Something Old, Something New

By Dr. Joseph Rossano and Dr. Jonathan M. Chen

Jonathan M. Chen, MD, and Joseph Rossano, MD, MS February is American Heart Month, an opportunity to focus on cardiovascular health. As co-directors of the Cardiac Center at Children’s Hospital of Philadelphia (CHOP), we focus on this every day, not just during the month of February, as we care for some of the 40,000 children born every year in the United States with congenital heart defects. For us, American Heart Month provides an opportunity to reflect on the strides we’ve made as a field, as well as the areas where we still need to make progress.

With that in mind, we thought we would highlight some of the biggest recent breakthroughs in pediatric cardiology that are allowing children with heart disease live longer, better lives – along with one change that could make the quality of those lives even better.

Something old

The lymphatic system is sometimes referred to as the “forgotten circulation” because, although Hippocrates referenced it in the 5th Century BC, it has been outside mainstream cardiology for the last 60 years or so. That has begun to change. Thanks to advances in imaging, including those led by researchers at the Jill and Mark Fishman Center for Lymphatic Disorders at CHOP, we are now able to “see” this complex network of lymph nodes, lymphatic capillaries and vessels, and lymph ducts and understand its underappreciated and understudied role in numerous diseases. We are now developing new treatments and surgical techniques to help patients whose lymphatic system isn’t functioning properly, due to leaky capillaries and vessels or flow disorders.

Something new

Part of what has restored our appreciation of the lymphatic system is the cutting-edge imaging technology we are now able to use to visualize this aspect of the human anatomy. But this goes beyond the lymphatic system. Pediatric cardiologists can now use 3D imaging and virtual reality to study heart problems – holding a three-dimensional image of a patient’s heart in their hands or stepping into a damaged ventricle and looking around. This might sound like science fiction, but virtual reality is now a routine tool in clinical practice. By viewing a patient’s scans virtually in a three-dimensional space, cardiac surgeons can examine an exact replica of the patient’s heart, looking at it from multiple angles prior to surgery to determine the best approach for that child. Once the domain of gamers, virtual reality is now changing how pediatric cardiology is practiced.

Something borrowed

Pediatricians have a saying that goes something like, “Children aren’t just little adults” – which is to say, medically speaking, pediatric patients are unique. The causes of disease and appropriate treatments will often be different for a child and an adult with the same condition. Nevertheless, some of the recent breakthroughs in pediatric cardiology have only come about due to similar breakthroughs in adult groups. For example, centrifugal continuous-flow ventricular assist devices (VADs) were initially approved as a bridge for end-stage heart failure adult patients until they could receive a heart transplant. That advance led to eventual studies in children with congenital heart disease, which showed these lifesaving devices could be used safely and effectively in pediatric patients as well.

Something long overdue

Unfortunately, the successes referenced above are very much the exception, not the rule. The truth is, we don’t have nearly enough FDA-approved pediatric cardiac devices. This is a problem across the field of medical devices – on average, less than a quarter of FDA-approved medical devices have an indication for pediatric use – but it is particularly challenging in the field of cardiology, where devices such as stents, valve replacements, and pacemakers regularly save adult lives but are few and far between for children.

A smaller market size and ethical considerations have hampered the field for decades, but we are long overdue for a thoughtful, creative approach in developing lifesaving medical devices for children with heart conditions. The FDA-sponsored System of Hospitals for Innovation in Pediatrics – Medical Devices (SHIP-MD) strategic framework is a step in the right direction. SHIP-MD brings together stakeholders from pediatric health systems, the medical device industry, academic institutions, and advocacy organizations to expedite the development of pediatric devices and reform a system that has not prioritized or incentivized device development for our smallest patients.

SHIP-MD is an important first step and one that we hope will spur further development of life-saving devices for children with heart conditions. Cardiologists have made huge strides in recent years in caring for children with heart conditions, and in the Cardiac Center at CHOP, we are committed to offering the best cardiac care and pushing for devices and treatments that will allow our patients to live healthy lives to their fullest potential.

Joseph Rossano, MD, MS, is Co-Director of the Cardiac Center and Chief of the Division of Cardiology at Children's Hospital of Philadelphia.

Jonathan M. Chen, MD, is Co-Director of the Cardiac Center and Co-Director of the Pediatric Heart Valve Center at Children’s Hospital of Philadelphia.