Cardiovascular Program

In recent years, there has been substantial growth, with a renovated inpatient space, a new intensive care unit and a new catheterization suite all completed in 2005. In addition, the clinical Cardiovascular Program is supported by a new research building, which opened in 2003.

The division is staffed by nurses dedicated to the care of children with heart disease. More than 2,000 patients were admitted to the cardiology inpatient service in 2004, 60 percent of whom underwent surgery. The average daily census is 22 patients.

The management of the cardiac medical patients is coordinated by the rotating first-year cardiology fellow, who leads a team of three pediatric residents on the service.

Teaching and supervision are provided by the attending cardiologist, rotating among Drs. Michael D. Freed, Jane W. Newburger, Peter Lang, Robert L. Geggel and Roger E. Breitbart.

Six nurse practitioners--Patricia O'Brien, RN, MSN, PNP, Heather Bastardi, RN, MSN, PNP, Clare O'Connor, RN, MSN, PNP, and Christine Larson, RN, MS, PNP--coordinate the care of the children recovering from surgery and heart transplantation.

Supervision and teaching is provided by two attending staff each day. The CICU staff are directly responsible for the perioperative care of all cardiac surgery patients in close collaboration with the cardiac surgery staff.

In addition to the usual intensive care management, all forms of pharmacologic support, mechanical ventilation, mechanical support of the circulation (ECMO and VAD) and renal replacement therapies are used in the CICU. A wide spectrum of patients are managed in the CICU, including newborns to adults with congenital heart disease, patients with acquired heart disease and heart failure, acute and chronic pulmonary hypertension and post-cardiac transplantation.

Peter Laussen, MD is the director of the CICU. Additional staff includes David Wessel, MD, Ravi Thiagarajan, MD, John Costello, MD, Mary Mullen, MD and Karen Booth, MD.

The director of the outpatient services is David R. Fulton, MD.

Senior staff cardiologists see patients during morning and afternoon sessions every day. Evening sessions are currently available at least one day each week.

Sub-specialty clinics, which include lipid, transplant, myopathy, adult congenital, arrhythmia, pacemaker and genetics are held on a weekly basis.

Consults are evaluated by a fellow and an attending staff cardiologist. Consults are seen at the time of the request. An in-house fellow, supervised by a senior staff member, assumes responsibilities for consults after 7 p.m. on weeknights. Appropriate cardiac testing (electrocardiography, echocardiography, cardiac catheterization) is performed by the divisions of the Department of Cardiology.

The Program is staffed by two transplant coordinators, cardiologists Laurie B. Armsby, MD, Leslie Smoot, MD, and Ravi Thiagarajan, MD, and Cardiac Surgeon Pedro del Nido, MD. The Program consists of a multidisciplinary team of consultants from nursing, social work, infectious disease, psychiatry and other allied health professionals.

The service evaluates and manages patients with end-stage heart failure, secondary to cardiomyopathy or congenital heart disease, for potential candidacy for a heart transplant. Since its inception in 1986, Children's has performed more than 150 heart transplants. The Program is responsible for the pre-, peri-, and postoperative management of the recipients.

On a monthly basis, either Michael Landzberg, MD, Mary Mullen, MD or Laurence Sloss, MD with the assistance of Disty Pearson, PA-C, Caitlyn O'Brien, PA-C and Susan M. Fernandes, PA-C and Candice Silversides, MD, Alison Knauth, MD, George Ruiz, MD, and Michael Singh, MD, are responsible for the inpatient BACH service -- cardiovascular service admissions and consultations on all adult patients with congenital heart disease --and act in concert with the medical teams.

John Mayer, MD, Pedro Del Nido, MD, Lawrence Cohn, MD, Tom Mihaljevic, MD, and John Byrne, MD, as well as Peter Lang, MD, and Edward Walsh, MD, participate in weekly patient care oriented conferences. Outpatient care is provided in a specialty clinic at both participating institutions.

Approximately 1,500 cardiac catheterizations were performed last year, at least 55 percent of which were interventional. Interventional procedures performed include: balloon valvotomy of pulmonary and aortic valves, including infants with critical pulmonary and aortic valvar stenoses; balloon angioplasty of residual coarctation of the aorta and stenotic branch pulmonary arteries; transcatheter closure of PDAs, ASDs, VSDs, aortopulmonary collaterals and other unwanted vascular structures; stent placement in pulmonary arteries, aortic coarctations and other locations; endocardial biopsies; and radiofrequency ablation of bypass tracts. Several of these procedures were developed at Children's over the past few years.

The division is directly involved in the care of all inpatients and outpatients with cardiac arrhythmias, including those in the cardiac intensive care unit. There is a dedicated electrophysiology catheterization suite with state-of-the-art recording and ablation equipment, where more than 400 procedures are performed annually. Non-invasive rhythm evaluation by Holter monitor monitoring, event recording, signal averaged ECG, T-wave alternans analysis, tilt-table testing and esophageal EP testing are included in the division's activities.

Outpatient care is delivered in specialized arrhythmia and pacemaker clinics, which meet three days per week.

The division's research activities span a broad range of interests, including the molecular genetics of arrhythmias, autonomic physiology, computer modeling of reentry circuits, whole-animal mapping and ablation studies. In addition, human clinical protocols for the development and testing of catheters, drugs and anti-tachycardia devices are being studied.

It is an active facility with state-of-the-art technology for 3D, 2D and M-mode echo, pulsed, continuous wave and color Doppler. Instrumentation includes 10 Hewlett-Packard Sonos 5500 cardiac imagers, a PC-based off-line analysis system developed in-house for M-mode, 2D and Doppler analysis, a commercial 3-D image reconstruction workstation, and a sophisticated video editing and image processing system for creating and editing still and video images. The laboratory recently implemented a digital image capture and archiving system to digitally record full-length echocardiographic exams and make them available, via intranet, throughout the institution. Laboratory personnel include 14 full time pediatric ultrasound technicians. The laboratory is certified by the Intersocietal Commission for the Accreditation of Echocardiographic Laboratories for pediatric transthoracic, transesophageal and fetal imaging.

Approximately 16,000 2D Doppler echocardiograms (including 1,100 fetal studies), and 6,100 left ventricular function studies are performed annually, with we have a sustained annual growth rate of 10 percent per year over the past 18 years. In addition to clinical evaluations, the laboratory participates in numerous research protocols, including evaluation of ventricular function parameters in a variety of congenital and acquired heart diseases, evaluation of the utility and reliability of noninvasive imaging and Doppler in diagnosis and outcome determination, and evaluation of new and emerging technology such as 3-dimensional echocardiography and tissue Doppler.

Access to the reports of most patient studies performed by the department is available electronically. This makes them available for research as well as continuing patient care and administration.

Data have been collected since 1973 on more than 90,000 patients, and include information from the catheterization lab, surgery, echocardiography, ECG, exercise tolerance tests and clinic visits. Hospital-wide data (i.e. ADT, clinical labs, etc) are accessible through the hospital's central servers. The department employs five computer support personnel and two statisticians full-time to provide support and programming. Computer training is available through both the department and the hospital.

Faculty members from all divisions in the Department of Cardiology lead or participate in prospective, multi-disciplinary and/or multi-center studies. Examples of such studies (ongoing or soon to begin) include:

The Departments of Cardiology and Cardiac Surgery enjoy a cooperative and constructive working relationship at Children's Hospital Boston. Joint efforts are an integral part of patient care, teaching and research. Several weekly combined conferences are held.

For easy and rapid review of the more common forms of heart disease in infants and children, there is a Teaching Collection that consists of 28 different types of congenital and acquired heart disease, each small container having several examples of the anomaly in question. There is also a collection of normal hearts, important for quantitation, from prematurity to adulthood. A series of teaching videotapes is available for review. The videotapes consist not only of the 38 presentations titled "Diagnostic and Surgical Pathology of Congenital Heart Disease" (directed by Richard Van Praagh, MD and Stella Van Praagh, MD), but also 37 additional tapes concerning Pediatric Cardiovascular Disease: New Approaches to Management (directed by Michael D. Freed, MD), and other subjects. Access to patients' clinical information and all other laboratory data facilitates research, as does a library of relevant journals, textbooks, and theses.

The Cardiac Registry is a unique, fully integrated teaching and research resource for congenital heart disease. The Heart Collection is now non-renewable and irreplaceable, because large unoperated examples of virtually all forms of congenital heart disease are no longer seen at autopsy in this country. The specimens of the Heart Collection have been saved over the past half century (1944-present), and they represent all eras of pediatric cardiology and cardiac surgery, from presurgical, to closed-heart, to open-heart.

Topics currently under investigation include the effects of different cardioplegia solutions and perfusion pressures on myocardial preservation, mechanisms of cerebral damage during bypass in neonatal animals, studies on the role of calcium and other second messengers and the affects of ischemia on immature myocardium, development of tissue engineered prosthetic cardiac valves and robotic techniques in cardiovascular surgery, and design and evaluation of electrophysiologic mapping techniques.

The molecular biology facilities include support for oligonucleotide synthesis, DNA sequencing, gel documentation and phosphoimaging in the biopolymer facility. Other techniques are well-supported including, the use of transgenic mice, gene chip analysis, the yeast two-hybrid system, expression cloning, cDNA cloning and site-directed mutagenesis. Basic protein biochemistry is also a major component of work. FPLC, cold rooms and electrophoresis apparatus are used in these endeavors. The laboratory maintains its own computer network consisting of a network linking Mac, PC and Unix machines.

Extensive equipment supporting basic cardiac electrophysiology and imaging includes eight patch-clamp electrophysiology setups, a Biorad confocal microscope adapted for tissue-slice work by using multiphoton illumination, a Zeiss confocal laser scanning microscope (LSM-410) adapted for two-photon imaging and caged release, a conventional fluorescence microscopes and evanescent field (TIRF) microscopy.