Over the past 50 years, paediatric cardiology has developed as a subspeciality of paediatrics linked to adult cardiology and cardiovascular (CV) surgery. It deals with diseases of the heart and the circulation in growing individuals and patients with congenital CV malformations and acquired CV disease (CVD) from foetal life to adolescent and adult age. Worldwide, 800 to 1,000 per 100,000 newborns are affected by a congenital CV malformation. One-third of these infants need hospitalisation and one or more cardiologic or surgical interventions directly after birth. An increasing number of all affected patients will need medical, catheter interventional or surgical treatments. Lifelong follow-up is necessary in a majority of these patients.
The incidence of acquired CVD in children and young adults is less well established and is subject to continuous change.
Over the past 50 years, and particularly during the last 20 years, diagnostic modalities and therapeutic options have shown revolutionary developments resulting in newer medical, interventional and surgical techniques with increasing survival rates. A continuous amelioration of the quality of life of these patients has been achieved. The modern treatment of congenital heart defects has led to normal or near normal adult life, even in several complicated defects that were previously fatal.
Paediatric cardiology problems will continue to persist but will change face due to prenatal interventions and early postnatal treatment.
Early interventions have created a new population of cardiac patients over the years. Even if the majority of the patients are doing well, new secondary and changing CV problems, and sometimes also general health problems, may evolve. They will require regular medical follow-up and several secondary CV interventions.
Genetics, embryology and morphology have, over many years, increased the knowledge of CV development and the inheritance of certain conditions. More recently, molecular biology has entered the field and is expected to promote revolutionary changes. Use of stem cell cultures is likely to become the ultimate solution for the treatment of heart diseases.
The paediatric cardiac population that will reach adulthood is progressively growing; thus, rather new challenges face the medical community - some of these situations will involve paediatric cardiologists but many more adult cardiologists and CV surgeons. The relative unfamiliarity of the medical community with these late-appearing problems pushes towards the development of new concepts. The medical society and industry of several fields is requested to come together and to solve these new challenges. Continuous medical education is required to maintain quality and safety and to create new means of treatment.
The patient population regarding paediatric cardiology is smaller than that of adult cardiology, but has equal needs. A concentration of human and material resources is mandatory in order to achieve and continuously maintain a high standard of care. National and international organisations have an important role in achieving this goal. Structured organisations are required among medical professionals - the Association for European Paediatric Cardiology (AEPC) is the organisation in Europe, and is likely to be the only one worldwide that represents medical professionals in paediatric cardiology on an entire continent. More than ever an increasing need is arising to share and harmonise medical education, results of technical improvement and medical data related to paediatric cardiology.
New imaging modalities developed after the Second World War, first in X-ray, resulted in the visualisation of vessels and heart chambers with angiography. In the 1980s the modes of haemodynamic assessment and the imaging modalities changed and were partially substituted by echocardiographic techniques. More recently, magnetic resonance imaging (MRI), angiography and computerised tomography (CT) have become more and more important diagnostic means. All of these imaging modalities are complementary methods - they provide precise means for the assessment of the diseased heart as early as 16 weeks of foetal life. For interpretation of these imaging modalities, doctors also need technical assistance. Due to rapid development in imaging modalities further specific and continuous training of the medical and technical staff is mandated.
For further progress the development of three-dimensional (3-D) online imaging modalities are of greatest interest. This progress is expected to provide even more precise and earlier diagnoses and more safety for surgeons, anaesthetists and intensivists in their daily work and search for new therapeutic modalities.
The first generation of catheter intervention was represented solely by the atrial balloon septostomy. In the last two decades, the second generation of these techniques has been implemented and has partly replaced surgical procedures. Catheter interventional treatment aimed first to relieve obstructions using percutaneous balloon dilatation procedures - valvuloplasties and angioplasties. Currently, closure of extra- and intra-cardiac communications, such as closure of atrial septal defects (ASD), is the field of interest. Technical development of the occluder design enables the procedures to be used as a regular practice providing equal safety and efficacy to surgery. Further sophisticated occluder designs should soon become available and dedicated stents will be needed to treat special 'congenital and post-surgical' obstructions.
In the last 10 years, paediatric invasive electrophysiology has become a regular part of the therapeutic arsenal. Pioneering experience in adult cardiology practice proved that further development in ablation modalities are needed to achieve higher safety and efficacy levels. Modern concepts of resynchronisation therapy in heart failure should be implemented for children in the near future. Currently, the dimensions of the devices mean definite limitations for their use. When decreasing the size of these products, miniaturisation is mandatory.
Recent improvements in anaesthesia techniques (anaesthetic and ventilating machines, specifically adapted instruments fitting to premature babies and children) have enabled surgeons to perform procedures as early as the neonatal age.
Surgeons like C W Lillehei, A Senning, Mustard, F Fontan, D Cooley and many others have become well-known pioneers in CV surgery and have made history. The second and third generations of paediatric CV surgeons have taken on the challenges and continue to develop new means for surgical interventions. Together with industry, they also try hard to develop methods of minimally invasive surgery requiring specific and smaller surgical instruments and material for prosthesis, valves and grafts, etc. The surgeons are increasingly reliant upon rapid on-line video-, ultrasound- and other computer-assisted techniques.
The pharmacology and pharmaceutic industry is going to have a greater impact in the daily practice of paediatric cardiology. Paediatric patients use the same well-known products that have been shown to be safe and effective in adult cardiac patients; however, pharmaceutical products have been rarely tested in children of different ages in the past. This has only changed recently and current specific studies are requested for the safe use of cardiac drugs even in children by state control authorities. This change may also stimulate more specific research and development of paediatric-orientated products.
Progress in the treatment of congenital heart defects is an unequalled triumph in medical history. Further development and on-going collaboration with industry and service providers will enhance life expectancy and the quality of life of those who suffer from heart diseases.