Downloaded from http://heart.bmj.com/ on June 25, 2015 - Published by group.bmj.
com
Global burden of cardiovascular disease
Paediatric heart care in India
R K Kumar,1 S Shrivastava2
1
Department of Pediatric
Cardiology, Amrita Institute of
Medical Sciences, Kochi, Kerala,
India; 2 Department of Pediatric
Cardiology and Congenital Heart
Diseases, Escorts Heart Institute
and Research Center, Okhla
Road, New Delhi, India
Correspondence to:
Dr Raman Krishna Kumar,
Amrita Institute of Medical
Sciences, Elamakkara PO, Kochi,
Kerala, India; rkrishnakumar@
aims.amrita.edu
Accepted 1 April 2008
984
ABSTRACT
There have been few systematic efforts to define the
burden of paediatric heart disease in India. Estimates
based on published studies on congenital heart disease
(CHD) at birth suggest a massive CHD burden. Absolute
numbers of children with other heart diseases are also
likely to be substantial. Given the enormity of the problem
the number of paediatric heart programmes and specially
trained paediatric cardiologists and paediatric cardiac
surgeons are woefully inadequate. They are largely
clustered in those parts of India that are experiencing
improving economy and human development. For the
average family the cost of care of a child with heart
disease is prohibitive because care of children with heart
disease often requires considerable human and material
resources, together with sophisticated technology. While
paediatric cardiology is only now being recognised in India
as a major specialty, there is a need to intensify efforts to
develop the specialty especially in those parts of India
where there are very few centres. The present challenges
are many and they include obtaining representative data
on disease burden, establishing quality institutions with
comprehensive paediatric cardiac programme training a
cadre of professionals for paediatric heart care, develop-
ing cost-effective management strategies and improving
awareness on diagnosis and management of paediatric
heart diseases.
The extraordinary geographical and cultural diver-
sity of India was recognised as independent India
was being established.1 One of the early challenges
faced by the nation at the time of independence
related to human development. The infant and
maternal mortality rates were extremely high in
the early 1950s for most of India.2 Since indepen-
dence, selected states in India showed impressive
improvement in various health indices, largely as a
result of improving literacy, specifically female
literacy.2 3 However, the track record for most of
the Indian states in improving human develop-
ment and health indices has been abysmal.4
In recent years selected areas of India are
witnessing unprecedented economic growth, lar-
gely ushered in by the forces of globalisation. This
has rapidly changed lifestyles, particularly in urban
India.5 Globalisation has also had a ‘‘flattening
effect’’ on India’s cultural diversity. India’s diver-
sity today stems from sharp regional differences in
economic growth and human development, in
addition to previously existing differences in
geography, language and religion. Large parts of
rural India still have among the worst human
development in the world, with extremely high
infant and maternal mortality and alarming levels
of malnutrition.4 As a result, it is perhaps
impossible to make generalisations on health
indices and disease prevalence in India.
These regional differences are likely to reflect on
cardiovascular disease profiles in various parts of
India. While most of India has witnessed an
increase in lifestyle-related cardiovascular disease
and diabetes, the problem appears particularly
worrying in some areas.6 Rheumatic heart disease
often mirrors human development and striking
regional contrasts in disease trends can therefore be
expected.7
Unlike acquired conditions, the prevalence and
profile of congenital heart disease (CHD) at birth is
unlikely to be significantly influenced by the above
mentioned factors. However, the condition of
healthcare delivery systems can significantly influ-
ence the early survival of newborns and infants
with serious forms of CHD.8 This is turn can have
an important effect on the profile of CHD
encountered beyond infancy.
The rapid economic growth in the recent years has
had a powerful impact on healthcare delivery in
India. Tertiary health care has largely been taken
over by the private sector. This sector has grown
impressively in terms of revenue generated and
number of hospitals and healthcare facilities.9
Comprehensive paediatric heart care that includes
prenatal diagnosis, newborn and infant heart
surgery and catheter interventions can only be
provided in sophisticated tertiary hospitals. In the
absence of health insurance the costs of paediatric
heart operations and catheter interventions are
prohibitive for most Indian families and only a small
proportion of India’s population (mostly urban) can
afford it. In this review we will focus on the current
situation of paediatric cardiac diseases in India. The
growth and development of services relating to
paediatric heart care in India will also be discussed.
DEVELOPMENT OF PAEDIATRIC CARDIOLOGY AND
PAEDIATRIC CARDIAC SURGERY
The first cardiac centres in India were established
in the early 1960s. For the next 30 years, facilities
for advanced heart care including cardiac surgery
for both adults and children were essentially
limited to very few large teaching institutions.
These programmes trained a number of cardiolo-
gists and cardiac surgeons over a 30 year period.
Training was simultaneously for both adult and
paediatric heart care. All trainees, with very few
exceptions, had their basic background in adult
medicine. Paediatric cardiology therefore did not
evolve as a subspecialty of paediatrics. Only a small
handful of individuals seriously pursued paediatric
cardiology and the number of dedicated paediatric
cardiac surgeons in the country was limited to less
than half a dozen.10 Pioneering and dedicated
efforts from these individuals was responsible for
the introduction of echocardiography, catheter
interventions11 and infant heart surgery in India.
Heart 2008;94:984–990. doi:10.1136/hrt.2007.139360
 Downloaded from http://heart.bmj.com/ on June 25, 2015 - Published by group.bmj.com
However, because of the paucity of institutions willing to take
care of children with heart disease, very little could be offered to
Indian children with heart disease until recently.
In the 1990s a few dedicated paediatric heart programmes
were established in the private sector in spite of serious
questions about their economic viability. With the establish-
ment these programmes and the formation of the Paediatric
Cardiac Society of India in the late 1990s, paediatric cardiology
and cardiac surgery are being recognised as separate specialties.
Dedicated training programmes in paediatric cardiology have
been created in these new programmes. Trainees from these
programmes are in turn seeking to establish newer centres. The
total number of infant and newborn congenital heart operations
performed in all the existing Indian centres put together was
less than 2500 in the year 2004. For a population of one billion,
it can be expected that there would perhaps be approximately
100 000 newborns with congenital heart disease requiring some
form of intervention during infancy. Thus, heart surgery
appears realistic today for only 2–3% of infants requiring
congenital heart surgery in India.12 13 This situation is likely to
change with rapid changes in the economy and human
development that we are now witnessing in many parts of
India. It may be useful, therefore, to chart a roadmap for
development of paediatric heart care for the country.
Figure 1 shows the various components of comprehensive
paediatric heart care from a national perspective. This model
can perhaps be applied to any specialty. This figure will form
the basis of this section of the review and each of the headings
will be discussed individually.
Defining disease burden
The major categories of paediatric heart disease from the
standpoint of relative numbers can be classified under the
following major categories:
c Rheumatic heart disease
c Congenital heart disease (CHD)
Figure 1 Chart showing a blueprint for
the development of paediatric heart care
from a national perspective. OB Gyn,
obstetrics and gynaecology.
Heart 2008;94:984–990. doi:10.1136/hrt.2007.139360
Global burden of cardiovascular disease
c Lifestyle-related conditions—childhood obesity and hyper-
tension
c Other conditions—Kawasaki disease, cardiomyopathy and
myocarditis.
No population-based systematic surveys on disease preva-
lence have been performed for CHD at birth. Although school
surveys are available for CHD,14–16 they cannot be used to
generate population-based prevalence data because of attrition
in early years, low school enrolment rates in many parts of India
and the possibility of children with CHD being absent from
school because of illness. Similarly, published studies based on
hospital statistics17 are also unlikely to be representative of the
population. An ideal study that can generate reliable data for
the population requires an organised infrastructure necessary
for optimal care of newborns and infants with CHD
(table 1).18 19 Such a situation does not exist even in the large
metropolitan areas of India. Given the reasonable uniformity in
CHD prevalence among various racial and ethnic groups in
previous large population-based studies from various parts of
the world,8 it may be fair to assume that the overall prevalence
of CHD at birth may not be substantially different in India.
There may, however, be differences in the relative prevalence of
certain specific conditions and this may be worth investigating.
It may, therefore, be appropriate to screen representative
cohorts of live births in selected parts of India to obtain an
idea of the typical profile of CHD in various parts of the
country.
The epidemiology of rheumatic heart disease in India will be
discussed separately. The information on other common
acquired heart diseases is limited to small case reports and
descriptive studies. Kawasaki disease (KD) is increasingly being
recognised and a number of reports have appeared in recent
years after initial descriptions in 1970s.20 21 Most reports are
from urban populations and there is a strong possibility that a
number of cases are missed.22 Awareness of manifestations of
KD has not been formally evaluated and may be quite limited in
many parts of India. There is a need to develop a comprehensive
985
 Downloaded from http://heart.bmj.com/ on June 25, 2015 - Published by group.bmj.com
Global burden of cardiovascular disease
Table 1 Estimation of prevalence of congenital heart
disease (CHD) among liveborn infants: requirements of an
ideal study
1 An area with a clearly identified resident population
2 All deliveries from this area should be medically supervised,
ideally in a hospital
3 All the hospitals in the area should be included
5 A well defined clinical protocol for screening CHD among
newborns
6 Complete referral of all suspected newborns with CHD to a
paediatric cardiology facility
7 Remaining newborns of the birth cohort should be followed up
at specified intervals and referred whenever CHD is suspected
8 A reliable echocardiogram for confirmation of CHD
9 A postmortem facility for all infants or newborns dying
without a clearly specified cause
national disease registry for KD.23 Other forms of inflammatory
vasculitis, such as aortoarteritis, are well recognised in Indian
children. Several unique features characterise the disease in
Indian children.24 25 They include a strong association with
tuberculosis, occurrence of heart failure and myocardial
dysfunction and involvement of the thoracic and abdominal
aorta.
Few epidemiological data are currently available about
myocarditis and cardiomyopathy in Indian children. Clinical
features and diagnostic approaches for a child with suspected
myocarditis are largely based on descriptions from studies
published in Western literature and the disease has not been
well characterised in Indian children.26 27
Changing lifestyles have started to have an impact in Indian
children. This is particularly true for urban children. Surveys
from selected cities have started to highlight the growing
prevalence of obesity in Indian children.28–31 Evidence from
prospective studies suggests that childhood obesity is directly
related to the incidence of hypertension, type 2 diabetes and
hypercholesterolaemia. According to the World Health
Organization, chronic diseases are the major cause of death in
almost all countries, including those in Asia. It is estimated that
70% of these deaths will happen in developing Asian nations
like China, India, Pakistan, Cambodia and Vietnam.32
Cardiovascular diseases (CVD) are responsible for the major
share of these chronic disease deaths. South Asians appear to
have worse CVD risk profiles when compared to white
Figure 2 Chart showing the human resources associated with comprehensive paediatric heart care.
986
populations with similar body mass index (BMI) levels. Small
increases in BMI among them may translate into a substantial
increase in the CVD burden.32 For this reason the trends
reported in India are alarming even though the overall
proportion of obesity and overweight children is lower than
reported in other countries. The magnitude of the problem is
already substantial and this is likely to rapidly increase in the
near future. More studies are needed with representation from
various regions. There is also an urgent need to develop
normative data for BMI and other anthropometric indices,
blood pressures and lipid profiles in Indian children.
Delivering paediatric heart care; developing quality institutions
Perhaps the most critical component of delivering paediatric
heart care relates to development of quality institutions that
should ideally become centres of excellence. Like many other
technology and resource intensive subspecialties, the success of
a paediatric cardiac programme is largely dependent on the
creation of a cohesive team of individuals. This team is
constituted by paediatric cardiologists, paediatric cardiac sur-
geons, anaesthesiologists, intensive care experts, nurses, tech-
nologists (catheterisation, perfusion, ultrasound) and other
support personnel (fig 2). Additional closely related specialties
include obstetrics and neonatology. A hugely challenging facet
of delivering paediatric cardiac care in the developing world
relates to establishment of new paediatric heart programmes.
Because of the paucity of pre-existing training programmes,
there is a tremendous shortage of trained staff in India.
Additional challenges include costs of infrastructure and
equipment and development of support services. Perhaps
because of these reasons all existing paediatric heart pro-
grammes in India are in hospitals with busy adult cardiology
and cardiac surgery programmes. The infrastructure, equipment
and many of the personnel are completely shared with adult
services. Paediatric heart programmes in India have not evolved
in children’s hospitals, unlike many programmes in the West.
Paediatric heart care in India is currently being delivered in
two settings. The first is a handful of large programmes with
impressive case volumes. As of 2007 there are only half a dozen
programmes in India with annual case volumes of more than
500 for paediatric heart surgery. The second setting is small
centres, mostly private establishments, with small case volumes
and limited personnel. The scope of comprehensive paediatric
cardiac care, particularly newborn and infant heart surgery, is
Heart 2008;94:984–990. doi:10.1136/hrt.2007.139360
 Downloaded from http://heart.bmj.com/ on June 25, 2015 - Published by group.bmj.com

Global burden of cardiovascular disease

very limited in smaller centres. Most centres are clustered in
large cities in selected regions in India. For large parts of the
country there are no paediatric cardiac centres. The most poorly
served regions include most eastern and all north-eastern states,
vast regions in western and central India.10 12 13 The majority of
children with CHD in these regions escape detection. For the
small percentage of cases where the condition is diagnosed early
enough for treatment, families are often intimidated by
financial implications and the prospect of seeking care at a
far-off centre. However, a small but growing number of families
do travel large distances to obtain treatment in selected Indian
centres that deliver comprehensive paediatric heart care. The
larger and relatively less expensive programmes in India are
often overwhelmed with numbers and have significant waiting
lists. The low rate of detection of CHD, and economic and
logistic considerations have perhaps ensured that only a tiny
proportion of cases from the most poorly served regions reach
these centres and keep the numbers to ‘‘manageable’’ levels.
A significant challenge relates to the prevailing mindset
regarding the financial viability of paediatric heart programmes.
Most private hospitals have been reluctant to establish these
programmes because the costs of care are substantial and often
cannot be recovered from patients. Open-heart operations for
CHD typically cost $4000–$6000 (£2500–£3000) in most private
Indian hospitals. Third-party payments are limited to situations
where either parent is employed by selected organisations
(mostly government) that provide comprehensive family health
coverage. Most insurance companies exclude congenital heart
defects from the list of conditions covered. Efforts to provide
financial support for individual patients through donations
Table 2 Differences encountered between patient populations with
congenital heart disease (CHD) from India and those from developed
nations
Specific differences Implications
Pulmonary hypertension from Need to evaluate carefully for development of
late presentation pulmonary vascular obstructive disease (PVOD)
before management of congenital heart defects
associated with increased pulmonary blood flow
Neurological insults: hypoxic Routine iron supplementation for infants with
insults to the developing brain, cyanotic CHD, careful preoperative neurological
brain abscess, stroke evaluation, parental counselling on late neuro-
developmental consequences
Malnutrition and anaemia Early correction whenever feasible, aggressive
because of both delayed dietary counselling of children with CHD
correction and high prevalence in
population
Lung infections are associated Early correction after initial control of lung infection
with shunt lesions
from government funds are limited to selected patients in a few
Indian states (such as Gujarat and Andhra Pradesh). This is not
feasible on a larger scale. From a public health perspective,
subsidies for expensive heart surgery or interventions would
perhaps amount to significantly misplaced priorities and are not
likely to be sustainable. Overseas agencies such as the Gift of Life
programme of Rotary International (www.giftoflifeinternational.
org) also fund paediatric heart operations in selected centres in a
limited way. However, donations and logistic support for capacity
building of selected centres in India may have a more lasting effect
when compared to funding assistance for selected heart opera-
tions. The Children’s Heart Link (www.childrensheartlink.org) is
an example of an organisation that is seeking to improve quality
of paediatric heart care by facilitating collaborations between
established centres in North America and new programmes in the
developing world.
Another challenge relates to quality of care. The outcomes
after paediatric cardiac surgery in infants and newborns are
critically dependent on the skills and cohesiveness of the
individual team members and there is a fairly steep learning
curve for the institution.33 Newly established programmes
therefore often need to have careful case selection policies in
the beginning. Careful prioritisation of care is often necessary in
the face of large numbers and limited resources. Most Indian
centres do not therefore routinely perform the Norwood
operation for hypoplastic left heart syndrome. Lesions that
can be corrected through a single operation often receive greater
priority over multistaged palliative procedures. Nosocomial
infections are a significant cause of mortality in this particularly
vulnerable group of patients and it is essential to establish a
robust infection control programme as new programmes are
being established.32
When compared to established programmes in developed
nations, there are noticeable differences in how paediatric heart
programmes are structured in India. Most paediatric cardiolo-
gists are forced to multitask and do not focus on specific areas
with in the specialty. For example, a paediatric cardiologist
could perform echocardiography, catheter interventions proce-
dures and look after intensive care. Dedicated services for
specific areas such as adult congenital heart disease, fetal
cardiology and paediatric electrophysiology have not been
developed in Indian centres.
Table 3 Cost-effective strategies for paediatric catheter-based
interventions
Problem ‘‘Solution’’
Cost of dedicated Sharing of catheterisation laboratory and personnel with
catheterisation adult cardiology programmes. Performing paediatric
laboratories for paediatric catheterisation procedures using single plane equipment;
catheterisation avoiding diagnostic procedures if alternative methods
provide the information

Frequent occurrence of infective Need for greater emphasis on dental hygiene for
endocarditis
High prevalence of neonatal
sepsis
High prevalence of low birth
weight
Pregnancy in the presence of a
significant heart lesion
Cost of disposable Reuse of catheter disposables after ethylene oxide
children with structural heart lesions
hardware sterilisation; using ‘‘adult’’ catheter hardware as alternatives
to selected paediatric catheter items
Careful septic screen is warranted before neonatal
heart surgery, judicious antibiotic use to prevent
Cost of dedicated Performing a majority of procedures under conscious
emergence of resistant strains of bacteria
anaesthesiology support sedation or ketamine anaesthesia with careful monitoring
for paediatric procedures
Need to recognise that limited reserves in low
birthweight newborns with heart defects are further
Cost of imported Offering less expensive surgical alternatives to those who
limited.
occlusive devices cannot afford occlusive devices; using alternatives to
expensive occlusive devices such as multiple coils to
Need to educate and counsel women in occlude large patent arterial ducts and other arterio-venous
reproductive age group; discussion of the situation communications; the less expensive duct occlude in place
with spouse of the ventricular septal occluder

Heart 2008;94:984–990. doi:10.1136/hrt.2007.139360 987

 Downloaded from http://heart.bmj.com/ on June 25, 2015 - Published by group.bmj.com
Global burden of cardiovascular disease
Role of institutions
Training
Apart from delivering care, institutions serve a number of other
vital purposes. Training of staff in all the facets of paediatric
heart care is largely possible only in busy institutions. Small
programmes with low case volumes cannot develop robust
training programmes. Until recently, training was largely
limited to a small number of institutions in India. There were
no formal structured programmes exclusively for paediatric
cardiology. Paediatric cardiology had to be learned as a part of
training in adult cardiology. After completion of training very
few saw opportunities to practise paediatric cardiology; besides,
most trainees did not have a basic background in general
paediatrics. As a result in the mid-1990s the total number of
dedicated paediatric cardiologists in all of India was less than a
dozen. A beginning was made recently with the establishment
of a structured training programme in paediatric cardiology by
the national board in four of the existing large paediatric heart
programmes in the country. The numbers of trainees emerging
from these programmes are grossly inadequate for the country’s
needs. The situation is far worse for paediatric cardiac surgery;
there are no dedicated training programmes yet. As a result
there is a great shortage of paediatric cardiac surgeons. The
shortfall is likely to continue for many years and existing
centres may find it particularly difficult to deal with growing
case numbers.
Developing specific strategies for Indian patients
Because of great differences in the CHD patient populations
that are typically encountered in India, specific management
approaches often need to be developed for Indian patients
(table 2). The differences relate to older age at presentation for
many of the congenital heart defects, high prevalence of
malnutrition and associated infections. Economic considera-
tions (below) also impact treatment practices significantly. A
number of important publications, mostly from selected Indian
Table 4 Cost-effective strategies for paediatric cardiac surgery
Problem ‘‘Solution’’
Limited availability of Delaying initial corrective operations for conditions requiring
conduits conduits, using the bidirectional Glen shunt—as a venous
shunt—as interim palliation for longer durations
Greater emphasis on alternatives for corrective operations
that do not involve the use of conduits—for example, the
double barrel repair for tetralogy of Fallot with coronary
crossing right ventricular outflow tract-conduit, Barbero-
Marcials repair for persistent truncus arteriosus
Cost of imported bypass Re-sterilisation and reuse of tubings and cannulas for 3–4
disposables uses; performing the bidirectional Glen operation under right
heart bypass without the use of a oxygenator
Cost of suture materials Indigenous suture materials
Human resources for Multitasking—for example, in absence of dedicated
intensive care unit care paediatric cardiac intensivists, postoperative care is often
delivered by cardiac surgeons, cardiologists and
anaesthesiologists
Complex heart defects Attempts to perform single-stage corrections albeit at
requiring single/ marginally higher risk—for example, performing aortic arch
multistage corrections repair with correction of intracardiac defects such as
ventricular septal defects closure or arterial switch options
Prosthetic materials Pericardial autografts as alternatives to expensive synthetic
materials such as polytetrafluoroethylene
988
institutions with paediatric heart programmes, highlight the
unique problems encountered in India and suggest solutions to
deal with them.33–45
Cost-effective practices
Because of severe cost constraints typically encountered in most
Indian institutions, a number of cost-effective practices have
evolved in India.46–53 These relate to management strategies for
individual conditions, institutional policies for catheter inter-
ventions and for cardiac surgery, as well as development of
specific operations and catheter-based procedures46 (tables 3 and
4). Some of the less expensive management strategies practised
for patients with CHD may not be perceived as ideal and their
long-term outcomes are likely to be less acceptable than those
that conform to the standards of care in developed nations. A
good example relates to patients requiring the use of conduits
for congenital heart surgery. Conduits are very expensive in all
but one or two programmes in India that have a homograft
bank. More importantly, conduits need regular replacement and
the prospect of repeated open-heart operations is completely
unrealistic for a number of patients and their families. As a
result, many Indian programmes attempt to postpone the
implantation of conduits through palliative procedures such as
aorto-pulmonary shunt and the Glen shunt.
Indigenous technology
Cardiology and cardiac surgery have been largely dependent on
and driven by imported technology. Because of the paucity of
institutions that focus on medical technology development,
there have been very few Indian innovations in cardiology and
cardiac surgery. The success of the TTK Chitra heart valve
underscores the feasibility and scope of innovative technological
solutions developed in India.54 55 This valve is a tilting disc
artificial heart valve prosthesis designed and developed by Sree
Chitra Tirunal Institute for Medical Sciences and Technology,
(SCTIMST), an autonomous institute under the Department of
Science and Technology, Government of India. TTK Chitra
heart valves are being used in over 175 major cardiac
programmes in the country. More than 15 000 valves have
been implanted since its first implant on 6 December 1990
(www.sctimst.ac.in/bmt/technologies3). Additional innova-
tions in cardiovascular technology that have found applications
include the bubble oxygenator and cardiotomy reservoir
(SCTIMST) and the permanent pacemaker (Shree Pacetronics;
www.pacetronix.com/clinic) and indigenously processed por-
cine xenograft conduits (www.frontierlifeline.com, www.
biotech.iitm.ac.in).
IMPROVING AWARENESS REGARDING PAEDIATRIC HEART
DISEASES
A number of problems relating to inadequate healthcare
delivery for children with congenital heart disease are the
result of poor awareness among care givers (table 5). This is
particularly true for many paediatricians in India. Most
postgraduate training programmes in India are in regions
with no paediatric heart programmes. As a result the average
postgraduate trainee in general paediatrics receives little
exposure in paediatric cardiology.10 This translates into a
situation where most children with heart disease escape early
detection. There is, therefore, an urgent need to educate
practising paediatricians through current medical education
programmes. Professional bodies such as the Indian Academy
of Paediatrics can help facilitate this process. The newly
Heart 2008;94:984–990. doi:10.1136/hrt.2007.139360
 Downloaded from http://heart.bmj.com/ on June 25, 2015 - Published by group.bmj.com
Table 5 Shortcomings in paediatric heart care in India
Broad category Shortcomings in India
Detection of CHD Only a tiny fraction of CHD detected Limited access to health care. Small proportion of supervised live
at birth and during infancy
Diagnosis Inaccurate diagnosis in a sizeable
proportion
Referral Delayed referral of many infants
and children
Treatment Small proportion of referred infants Few institutions with good standards of care, care too expensive for
and newborns actually receive
definitive treatment for CHD
Prevention Very few termination of
pregnancies because of diagnosis
of CHD
Very few families adequately
counselled
Healthcare planning No national policy for CHD
treatment
formulated Paediatric Cardiac Society of India (PCSI) has
defined education of paediatricians as one of its most
important goals. The PCSI is working earnestly in educating
paediatricians, postgraduate students in paediatrics through
regular continuing medical education programmes, news-
letters and annual conferences. There is also a need to include
structured training in paediatric cardiology in the curriculum
of postgraduate training in Indian institutions. Wherever
possible, rotations should be organised in institutions with
paediatric heart programmes. It is also perhaps necessary to
educate caregivers in closely related specialties. Adult cardiol-
ogists often have to care for children with heart disease in
many Indian hospitals. Although some of them are familiar
with common congenital heart defects, they typically do not
have any exposure to a structured paediatric cardiac pro-
gramme and are unable to handle small infants and newborns.
Obstetricians-gynaecologists and radiologists have to be
familiarised with basic ultrasound screening for fetal
heart defects.
CONCLUSIONS
Notwithstanding the accomplishments in recent years it is
perhaps fair to state that paediatric heart care in India is still
rudimentary. Given the significant burden of readily treatable
conditions, such as diarrhoea and respiratory conditions,
congenital heart disease is not yet a paediatric health priority
from a national perspective. There is a need for evolving a
mechanism to determine disease burden for major categories of
paediatric heart diseases in India. There is an urgent need to
develop quality institutions for delivering care, training profes-
sionals, driving research and developing specific strategies that
would be realistic in the Indian context. There is also a need to
intensify efforts to educate general paediatricians and other
health professionals who encounter children with heart disease.
With improving human development and economic progress
the demand for quality paediatric heart care is likely to grow
Heart 2008;94:984–990. doi:10.1136/hrt.2007.139360
Global burden of cardiovascular disease
Reasons
births
Limited ability of many paediatricians to detect heart disease
because of limited exposure of paediatricians to paediatric
cardiology during their postgraduate training
Limited use of pulse oximeter for routine screening of newborns
Very limited specialised paediatric echocardiography expertise
Limited knowledge of natural history of many forms of CHD; lack of
awareness about newer developments in the specialty; lack of
awareness about what is available within the country
most people
Very limited fetal echocardiography expertise
Very few centres with infrastructure for advanced chromosomal
analysis and genetic studies
Very little data on CHD epidemiology, CHD not perceived as an
important paediatric health problem
exponentially in India. However, the challenge of delivering
quality care at a cost that is affordable to the majority of
affected families is likely to remain for a very long time.
Competing interests: None.
REFERENCES
1. Guha R. India after Gandhi, the history of world’s largest democracy. London:
Macmillan, UK, 2007.
2. Ramji S. The National Family Health Survey (1998–99): childhood mortality. Ind
Pediatr 2001;38:263–6.
3. Syamala TS. Relationship between sociodemographic factors and child survival:
evidence from Goa, India. J Hum Ecol 2004;16:141–5.
4. Mehrotra R, Sachdeva AS, Ramanamurthy SV. National Human Development Report
2001, http://hdr.undp.org/reports/detail_reports.cfm?view = 122.
5. Friedman TL. The world is flat, the globalized world in the 21st century. New York:
Farrar, Straus and Giroux, 2005
6. Reddy KS. Cardiovascular disease in non-western countries. N Engl J Med
2004;350:2438–40.
7. Kumar RK, Rammohan R, Kaplan EL, et al. Epidemiology of streptococcal pharyngitis,
rheumatic fever and rheumatic heart disease. In: Narula J, et al, eds. Rheumatic
fever. Washington, DC. American Registry of Pathology 1999:41–78.
8. Hoffmann JIE. Incidence of congenital heart disease. I. Post-natal incidence. Pediatr
Cardiol 1995;103:743–7.
9. WHO Task Force on Research Priorities for Equity in Health and the WHO
Equity Team, Priorities for research to take forward the health equity policy agenda.
Bull World Health Organ 2005;83:948–53.
10. Saxena A. Congenital heart disease in India: a status report. Indian J Pediatr
2005l;72:595–8.
11. Radhakrishnan S, Shrivastava S. Nonsurgical management of congenital heart
disease. Indian J Pediatr 1998;65:195–210.
12. Kumar RK. Congenital heart disease management in the developing world (letter).
Pediatric Cardiology 2003;24:311.
13. Vaidyanathan B, Kumar RK. The global burden of congenital heart disease.
Congenital Cardiol Today 2005;9:1–5.
14. Gupta I, Gupta ML, Parihar A, et al. Epidemiology of rheumatic and congenital heart
diseases in school children. J Indian Med Assoc 1992;90:57–9.
15. Thakur JS, Negi PC, Ahluwalia SK, et al. Congenital heart disease among school
children in Shimla Hills. Indian Heart J 1995;47:232.
16. Vashishtha VM, Kalra A, Kalra K, et al. Prevalence of congenital heart disease in
school children. Indian Pediatr 1993;30:1337–40.
17. Khalil A, Aggarwal R, Thirupuram S, et al. Incidence of congenital heart disease
among hospital line births in India. Indian Pediatr 1994;31:519–27.
18. Ferencz C, Rubin JD, McCarter RJ, et al. Congenital heart disease: prevalence at live
birth. The Baltimore-Washington Infant Study. Am J Epidem 1985;121:31–6.
989
 Downloaded from http://heart.bmj.com/ on June 25, 2015 - Published by group.bmj.com

Global burden of cardiovascular disease

19. Fyler DC. Report of the New England Regional Infant Cardiac Program. Pediatrics 39. Vaidyanathan B, Kumar RK. Neurological complications and neurodevelopmental
1980;65(suppl):375–461. sequelae after congenital heart surgery. Indian Heart J 2004;56:286–92.
20. Kushner SI, Macnee HI, Burns JC. Impressions of Kawasaki syndrome in India. 40. Sharma R, Choudhary SK, Juneja R, et al. Left ventricle is better suited as pulmonary
Indian Pediatr 2006;43:939–42. ventricle in simple transposition with severe pulmonary hypertension. Ann Thorac
21. Krishnakumar P, Mathews L. Kawasaki disease is not rare in India. Indian J Pediatr Surg 2002;74:1612–5.
2006;73:544–5. 41. Sharma R, Raizada N, Choudhary SK, et al. Does inhaled nitric oxide improve survival
22. Chakravarty S, Parmanik S, Thapa R. Difficulties in the diagnosis of Kawasaki in operated congenital disease with severe pulmonary hypertension? Indian Heart J
disease. Indian Pediatr 2006;43:728–31. 2001;53:48–55.
23. Khubchandani RP, Khemani C. Kawasaki disease registries reap results: experience 42. Choudhary SK, Bhan A, Sharma R, et al. Repair of total anomalous pulmonary
in Mumbai. Indian J Pediatr 2006;73:545. venous connection in infancy: experience from a developing country. Ann Thorac Surg
24. Muranjan MN, Bavdekar SB, More V, et al. Study of Takayasu’s arteritis in children: 1999;68:155–9.
clinical profile and management. Postgrad Med 2000;46:3–8. 43. Sharma R, Bhan A, Juneja R, et al. Double switch for congenitally corrected
25. Shrivastava S, Shrivastava RN, Tandon R. Idiopathic obstructive aortoarteritis in transposition of the great arteries. Eur J Cardiothorac Surg 1999;15:276–81.
children. Indian Pediatr 1986;23:403–10. 44. Kaushal SK, Iyer KS, Sharma R, et al. Surgical experience with total correction of
26. Kumar RK. A practical approach to treatment of cardiomyopathy in children. tetralogy of Fallot in infancy. Int J Cardiol 1996;56:35–40.
Indian J Pediatr 2002;69:341–50. 45. Iyer KS, Sharma R, Kumar K, et al. Echocardiographic criteria for assessment of left
27. Kothari SS, Dopeshwarkar RA, Saxena A, et al. Dilated cardiomyopathy in Indian ventricular preparation in rapid two stage arterial switch operation for simple
children. Indian Heart J 2003;55:147–51. transposition. Ann Thoracic Surg 1995;60:658–64.
28. Chhatwal J, Verma M, Riar SK. Obesity among pre-adolescent and adolescents of a
46. Kumar RK, Tynan M. Catheter interventions for congenital heart disease in the Third
developing country (India). Asia Pac J Clin Nutr 2004;13:231–5.
World. Pediatr Cardiol 2005;26:1–9.
29. Ramachandran A, Snehalatha C, Vinitha R, et al. Prevalence of overweight in urban
47. Dalvi B, Goyal V, Narula D, et al. New technique using temporary balloon occlusion
Indian adolescent school children. Diabetes Res Clin Pract 2002;57:185–90.
for transcatheter closure of patent ductus. Cathet Cardiovasc Diag 1997;41:62–70.
30. Raj M, Sundaram KR, Paul M, et al. Obesity in children—time trends and relationship
48. Kumar RK, Krishnan MN, Venugopal K, et al. Bioptome-assisted simultaneous
with hypertension. Natl Med J India, 2007;20:288–93.
31. Mohan B, Kumar N, Aslam N, et al. Prevalence of sustained hypertension and delivery of multiple coils for closure of the large PDA. Cathet Cardiovasc Interv
obesity in urban and rural school going children in Ludhiana. Indian Heart J 2001;54:95–100.
2004;56:310–4. 49. Anil SR, Sivakumar K, Kumar RK. Coil occlusion of the small patent ductus arteriosus
32. World Health Organization. WHO global report. Preventing chronic diseases: a vital without arterial access. Cardiol in the Young 2002;12:51–6.
investment. Geneva: WHO, 2005. 50. Kumar RK, Anil SR, Philip A, et al. Bioptome-assisted coil occlusion of moderate-
33. Bakshi KD, Vaidyanathan B, Sundaram KR, et al. Determinants of early outcome large patent arterial ducts in infants and small children. Cathet Cardiovasc Interv
after neonatal cardiac surgery in a developing country. J Thorac Cardiovasc Surg 2004;62:266–71.
2007;134:765. 51. Vaidyanathan B, Kannan BRJ, Kumar RK. Device closure of residual ventricular
34. Chowdhury UK, Subramaniam GK, Kothari SS, et al. Congestive heart failure in septal defect after repair of tetralogy of fallot using the Amplatzer duct occluder.
unoperated tetralogy of Fallot: can hypoxia be a cause? Indian Heart J 2005;57:65–7. Indian Heart J 2005;57:64–6.
35. Sharma R, Bhan A, Choudhary SK, et al. Ten-year experience with the arterial switch 52. Shivaprakasha K, Rameshan I, Kumar RK, et al. A new technique of right heart
operation. Indian Heart J 2002;54:681–6. bypass for congenital heart surgery. Ann Thorac Surg 2004;77:988–93.
36. Vaidyanathan B, Roth S, Gauvreau K, et al. Somatic growth after ventricular septal 53. Pinto RI, Dalvi B. Transcatheter guidewire perforation of the pulmonary valve as a
defect repair in malnourished infants. J Pediatr 2006;149:205–9 palliative procedure in pulmonary atresia with intact interventricular septum. Indian
37. Bhatt M, Roth S, Kumar RK, Gauvreau K, et al. Management of infants with large, Heart J 2004;56:661–3.
unrepaired left-to-right shunts and respiratory infection requiring mechanical 54. Bhuvaneshwar GS, Muraleedharan CV, Vijayan GA, et al. Development of the Chitra
ventilation. J Thorac Cardiovas Surg 2004;127:1466–73. tilting disc heart valve prosthesis. J Heart Valve Dis 1996;5:448–58.
38. Vaidyanathan B, Roth SJ, Rao SG, et al. Outcome of ventricular septal defect repair 55. Sankarkumar R, Bhuvaneshwar GS, Magotra R, et al. Chitra heart valve: results of a
in a developing country. J Pediatr 2002;140:736–41. multicenter clinical study. J Heart Valve Dis 2001;10:619–27.

Let us assist you in teaching the next generation

Figures from all articles on our website can be downloaded as a PowerPoint slide. This feature is ideal
for teaching and saves you valuable time. Just click on the image you need and choose the
‘‘PowerPoint Slide for Teaching’’ option. Save the slide to your hard drive and it is ready to go. This
innovative function is an important aid to any clinician, and is completely free to subscribers. (Usual
copyright conditions apply.)

990 Heart 2008;94:984–990. doi:10.1136/hrt.2007.139360

 Downloaded from http://heart.bmj.com/ on June 25, 2015 - Published by group.bmj.com

Paediatric heart care in India

R K Kumar and S Shrivastava

Heart 2008 94: 984-990

doi: 10.1136/hrt.2007.139360

Updated information and services can be found at:

http://heart.bmj.com/content/94/8/984

These include:

References This article cites 50 articles, 2 of which you can access for free at:
http://heart.bmj.com/content/94/8/984#BIBL

Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Topic Articles on similar topics can be found in the following collections

Collections Drugs: cardiovascular system (8383)
Congenital heart disease (694)
Health policy (210)

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/