pediatric

Pediatric Heart Surgery: Congenital Heart Defects

by Columbia Surgery on May 2, 2014

Congenital Heart Center treats the sickest of newborns, with outcomes among the best in the nation.

Every year, about 30,000 children in the United States, about one percent of all live births, are born with congenital heart defects. Many babies require surgery within hours of birth.

Under the direction of pediatric cardiovascular surgeon Emile Bacha, MD and pediatric cardiologist Julie A. Vincent, MD the Congenital Heart Center is one of the largest and most preeminent pediatric cardiology and cardiac surgery centers in the nation. Families come from around the country and around the world to seek the most advanced, safest, and proven treatments for newborns with life-threatening conditions such as transposition of the great arteries, hypoplastic left heart syndrome, and complex left ventricular obstruction.

183177647
Prenatal Diagnosis and Intervention

For some children, taking care of their hearts must begin even before they are born. The Congenital Heart Center has one of the largest and most experienced maternal-fetal medicine teams in the country; the Carmen and John Thain Center for Prenatal Pediatrics is the only one of its kind in the metropolitan New York area, offering comprehensive, multidisciplinary prenatal diagnosis and therapy in conjunction with pediatric subspecialty consultation.

Cardiac Critical Care

A highly specialized team of neonatologists and cardiologists with subspecialties in neonatal cardiac care, the Congenital Heart Center offers the enormous resources needed when treating serious heart defects. The center offers all levels of care and one-to-one patient/nurse ratios.

Surgeons at the center perform more than 600 surgeries for congenital heart disease every year and offer the best possible surgical outcomes. Despite treating babies with some of the most complex heart conditions, survival rates at the center significantly surpass the national average, with children routinely returning to normal levels of activity and living into adulthood. The mortality rate for newborns at the Congenital Heart Center is among the lowest in the nation: 4.6% compared to a national benchmark of 9.8%*. In 2013, U.S. News & World Report ranked NewYork-Presbyterian as one of the top pediatric heart and heart surgery programs nationally, reflecting its reputation and surgical outcomes, the expertise of our surgical teams, volume of cases and other patient-care related data.

According to Dr. Bacha, “By focusing exclusively on neonates with cardiac disease, we feel we have developed unsurpassed expertise in the care of low birthweight and premature babies in particular.”

Pediatric Interventional Cardiology

The center has particular expertise in pediatric interventional cardiology, a unique specialty that involves the non-surgical treatment of congenital and acquired cardiovascular disorders. A few examples of catheter-based interventions include:

  • Angioplasty, including dilation and stent implantation, to open narrowed arteries and veins
  • Atrial septoplasty or blade septostomy to treat pulmonary hypertension
  • Coil and Amplatzer device closure of open ductus
  • arteriosus, atrial septal defect, Fontan fenestration, and patent foramen ovale.

Surgeons and interventional cardiologists at the center use an innovative hybrid technique, combining surgery with a catheter-based intervention, to treat babies with hypoplastic left heart syndrome. This approach achieves comparable results as the Norwood procedure, and can sometimes be safer for high risk infants because it avoids using the heart-lung machine.

Other advanced therapies available at the Congenital Heart Center include:

  • Minimally invasive, transfusion-free repair of atrial septal defect and ventricular septal defect
  • Hybrid procedure to close ventricular septal defect
  • Percutaneous (under the skin) valve replacement therapy.

The center is renowned for its pioneering work in pediatric heart valve repair, its expertise in ventricular assist devices, and outstanding results with the use of extracorporeal membrane oxygenation (ECMO) in children with cardiorespiratory failure.

For information about The Congenital Heart Center at NewYork-Presbyterian Morgan Stanley Children’s Hospital, please visit: nyp.org/kids or call: 212.305.2688.

*Mortality data provided by Society of Thoracic Surgeons database

{ 2 comments }

Pediatric Digestive Care: Esophageal Atresia

by Columbia Surgery on March 22, 2014

NYP/Columbia establishes program dedicated to long-term, multidisciplinary care of the esophagus.

Esophageal atresia (EA) is a congenital condition (present at birth) in which the esophagus is interrupted and fails to connect the mouth to the stomach as it should. The upper part of the esophagus ends in a blind pouch, and, in the most common form, the lower esophagus connects the airway (trachea) to the stomach (a trachehoesophageal fistula, or TEF). These conditions (EA and TEF) can occur separately, but most often occur together. Babies with EA, TEF, or EA-TEF must undergo surgical repair, often very soon after birth. Without treatment, attempting to eat could cause babies to aspirate milk and stomach acid into the trachea and lungs.

460595027c

According to William Middlesworth, MD, a pediatric surgeon at NewYork-Presbyterian Morgan Stanley Children’s Hospital and Surgical Director of the Esophageal Atresia Program, clear surgical guidelines are in place regarding how to best restore continuity of the esophagus and separate it from the trachea. Since the first repair in 1945, surgery has been successful in the vast majority of children, and mortality has significantly declined. Dr. Middlesworth and colleagues at NewYork-Presbyterian offer minimally invasive surgical options for EA repair in appropriately selected patients. When appropriate, they repair esophageal atresia using a thoracoscopic approach, which entails three small incisions in the chest for a surgical camera and instrumentation.

Reflux and EA

While a successful operation is the first step, it is now recognized that children do best when they receive careful long-term follow up. Surgery corrects the abnormal anatomy, connecting the ends of the interrupted esophagus and separating it from the trachea, but not the physiology (function) of the esophagus. Dr. Middlesworth and his colleagues recognize that children with EA need to be monitored as they grow and develop, even in the absence of any obvious clinical symptoms. One of their top concerns: acid reflux.

Although they may be unaware, most children born with EA have some degree of acid reflux, which can lead to problems years after surgery. More accurately, what is understood as reflux is really a form of dysmotility (impaired clearance) of the esophagus, according to Dr. Middlesworth. Children with EA-TEF are at risk for formation of strictures, or narrowed spots, where the interrupted esophagus was sutured together. Strictures can also form in the esophagus due to inflammation caused by acid, explains Julie Khlevner, MD, a pediatric gastroenterologist who specializes in diagnosing and treating patients with gastrointestinal motility disorders. Dr. Khlevner is Director of the Pediatric Gastrointestinal Motility Center at Morgan Stanley Children’s Hospital of NewYork-Presbyterian and Medical Director of the Esophageal Atresia Program.

Both strictures and impaired esophageal motility can result in food and stomach acid lingering in the esophagus, which is not equipped to handle it. As readers may already know, prolonged acid reflux can lead to Barrett’s esophagus, a dangerous precancerous condition.

No clear treatment guidelines

“Despite having treated this condition for over 75 years, doctors have not been able to develop and agree upon clear guidelines regarding the best way to monitor and treat children born with EA or EA-TEF,” says Dr. Khlevner. There is no evidence-based protocol to follow, because adequate studies have not yet been conducted in the relatively small number of patients affected by this rare disease. Without such evidence to guide them, individual doctors are left to use their best judgment in choosing mild acid suppressant medications, aggressive acid-reducing medicines, medications to improve motility, dietary recommendations, and anti-reflux surgery (such as Nissen fundoplication). As many as half of children may require interventional procedures to dilate strictures in the esophagus.

“Medications for reflux can have serious side effects such as increased risk of C. difficile infection, respiratory infection, and bone loss,” says Dr. Khlevner. “We want to prevent reflux without doing damage with these drugs.” Or, as Dr. Middlesworth phrases it, “We need to manage these patients in a way that will keep their esophagus healthy not just for their first 18 years, but their first 80 years.” Many questions remain unanswered, such as whether children need to take medicines for the rest of their lives, whether mild or aggressive medications should be used, how frequently such children need to be monitored, and when surgery should be considered to treat reflux.

Esophageal Atresia Program: New model of care

In order to provide the best care possible for their patients, Dr. Middlesworth and Dr. Khlevner decided to take action. Together they formed a new program dedicated to the treatment of children with EA-TEF, with the following goals:

  • Providing coordinated multidisciplinary care that addresses all facets of their patients’ conditions
  • Determining how to safely and effectively treat silent reflux and other complications associated with EA
  • Helping older patients to transition to practitioners caring for adults who are well versed in the special needs associated with EA
  • Conducting research to identify genetic abnormalities underlying EA and related anomalies
  • Conducting longitudinal clinical research in order to develop best-practice treatment protocols.

Drs. Middlesworth and Khlevner now monitor children using endoscopy and impedance/pH studies to assess whether the esophagus is inflamed and to see if too much acid is present in the esophagus. This can help guide anti-reflux therapy and help avoid both over-treatment and under-treatment.

One visit rather than ten

The collaborative format of the EA program also addresses an important need for patients and their families: the need to see multiple specialists for complicated, multi-system birth defects in the spectrum known as VACTERL (Vertebral anomalies, Anal atresia, Cardiac defects, Tracheoesophageal fistula and/or Esophageal atresia, Renal & Radial anomalies and Limb defects). Elsewhere, parents must bring their children to individual specialists for care of these problems, but the collaborative team at NewYork-Presbyterian Morgan Stanley Children’s Hospital includes the range of experts so that a child may see multiple specialists in a single visit, rather than making multiple separate trips. The program plans to include specialists in pediatric cardiology, pulmonology, and otolaryngology (ENT) as well as feeding therapists. Dr. Middlesworth notes, “Caring for children with complex and unusual problems in a multi-disciplinary context, making life easier for families, is what the Morgan Stanley Children’s Hospital is all about.”

To learn more, visit http://childrensnyp.org/mschony/digest-tracheo or call 212.342.8586.

{ 0 comments }

Formerly Conjoined Twins Make Medical History at NYP – Again!

January 10, 2014

TweetOver 20 years ago, conjoined twins Carmen and Rosa Taveras were brought to Morgan Stanley Children’s Hospital NewYork-Presbyterian to be separated in a groundbreaking surgery. The twins were separated by a team of 52 doctors, nurses, respiratory therapists, technicians, and others in a 14-hour operation that involved rerouting and dividing the internal organs and reconstructing […]

Read the full article →

New Faculty Announcement: Steven Stylianos, MD, Chief of Pediatric Surgery

October 2, 2013

TweetPlease join us in welcoming Steven Stylianos, MD, Chief of Pediatric Surgery, Columbia University College of Physicians and Surgeons, and Surgeon-in-Chief at Morgan Stanley Children’s Hospital of NewYork-Presbyterian. Dr. Stylianos most recently served as Chief of Surgery at Miami Children’s Hospital from 2005 to 2011 and at North Shore-LIJ from 2011 to 2013. His arrival […]

Read the full article →

Spotlight on Graduating Chief Resident Dr. Stephen Oh

August 22, 2013

TweetStephen Oh, MD, a recently graduated member of the 2013 class at Columbia University’s Surgical Residency Program, is now continuing his medical education with a fellowship in pediatric surgery here. We caught up with him shortly after graduation to discuss his experience as a resident. How long have you been at Columbia? What was your […]

Read the full article →

How to Prepare Children for Surgery

November 16, 2012

TweetNo parent welcomes the idea of a child having surgery. But there are ways to lessen the toll of an operation on both you and your child. “The single most important thing parents can do is to become as knowledgeable as possible about their child’s condition or illness and the planned procedures beforehand,” says Angela […]

Read the full article →

U.S. News & World Report Recognizes 33 Top Doctors at NYP/Columbia Department of Surgery

September 21, 2012

TweetCongratulations to the thirty three surgeons at the Department of Surgeon for being recognized by U.S. News & World Report in their 2012 list of Top Doctors. Of these top-ranked surgeons, U.S. News further identified seventeen physicians as being in the top one percent in the nation in their specialties. U.S. News & World Report’s […]

Read the full article →

One-Day Symposium on Cardiovascular Research

August 27, 2012

TweetThe First Annual Cardiovascular Translational Research Symposium will be held on September 22 at The Valley Hospital Conference Center in Ridgewood, New Jersey. Jointly sponsored by Columbia University College of Physicians and Surgeons and The Valley Heart and Vascular Institute, the conference focuses on the impact of translational research on cardiovascular medicine. Keynote Speaker Valentine […]

Read the full article →

Article Highlights Collaboration between Columbia Surgeon and Biomedical Engineer

August 9, 2012

TweetA current story in Columbia Magazine, a quarterly published by Columbia University, features Jeffrey Ascherman, MD, FACS, Site Chief, Division of Plastic Surgery at NewYork-Presbyterian/Columbia University Medical Center and Gordana Vunjak-Novakovic, Professor of Biomedical Engineering at Columbia’s Fu Foundation School of Engineering and Applied Science. Dr. Ascherman, who specializes in treating children with facial deformities, […]

Read the full article →

NY Magazine Recognizes 16 Top Docs at NYP/Columbia

June 7, 2012

TweetCongratulations to sixteen surgeons at the Department of Surgery for being named top doctors by New York Magazine. This annual list recognizes 1160 physicians from New York, New Jersey, and Connecticut who are considered top in their fields of expertise. This year, the magazine recognized faculty from nine divisions at NYP/Columbia Department of Surgery: Plastic […]

Read the full article →