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Dr. Mike Smith (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Mike. And with me is Dr. Aseel Dabbagh, a pediatric cardiologist from Children's Mercy. Joining us is also Dr. Jeff Shuler, another esteemed pediatric cardiologist. Today, we are diving into a panel discussion on Heart to Heart" Pediatric Cardiologists on Caring for Children with Congenital Heart Defects. Doctors, welcome to the show.

Dr. Aseel Dabbagh: Thank you for having us.

Dr. Jeff Shuler: Thanks for having us.

Host: Dr. Dabbagh, I'm going to go ahead and start with you. What are the most common types of heart defects you're dealing with and how do they vary in complexity across age groups?

Dr. Aseel Dabbagh: Thank you. That's an excellent question. So, the field of pediatric cardiology is considered niche, but we actually see a vast array of congenital heart defects. They can range from very-- to our mind,-- simple, so a PDA, which is a remnant in fetal physiology, that can close on its own, but sometimes needs our assistance to simple holes in the heart, in the septum, such as a ventricular septal defect or a VSD or an atrial septal defect or an ASD, and some valvular pathologies like pulmonary stenosis, as well as coarctation of the aorta and more complex defects like Tetralogy of Fallot and hypoplastic left heart syndrome. And depending on the complexity of the disease, the treatment, of course, will vary as well.

Host: You know, Dr. Dabbagh, sticking with you for a second. When you look at these common heart defects that you're treating, how has picture changed over the years? What was the prognosis for a child just, say, 20, 30 years ago versus today?

Dr. Aseel Dabbagh: Yes. It really depends on what the actual heart disease is, but simple defects like PDA or VSD could have a relatively healthy life depending on how small it is. But if it's a lot bigger, then it could definitely end up causing significant morbidities such as pulmonary hypertension. But with our advancements in technology and diagnosis, we've really definitely helped treat a lot of patients, whether that's with surgical correction or diuretic use or catheter-based approaches and these patients go on to have a very healthy life.

Host: Dr. Shuler, how do you approach early diagnosis and intervention, especially in cases detected prenatally or in the neonatal period?

Dr. Jeff Shuler: That's a great question, and another question that kind of gets at the idea of how much things have changed in this field over not that long of a time period. And just to add to that last question, I think that, things that couldn't be repaired not that long ago, you know, are very routinely repaired now. And so, things have evolved in a significant way. Surgeries on the heart weren't happening until the '40s and '50s. And then, now, the complexity of what can be done is pretty incredible when you think about how short of a time span that is.

And then, back to your question and kind of the idea of early diagnosis and identifying these things early is another thing that has really changed. When we look back on how this field has evolved, the ability to identify congenital heart disease before a baby is born is now kind of the standard and the norm. And we routinely do identify complicated congenital heart defects before a baby's born. And that is critically important and very helpful for a lot of reasons. It helps us identify which babies that are going to be born have specific needs for which hospital is appropriate or safe for them to be born at. Whether infusions of medications like prostaglandin infusion are going to be critical to allow for them to have a smooth transition into life after birth.

And so, identifying these things before a baby is born allows for planning and management, but also families to understand what interventions are anticipated and what the options are, and to be able to think about it ahead of time and not just in the acute setting of figuring it out if the diagnosis is made after birth.

Host: Dr. Shuler, since we talked a little bit about where we were in the past, where we are today, I'd like to ask you what excites you the most about diagnosis and treating congenital heart defects in children that you see in the future coming.

Dr. Jeff Shuler: I'm not a fetal expert myself. There are lots of niches within cardiology, but I would say that something that is really exciting to think about is interventions, whether it's medical with medications or actually interventions with procedures before a baby is even born. That is something that is occurring already. And I see likelihood of potential advancements of that in the future. But that is not my personal expertise. But that's certainly one of the aspects of where things may be heading in the future.

Host: Dr. Dabbagh, what are some of the key considerations that you have to make when developing long-term care plans for children with complex defects?

Dr. Aseel Dabbagh: Yeah. So with complex defects, we have to think lifelong. If you think about it, congenital heart disease is an evolving field and a lot of the patients who were getting surgeries and interventions, that was only happening around 40, 50 years ago. So now, they're adults. And the key considerations are evolving from that sense in how long-term complications can come up in that timeframe.

So now, we're learning as well as knowing the patients who have come before about how to treat them as they grow older and what complications can arise such as rhythm abnormalities, or effects of the surgery, or congenital heart disease that can evolve into heart failure. So, lots of different things to take care of depending on the actual disease. Of course, it's always patient-centered. And we try to minimize those risks by routine follow-ups, of course. But sometimes we have to deal with things as they come and go from there.

Host: Dr. Dabbagh, what do you think about the future? What excites you about the future in your field?

Dr. Aseel Dabbagh: I think for me, it's similar to Dr. Shuler with the fetal interventions. I've seen a couple of patients myself who've had fetal interventions, and they were successful and minimized the heart disease extent and morbidity that it caused the patient after they were born. So, that's definitely an exciting field. And like Dr. Shuler, I'm not a fetal expert per se, but it's definitely been something that's very exciting.

Host: Dr. Shuler, how do you support the families in all this? This is a lot that's going on, right? They have a neonatal child. And all of a sudden, there's a heart condition and big words are being thrown around and stuff. How do you support them in all that?

Dr. Jeff Shuler: Yeah. That's a very difficult aspect of this job. But honestly, to me, the most important and rewarding and the part of the job that I take very seriously, and I think all of my cardiology colleagues do, and it's how do you make something this scary and this complicated understandable to a family, especially in the moments where they're learning about it and all the heightened emotions like you mentioned, it's a very difficult thing.

And so, I think, in general, we spend a lot of time with families, spend a lot of time drawing things, drawing out a heart, how blood flows through the heart and how it's different in your child, and what can we do to help mitigate those differences. And so, it's a lot of time and a lot of Shared kind of teaching back and forth and making sure they understand what you're talking through. And I think drawing and using figures and diagrams has come a long way. You know, some of us draw hearts. Some of us also use really high fidelity either videos of diagrams of hearts or actual models of hearts, three-dimensional printed hearts. There's a whole world of how do we visualize a heart and explain it to ourselves, both medically, but also to families. And so, there's a lot of time and discussion, I think, is what it comes down to.

Host: Do other specialties get involved in that support?

Dr. Jeff Shuler: There's a big collaborative nature to our field across a lot of subspecialties. But I think, to that point, working with radiology, so we have a lot of cross-sectional imaging of complex congenital heart defects where there's a collaborative effort between both a cardiac imager as well as a radiologist. And so, sometimes that's one thing I can think of to that point. But we're certainly collaborating with neonatal doctors and pediatricians and everyone who's involved in the care of these children in a very multidisciplinary way.

Host: And Dr. Dabbagh, you're kind of in a position to really help coordinate a lot of that, right? So, how difficult is that to get the cardiac surgeons on board. And then, I'm sure there's some genetic aspects involved in primary care pediatrics. What kind of process do you have to go through?

Dr. Aseel Dabbagh: So, kind of going back to what I was saying earlier about how the field of congenital heart disease has advanced, as we've learned over the past 60 or so years, about what these patients need, we've, as a field, developed more of a collaborative, as Dr. Scheller was saying, in how we treat these patients even before birth. And so, after they're born, everyone is already on board and usually aware of most patients who are born with congenital heart disease, including the neonatologists and pediatricians, as well as the geneticists and our cardiac neurodevelopmental team who helps these kids thrive.

And it's kind of, at least at our organization, is very streamlined, as far as what these patients can need. And so, lots of things happen behind the scenes. But when we do have a new diagnosis, it's very streamlined still to get everyone on board. And as part of a collaborative, we have weekly discussions about patients and their needs, as well as a day-to-day basis of more specific needs and coordinating all of these things for these patients. But it's very coordinated as we've learned over the past decades.

Host: Dr. Shuler, we talked about the future and both of you agree that the procedures in those prenatal time periods is really amazing. But you guys specifically, in your practice right now, what has impacted your approach to treating defects in the most recent years?

Dr. Jeff Shuler: I think one of the big things that's evolved recently is finding innovative ways to repair defects that we've already been repairing. So, a lot of defects that historically had only been able to be repaired with a surgery, now we've developed the interventional cardiology group, the ability to repair a lot of these things with less invasive what we call transcatheter or in the cath lab approaches that don't involve a full cardiopulmonary bypass and the full cardiac surgery that used to be necessary. And so, there's a lot of discussion in those meetings that she was just talking about where we're talking with our colleagues, which means us cardiologists, but also the interventional cardiologists and the cardiothoracic surgeons to answer one question, which is commonly asked which is this a defect that we need to repair surgically or can we repair this with a less invasive catheter approach? And so, repairing things in the cath lab and intervening and diagnosing things in the cath lab is a very real part of our current era of pediatric cardiology and a really significant and excellent advancement that's happened over the recent history.

Then, one last thing I would add to that is imaging technology, the ability to see things that we couldn't see before, and to visualize them and evaluate them with different techniques like not only echocardiography, but also things like MRI and 4D flow and 3D models and lots of different highly advanced techniques that have evolved and are routinely used now, makes it a lot easier to visualize and help figure out the best plan for these patients.

Host: Dr. Dabbagh, how do you prepare patients and families for the transition from pediatric to adult congenital heart disease care?

Dr. Aseel Dabbagh: So, we like to start with our patients in their early teen years, similar to a pediatrician, as we are pediatricians to begin with. And we start talking to the patients really about what their cardiac diagnosis is and what they understand of it and what they should be thinking about in the future as far as their risk factors and if there are any job considerations that need to be thought of or any exercise limitations and stuff like that.

But as far as transitioning them to an adult congenital provider is the biggest thing. And that's one of the advancements that have come out of us learning about these long-term considerations. And the good thing about that is an adult congenital heart provider is trained on congenital heart disease. And so, yes, we're transitioning them to a different provider, but they will still understand everything about their disease and we'll work with a pediatric cardiology team and surgeons to take care of them.

Host: Dr. Shuler, is there any last word you have for the listening audience?

Dr. Jeff Shuler: Mostly, I just want to thank people for listening in and being interested. And like she said at the beginning of this, this is kind of a niche field and it's not a routinely very common thing. But for us, it's very common and there are a lot of variables to be aware of. And so, any interest and people wanting to learn more about our field is greatly appreciated and we're always happy to answer questions and talk through things with anybody.

Host: Dr. Dabbagh?

Dr. Aseel Dabbagh: Yeah, I would echo what Dr. Shuler said and that we're always happy to answer questions, and do any sort of education to really benefit our patients in the end.

Host: Fantastic. This has been great information. I want to thank both of you for coming on the show today. For more information, visit cmkc.link/cmepodcast. If you enjoyed this podcast, please share it on your social channels and explore our entire podcast library for topics of interest to you. This is Pediatrics in Practice, a CME podcast. I'm Dr. Mike. Thanks for listening.