 5 • SCHOOLING Of 14 pts over the age of 18 yrs - 11 have completed Matric.

16. The Arterial Switch Operation in Patients under 3 Months of Age J J Drummond-Webb, RBB Mee Department of Pediatric and Congenital Heart Surgery Cleveland Clinic Foundation Children’s Hospital Cleveland, Ohio

17. Arterial Switch Operation ASO regardless of coronary anatomy Simple TGA:< age 2 months TGA - VSD : < age 3 months Complex TGA - Arch obstruction: 1-stage neonatal repair

18. HISTORICAL REVIEW • 1967 – 2007: ECHOCARDIOGRAPHY • 2-D: T T E & T E E ( Diagnostic & Intraoperative ) • Doppler & Colour Doppler – estimate pressures & valvular function • Estimate ventr. function ( esp LV ) • As an aid in interventions • Contrast echoes • Foetal echoes

19. HISTORICAL REVIEW • RECOGNITION OF PAED CARDIOLOGISTS Initially paed cardiac problems were seen by the adult cardiologists, but a number of paediatricians were already interested in the early 1960s. • Bill Winship – 1962 Cardiac OPD at King Edward, and caths at Wentworth. 1964 CSIR Fellow at Groote Schuur. 1968 – Paed cardiologist at Wentworth. • Myself – 1962 -1965 Started with caths at Bara. 1966-68 Cardiac clinic at TMH & caths at JGH with John Barlow. 1969 Fellow at Children’s Hospital, Chicago. 1970 – Paed cardiologist at TMH • Hymie Joffe – 1970 started unit RXH (ex Boston )

20. HISTORICAL REVIEW • RECOGNITION OF PAED CARDIOLOGISTS (contd) • 1978 – Budgie v.d. Merwe at Tygerberg ( trained by Dr.S. Blake ) • 1978 – Andre Bruwer at Bloemfontein. Dedicated paed cath lab from outset. • REGISTRATION AS SPECIALTY: • 1978 – with SAMDC. Paediatrician plus 2 years training in a recognised paed cardiology unit. • NOW – CMSA – College of Paediatricians: Cert Cardiology(SA) Paediatricians, and HPCSA.

21. HISTORICAL REVIEW • INTERVENTIONAL CARDIOLOGY • 1990:Report on 193 procedures in RSA from 1983 to July 1990. Balloon valvuloplasties: 99 –valvar PS; 43 – rheumatic mitral stenosis. • 1990-93: Report on trancatheter closure of PDA in 50 cases with the Rashkind device. • NOW: Use of various Amplatzer occluders to close ASDs & VSDs; Stents for Coarctation & Pulm Art Stenosis; occlusion of AV-Fistulas. ( Recent workshop by Dr. Hijazi at Sunninghill ).

22. HISTORICAL REVIEW • 1996 – ROUND TABLE DISCUSSION Paediatric cardiac problems in S Africa – sponsored by Prof Brink , Cardiovascular Journal of Southern Africa • Cong heart disease accounts for 2/3 of the problem. • ? Establishment of a national register & standardised data base – for a more accurate picture. • Rheumatic heart disease – role of the National Health Service. • Lack of trained electrophysiologists to manage paed. arrhythmias. • Indications for & results of cardiac surgery not covered.

23. HISTORICAL REVIEW • 1997 – 2007: PATIENT CARE • General decline – esp. for indigent patients at Academic Hospitals. • Financial constraints – Drop in number of medical posts, loss of nursing staff to private sector & overseas. Result: waiting list for surgery, difficulties with obtaining new equipment. • 2002 – Workshop on “MODERNISATION OF TERTIARY CARE SERVICES” • 2003 - One solution: Western Cape Paediatric Cardiology Service.

24. HISTORICAL REVIEW • PATIENT CARE ( CONTD ) • Impact of HIV-Aids. • ? Extending our service to sub-Saharan Africa. • The role of the Walter Sisulu Paed Cardiac Centre. • Closer co-operation between Academic & Private units. • Another burden! Creation of GUCH clinics.