Heart Murmurs

Winter 2013

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75 years of cardiovascular innovations at Boston Children's

The cardiologists, cardiac surgeons and other clinicians in the Cardiovascular Program at Boston Children’s Hospital have consistently lived up to the words of surgeon pioneer Robert Gross, MD, who ushered in the field of congenital heart surgery. On Aug. 26, 1938, when his boss was traveling for a family holiday, this chief resident performed the world’s first ligation of a patent ductus arteriosus (PDA) in a 7-year-old girl. This year marks the 75th anniversary of that landmark operation, which demonstrated that intervention on the great vessels within the chest was possible, with curative outcome1.

“Prior to Dr. Gross’s successful procedure, opening a child’s chest to work on the blood vessels carried a mortality risk of almost 100 percent,” explains Pedro del Nido, MD, chief of cardiac surgery at Boston Children’s. “Gross set a standard for innovation at our institution by tackling clinical challenges for which other physicians thought there were no solutions. Every chief of cardiology or cardiac surgery who has followed him has attempted to solve complex clinical problems in a similar manner.”

Gross and his colleagues didn’t stop transforming cardiology there. He and Charles Hufnagel, MD, recommended surgical correction for coarctation of the aorta2, which was later performed by Clarence Crafoord, MD; he 

sewed an atrial well on the right atrium for atrial septal defect closure without need of circulatory arrest3; and he performed surgical correction of the aortopulmonary window4.

“Establishing the tradition of bench to bedside, which is unique to academic medical centers, Gross took what he learned in the Pathology Department and applied many diligent hours of research to a widely recognized clinical problem,” says Richard Van Praagh, MD, of the Cardiac Pathology Department at Boston Children’s, who began working as a resident at the institution in 1953.



Collaboration is key

During a 22-year tenure as chief of cardiac surgery at Boston Children’s, Aldo Castañeda, MD, fostered a tradition of collaboration among the cardiologists, cardiac surgeons, cardiovascular nurses and the entire interdisciplinary team.

“In fact, Castañeda was my strongest supporter when I arrived in Boston Children’s in 1984, even though interventional cardiology was a fairly nascent field at the time,” says James Lock, MD, cardiologist-in-chief at Boston Children’s. “Since the surgeons here were so open to innovatively treating patients with congenital heart disease, they quickly accepted the work that I had been pursuing before my arrival, including performing angioplasty in the pulmonary arteries and venous obstructions.”

By the mid-1980s, the burgeoning Cardiology Program was the first to perform percutaneous valvuloplasty on a mitral valve in the United States, as well as the first to close a ventricular septal defect in the catheterization lab and the first to percutaneously close patent foramen ovale to prevent strokes5. The evolution accelerated from there, and by the early 1990s, interventional cardiologists at Boston Children’s reported successful outcomes of a modified Fontan operation with baffle fenestration and subsequent transcatheter closure6.

“While cardiologists and cardiac surgeons bring different perspectives to the table, we are all tackling the same disease,” says del Nido. “We recognize that there are certain patients who require medical therapy and others who require surgery or a catheter-based intervention. There can’t be a competition among specialties—there must be a collaboration to the point that we recognize when the other specialty’s approach is appropriate for the individual patient.”

This “spirit of innovation that emanated from cardiac surgery” expanded to interventional cardiology, and then to electrophysiology and noninvasive cardiac imaging, explains Lock.

Out of this collaborative process, the programs have worked together to discover a better treatment process for hypoplastic left heart syndrome (HLHS)—which for the previous six decades had predominantly relied on shunts. In 2001, surgeons performed the world’s first successful in utero treatment of HLHS in a 19-week-old fetus. Five years later, the interventionalists performed the world’s first in utero cardiac stenting to treat HLHS with intact atrial septum in a 30-week-old fetus. Over the past 12 years, the teams have established the staged left ventricle recruitment strategy, which uses the standard single-ventricle treatment for HLHS and additional procedures to spur the body’s capacity for healing and growth and encourage the
small left ventricle to grow and function.

The beat drums on

Large academic medical centers are uniquely positioned to continue to foster multidisciplinary laboratory and clinical research, in spite of potential regulatory and funding barriers to innovation.

“The regulatory climate that requires a great deal of data to prove safety and effectiveness can create a barrier to market penetration, as we’re assessing rare, pediatric conditions,” says del Nido. However, the FDA is starting to engage with academic medical centers for pediatric research, exemplified through the creation of the agency’s Pediatric Device Consortia, of which Boston Children’s was one of the first members.

“Another barrier is that industry is less willing to invest in pediatric innovations, because it’s a smaller market due to the size of the patient population,” says del Nido. As a result, the Boston Children’s Heart Center has seen the benefit of engaging with medical device makers, pharmaceutical manufacturers and technology companies early in the research process to collaborate on commercialization.

In the era of health care reform, the next wave of innovation may come from a way to systematically to address gaps in care and scrutinize health care resources. “SCAMPs (Standardized Clinical and Management Plans) could have major impact on these considerations, as their spread across the pediatric and adult populations has been incredibly rapid,” says Lock. “SCAMPs is the only current method of standardizing care that fosters innovation, because it allows clinicians to interact with the guidelines. It shouldn’t be a surprise that SCAMPs originated in an institution that has a legacy of fostering innovation.”

“Throughout our long history of developing unique treatment approaches and new inventions for pediatric patients, which have drastically impacted pediatric cardiology at large, Boston Children’s has always encouraged the individual physician-researcher through exposure to bench research, proper resources and supportive collaboration to allow each individual’s innovative spirit to soar,” says Van Praagh.

References

1. Vricella LA, Gott VL, Cameron DE. “Milestones in Congenital Cardiac Surgery.” 989-998.

2. Gross RE, Hufnagel CA. “Coarctation of the Aorta—Experimental Studies Regarding Its Surgical Correction.” N Engl J Med 1945; 233:287-293.

3. Gross RE, Watkins E, Pomerantz AA, Goldsmith EI. “Method for Surgical Closure of Interaurical Septal Defects.” Surg Gynec & Obst. 96:1;1953.

4. Gross RE. “Surgical Closure of an Aortic Septal Defect.” Circulation. 1952;5:858-863.

5. Bridges ND, Hellenbrand W, Latson L, Filiano J, Newburger JW, Lock JE. “Transcatheter Closure of Patent Foramen Ovale after Presumed Paradoxical Embolism.” Circulation. 1992;86:1902-1908.

6. Bridges ND, Lock JE, Castenada AR. “Baffle Fenestration with Subsequent Transcatheter Closure. Modification of the Fontan Operation for Patients at Increased Risk.” Circulation. 1990;82:1681-1689. 

 

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