Cardiac Surgery: Expanded surgical program requires dedicated cardiac care services

Cardiac surgeon Frank Hanley, M.D., director of the Children's Heart Center at Packard, aims to develop the top center for pediatric heart care in the world.

WINTER 2002 - Although medications and catheterization procedures can be used to treat more conditions than ever, surgical excellence still lies at the heart of the pediatric cardiac program at Lucile Packard Children's Hospital.

In the past year, Packard has recruited two of the foremost pediatric cardiac surgeons in the world: Frank Hanley, M.D., and V.Mohan Reddy, M.D., both from the University of California, San Francisco. These physicians have provided their expert surgical skills to hundreds of children with severe cardiovascular problems, and have mapped a course to completing the heart center's surgery program. "Our goal is to be the best place for pediatric heart care in the world," Hanley says.

To do that, Hanley explains, the Children's Heart Center will need to have certain components in place, including a state-of-the-art clinical program, excellent research, a strong teaching program, and facilities tailored to caring for children with heart problems.

"We've made a number of fantastic recruitments on the clinical side," Hanley says. "What we need to do now is have dedicated surgical and intensive care units where our team can use their expertise to provide kids the best care possible."

A Need for Pediatric Services

Since opening its doors 11 years ago, Packard Hospital never has had its own operating rooms. Pediatric surgery always has been performed at Stanford's adult hospital. This has caused difficulties in scheduling surgeries, and operations often have to be scheduled at odd hours.

Having space dedicated to all aspects of cardiac care will allow Packard Hospital to treat more children with heart problems, and will improve the quality of care for young heart patients, Hanley explains.

As more children with grave heart problems are cared for at Packard, specialized facilities, such as a cardiac intensive care unit, will be needed.

"The skills necessary to take care of adult cardiac patients are different from those required to take care of pediatric heart patients," he says. "It takes a focused effort by a lot of individuals."

"That's why I don't do adult heart surgery,"Hanley says. "The truth is that when you get this specialized you have more in common with other pediatric specialists than with other surgeons." The same focus on pediatric care is required at each stage of treatment, including post-operative treatment in a dedicated cardiac intensive care unit. "If you look at where patients face the most challenges, it is in the intensive care unit," Hanley says. "Preoperative management and diagnosis usually goes very well, and rarely do big problems occur in surgery or post-operative recovery. So if you want to improve outcomes you have to put kids where they can be watched over by intensivists who are skilled in pediatric cardiac care."

A Delicate Procedure

Another critical element of the Children's Heart Center is a pioneering program in minimally invasive surgical techniques, which allow physicians to perform complex surgeries through small incisions. Packard's Michael Black, M.D., has been a leader in the development of robotic surgery, which gives surgeons the control to operate on very tiny, delicate structures.

Closely related to minimally invasive arthroscopic surgeries are procedures that can be done via a catheter, such as the expansion of narrowed veins with a balloon or a stent.

Research on these techniques already is providing hope that children's heart problems can be fixed in the womb, while they are still minor. Surgery on tiny premature babies and the potential for surgery on fetuses are major focuses of V.Mohan Reddy, M.D.

"Fetal heart development is finished by about the eighth week of gestation, but minor problems in the heart at eight weeks keep growing and affect the heart, lungs, liver, and kidneys," Reddy says. "Even operating on the day of birth is too late for a lot of these conditions."

If physicians can go in and perform a procedure while the fetus is still developing, the cardiac problems will not fester and grow until birth.

Each week, Packard surgeons travel to children's hospitals in Oakland and Fresno to share their expertise with local surgeons and perform surgeries on children in those communities.Working with so many children also has the added benefit of creating a treasure trove of knowledge about procedures and outcomes.

"In order to move the field forward and be considered a leader, it is not enough to do state-of-the-art work," Hanley says. "You need to be the ones defining the state-of-the-art."