Beyond the Heart – Marissa’s Story

There is still much unknown about adult Congenital Heart Disease Patients and the long term effects of their treatment in childhood. This week, Marissa, a single ventricle patient about to complete her nursing degree, shares her story of an unexpected complication, which almost cost her future in nursing. 

I call myself a “heart patient”, but why? Sure, I was born with six complex congenital heart defects, but my heart disease effects more than just one body system. As a 21-year- old Single Ventricle Fontan, I’ve always had my routine EKGs, echocardiograms, stress tests, halter monitors- you name it. Because I am a fontan, I’ve been made aware of the high likelihood of developing liver cirrhosis, so I have liver ultrasounds each summer. There can be issues with pregnancy, exercise tolerance, mental health disorders, and an overall a deterioration of the Fontan circulation. I’ve always been very realistic and knowledgeable with my own health condition, which is why I was so surprised when I heard my doctor say the words “you have T-cell Lymphopenia related to your Fontan circulation”.

In November of 2016, I underwent a diagnostic endoscopy that yielded abnormal findings. A week later, I found out I had an infection lining my esophagus. I presented with no symptoms and had been completely unaware of the infection. The treatment was simple, a two-week course of oral antibiotics, but my doctor felt I needed to undergo further immunology testing, considering this was an opportunistic infection. After three separate lab studies showing low immune cell counts, I was referred to an Immunologist in Philadelphia. Since then, I’ve seen three separate immunology specialists.

Marissa and her Mom wearing surgical masks while flying, to protect themselves.

T-Cell Lymphopenia is a secondary immunodeficiency that results in decreased levels of T cells (infection fighting cells) within the blood. The high pressures within my circulation do not allow my lymphatic system to release the proper amount of T-cells needed within a healthy individual. For me, my case is mild and was caught early, however; the newfound diagnosis almost ended my career as a nurse before it even began.

When I finally received my official diagnosis, I was in my third year of nursing school. I was attending clinical rotations twice a week, and I was already working in a hospital setting. Many specialists were unfamiliar with my diagnosis in relation to my childhood heart surgeries. Before I began my senior year of school, I visited a new doctor who advised I avoid patients with any form of a transmittable illness. I was advised to wear a mask in crowded spaces, to avoid friends or family members who were ill, and I was given immunizations intended for those with a weak immune system. Having these new restrictions was difficult, and it was a daily reminder that I will always fight this chronic illness; I’ll never be considered
“healthy”.

 

Marissa dressed as a nurse for Halloween when she was 9 years old.

When starting my last year of nursing school, I was told I couldn’t complete the program with the accommodations my doctor required. I was devastated to find that I may not be able to graduate with my nursing degree, and I may not be able to fulfill my passion to work as a nurse. I had spent three years studying and preparing to succeed in my future career, and it all came to a halt on a warm August day. I’ve always tried to treat myself as normal as possible; I’ve never wanted my congenital heart defects to define me as an individual. I knew this career would be tough, especially for someone with a single ventricle. Nursing school is the most challenging thing I’ve ever done, but hearing that I wouldn’t be able to graduate because of my heart was the worst part. No matter how hard I studied, how well I performed in clinical, and how well I prepared for my future, that didn’t matter anymore. With this crushing reality, I requested a third opinion from a pediatric specialist, hoping this physician would have more experience considering Congenital Heart Defects are from birth.

 

Marissa in her scrubs now, at the age of 20 years old.

Thankfully, after visiting a third immunologist, I now have no restrictions related to my T-Cell Lymphopenia. I will require follow-up care to monitor my T-cell and vaccination levels, however, I have NO restrictions in the clinical setting. I’m allowed to finish my degree to fulfill my dreams and work as a nurse. I’m incredibly grateful to have been able to see a specialist who was familiar with my diagnosis. Apparently, T-Cell Lymphopenia is present in a small percentage of Fontans by the time they reach their early 20’s.

 

CHD does go beyond the heart, and affects the body in various ways. It’s important that we as patients receive lifelong care, but this can be challenging when complications arise outside of the heart. Although it took over a year, I’m thankful to have received the proper diagnosis and plan of care. I want to inspire others to be an advocate for themselves and to not give up on their dreams. Life can get difficult sometimes, but through determination we can reach our goals,even when taking an unconventional path.

 

 

 

 

 

Marissa Mendoza lives in New Jersey and was born with six complex congenital heart defects. She was diagnosed with a Ventricular Septal Defect, Congenitally Corrected Transposition of the Great Arteries with Ventricular Inversion, Pulmonary Atresia, Bilateral Superior Vena Cavas, and Dextracardia. She underwent three open heart surgeries before the age of two, now classifying her as a Single Ventricle Fontan. She is a senior year nursing student graduating in May, 2018 and has a passion for working in pediatric cardiology. Marissa has a lifelong goal to increase awareness of Congenital Heart Defects and serve as an advocate for not only herself, but for the millions of others facing this chronic condition.

 

Beyond the Heart – Rebeka’s Story

CHD can affect so much more than the heart, yet physicians unfamiliar with Congenital Heart Disease may have trouble seeing the big picture. In this week’s post Rebeka Acosta, PCHA Steering Committee member and Mom to two heart warriors, shares the struggle of coordinating care outside of cardiology.

In the last few decades, science and research surrounding congenital heart disease has uncovered many connections to other body systems. As the parent of two heart warriors with additional diagnoses and unique family histories, it is imperative for me to keep up with research, be able to educate non-cardiac
practitioners, and advocate for my kids’ entire bodies. If that sounds like a full-time job, you are correct!

 

 

My youngest son has single ventricle anatomy and experiences challenges in the neurodevelopmental and neuropsychology spheres. Difficulties with word recall, attention and focus, and auditory processing have left many clinicians with puzzled looks on their faces. Some prescribed therapies with scientifically unproven results, while refusing the connection to CHD. Others were willing to learn and adjust their techniques to best work with him. Looking back, gross motor delays around 3-5 years old were the least of his challenges!

 

My oldest son with minor anatomical cardiac differences has multiple airway and pulmonary disorders, which include treatment from multiple specialists. Who knew the airway was as complex as the heart? His airway diagnoses are part of the outdated school of thought that “kids will eventually grow out of it”, so it has been a several years battle to find clinicians that specialize in and treat them. We are all excited for his evaluation next month and the possibility of a surgical repair!

 

 

Our family has made tough choices regarding medical treatment, mental health, and education for both of our children. They were not always popular amongst family or friends, but they were best for the kids. After eight years parenting these awesome warriors on the CHD roller-coaster, we are on the right track. For everyone starting out, remember to speak up and do so loudly. You are the
expert and your child’s primary care provider.

 

 

Rebeka Acosta lives in Las Vegas with her husband, two heart warriors and two Great Danes. A researcher by nature and healthcare finance coordinator by training, she enjoys keeping up with congenital cardiac literature and always reviews insurance claims line by line. Before relocating to Southern Nevada, Rebeka was a founding member of the Washington chapter of PCHA. She now volunteers on the National Steering Committee and enjoys attending the annual legislative conferences and
transparency summits. Rebeka welcomes connections at racosta@conqueringchd.org. You can also follow Gavin & Taosies’ CHD adventures on Instagram.

Beyond the Heart – Anna’s Story

The effects of Congenital Heart Disease aren’t limited to the heart. Patients will often experience complications with other body systems. This week Anna Archer shares her how her late CHD diagnosis caused a brain abscess.

Growing up and Diagnosis
I was your average, ordinary, little girl for the first decade of my life and lived an idyllic life with my (incredible) parents and eight sisters and brothers (yes, you read that right), in the Pacific Northwest. When I was ten, I started showing symptoms of my undiagnosed CHD. I started becoming slightly short of breath and cyanotic with exertion, I was easily fatigued, and I probably slept more than most kids my age. After running through a whole gamut of testing, we finally received my diagnosis of Tetralogy of Fallot with a VSD, Eisenmenger’s Syndrome, and Pulmonary Arterial Hypertension.

Surgery to repair my heart was not an option for me, so life meandered on after my diagnosis, but I maintained my health for most of my second decade, it declining only in the last year or two. A few months after I turned 20, I was listed for a double-lung and heart transplant. Many years later, I learned that my parents thought they might lose me that winter, but I survived, and, a few years later, I was thriving again. I became healthy enough to go off the list after six years on it. In September of 2012, I got married and moved to Southern Nevada, where I currently live.

To better understand the plot twist, you need to have some understanding of my heart. I have what is called a bidirectional shunt with my VSD. It acts as a “pop-off” valve if you will, allowing my blood to change directions as needed, to relieve the pressures between my heart and lungs. Bacteria that should get caught in my lungs and give me a cold, is able to bypass them, through the shunting in my VSD, and maneuver its way up to my brain. There it made itself comfy cozy and became a brain abscess.

Plot twist! AKA: The Brain Abscess
On Monday, February 25th, 2013, I had a headache. Now, this isn’t abnormal in and of itself, except it didn’t go away. I still had a headache on Tuesday, and Wednesday. It was a pulsing kind of headache. Sometimes it would be a dull ache, then I would get these waves of intense pain. By Thursday, I was becoming concerned that I had injured myself while working out with my husband the weekend before. Friday came and went with no improvement, despite caffeine, ibuprofen, oxygen, and resting all day. On Saturday, I had decided if it wasn’t better by Monday, I would call my cardiologist’s office and see what they recommended. I had only seen my new cardiologist twice at this point, so I still wasn’t very familiar with how everything worked at their office.

Around 3am on Sunday, March 3rd, I started vomiting. This is always taken very seriously, as I dehydrate quickly, and what little energy I normally have is drained almost immediately. After a second round of vomiting, I woke my husband up and asked him to take me to the ER; something was definitely wrong.

The ER was fairly quiet that night, and I was taken back almost immediately. They worked through everything respiratory/heart/lung related first, chest x-ray and bloodwork, the most obvious concerns with a CHD/PAH patient. After everything came back clear, they sent me for a head x-ray. I remember someone coming into my room and asking”have you ever had anything show up on your scans”, I said “not that I knew of,” and thought it kind of a silly thing to ask (little did I know). Then I was sent for a head MRI… I wasn’t as concerned as I, perhaps, should have been. I supposed that since my head hurt, it made sense they were checking it out. I never thought something would actually show up on those scans.

The ER doctor came in, and told me I had a mass in my brain, and I needed to have a brain biopsy done. I was shocked, and in some sort of denial, because I told him flat out that surgery wasn’t happening. They couldn’t do surgery on me, it was too risky, it was reserved for life and death situations, and this was obviously not a life or death situation. He insisted that I needed to wrap my mind around it, because it would have to be done. Then he told me to look up glioblastoma, then left the room after reiterating that I would need to have surgery. I knew what a glioblastoma was, one of our family friends had died from it. I looked it up anyways; one to two year survival rate with successful treatment. I called my Dad and cried as I explained what little I knew.

I have been blessed with amazing parents, my Dad is a respiratory therapist and my Mom went to nursing school. It took my Dad almost an hour to calm me down when I called him about my brain scans, and finally, he said he would call my Mom and tell her what was going on. I didn’t think I could do it and be any amount of comprehensible. A little while later my Mom called, and I cried with her. Somebody, I’m not sure if it was myself, or one of my parents, let the rest of my family know what was going on. I have also been blessed with amazing siblings. Each and every one of them has supported me through thick and thin. They worked things around in their lives so that Mom could fly out to Las Vegas to be with me for the impending surgery and recovery.

Somewhere in the mess of things, I was coherent enough to call my cardiologists office and let them know what was going on, as well as telling the ER people that they needed to connect with my cardiologists office. The neurosurgeon who was going to be performing my surgery came in sometime that Sunday. He looked over my scans and to talk to me and my husband. He was much more calm, and kind about things. He told us that “the mass in your brain could be any number of 100 or more different things, and I simply wouldn’t know more until I get in there to check it out during the biopsy”. I felt much better about things after talking to him; I’d had enough of this glioblastoma talk.

Surgery was scheduled for the next day, Monday, March 4th, but it ended up being postponed, because they couldn’t get my blood thick enough (I’d been on blood thinners since I was diagnosed). After a few platelet transfusions, and a couple of vitamin K shots, it was finally thick enough to schedule the biopsy. I count this as a blessing on multiple levels, as it allowed some extra time for my Mom and one of my brothers to fly into town that day.

Tuesday, March 5th, 2013, my six-month wedding anniversary, I had brain surgery. My family was told the biopsy would take around one and a half to three hours, so you can imagine the almost heart-attack they all had when the surgeon came out after 45 minutes! He said everything went great, the abscess was right next to my skull, and not buried into my brain, so he was able to remove the entire thing and flush it out with antibiotics and antibacterials, before closing me up again. The abscess ended up being about the size of a golf-ball or meyer lemon.

 

 

For the next day or two my timeline is a little wonky. It was my first experience being intubated, and my first experience with any kind of narcotic (I’m apparently fluent in ASL when I’m on narcotics, I don’t remember this). What I do remember, is that my husband, mom, brother, mother-in-law were all there. I was surrounded by a million beeping machines, and my family. My best friend flew into town a few days later, followed by my dad the next weekend. I was surrounded by those who loved me. I remember distinctly getting my hair dry-washed by a nurse, which was the most incredible feeling in the world at the time. The night nurse, who made my life sane again. My Dad talking medicalese to the doctors, to explain that resting oxygen levels in the mid 70’s were perfectly normal for me. Slowly entering the social media field again, and the outpouring of prayers and support from family and friends across the country. Continual jokes about having a “few loose screws” now.

The “short-term” recovery ended up taking just over two months. I was released from my Infectious Disease doctor on May 8th and Neurosurgeon on May 16th. I say “short-term” recovery, because I was still recovering from some aspects six months later, a year later, two years later, even now.

Some things I wish they had done, was suggest I see a psychologist, and do neuropsych testing. My abscess could’ve been much worse, bigger, deeper into my brain, in a different spot, any number of things could’ve made recovery that much harder and longer. There wasn’t anything obviously different, or wrong, after the surgery, but lots of teeny tiny things that slowly built up, and built up, and built up, to become large problems later on. My abscess was in the frontal left lobe of my brain, and the frontal lobe functions include things like mood, personality, memory, behavior, decision making, judgement, initiative, planning, reasoning, intelligence, movement, and inhibition. I lost all semblance of self-confidence. I forgot how to cope. I became incredibly jealous. I wasn’t the same, and I didn’t know it for awhile. When I figured it out, I didn’t know how to fix it. Rewiring the brain is hard work. It’s an exhausting, frustrating business.

After I had a bad reaction to some allergy medications in the summer of 2016, along with some of life’s tougher moments, I became severely depressed, and developed anxiety. I had called my cardiologists office to see if there were any medications I could take, and as I’m bawling my eyes out with my nurse, they told me they had a psychologist I could see. We made an appointment for the next day. It’s been an incredible, life-saving, life-changing experience. For the past year and a half, I’ve seen my psychologist every week to two weeks, and I can’t recommend it enough. We’ve worked a lot on rewiring my brain, learning how to cope in various situations, and to remember that I am enough.

It’s a continual process, learning who you are, and what you are capable of, if only you give yourself half a chance.

Anna (Becky) Archer is 31 and lives in Las Vegas, NV with her husband and kitten. When Becky isn’t busy at her part-time job as a filing clerk, you can find her playing video games, knitting,
crocheting, swimming in her pool, shooting photos, hiking, going to the movies, and hanging out with family and friends. She is a Heart Warrior, PHighter, and Survivor. She has a fierce
perseverance for living.

Advice – 10 Pieces of Advice for the New CHD Parent

Learning your child has a CHD can be overwhelming. Suddenly, you’re thrust into unfamiliar territory filled with strange terminology and new doctors. But so many families have bee there too, and they have so much knowledge to share, garnered through their experience.  PCHA recently asked the CHD Community,  families and patients, to share their advice for new parents feeling overwhelmed. This is what they had to say.

 

 

1. You Are NOT Alone

CHD is the number one birth defect, there are lot of parents or patients in your community to learn from and lean on. Parents often find it helpful to talk to each other, someone who knows what their going through.
Also, don’t be afraid to take your friends and family up on the help they offer. They love you, and are there to help lighten your load. Let them.

 

2. Take Care of Yourself

You want to be there for your Heart Warrior, but you are only human. Sometimes you need a break too. If you’re not getting the rest you need, you’re less able to effectively care for your child.

 

 

3. Go Easy on Yourself

When you learn your child has a CHD so many different emotions will flood through you. Remember this is normal. Be kind to yourself, and take comfort in that your Heart Warrior will understand you’re doing your best for them.

4. Treat Your Heart Warrior as “Normal” as Possible

Let your Heart Warrior find their own limits, and push them to enjoy as much of life as they can. It’s important that they also learn responsibility and accountability, like their heart healthy counterparts. They  will need to be able to manage their own care and know their condition as they grow up.

 

 

 

 

5. You are Stronger than You Think

The diagnosis is scary, and it can be overwhelming, but you are more capable than you think. And so is your Heart Warrior. Their propensity for resilience may surprise you and provide you will courage.

 

 

6. Take One Day at a Time

There will be good days and bad days, sometimes good hours and bad hours. Enjoy every positive moment, and try not to spend time worrying too much about the future.

 

 

7.  Don’t be Afraid to Advocate for Your Child

It’s OK to question your child’s doctor. It’s OK to get 2nd opinions. You are your child’s voice, and it’s OK to speak up when you need clarification or when your uncomfortable with a situation.

 

 

8. Every Child is Different

It is natural to want to know what to expect and compare our Heart Warrior’s journey with others that have the same CHD. But what goes for one child, may not be true for another.

 

9. Ask Questions and Keep Records

Your child’s doctors will throw a lot of new terms at you and explain unfamiliar procedures. Ask questions about what you don’t understand. There is no such thing as a stupid question.
Write it down. Anything that is important or difficult to remember, write it down.  Keeping records is important to keep things straight , especially if you are seeing multiple doctors at various locations.

10. Educate Yourself

Don’t Google. Make sure you find trusted resources to learn about your child’s condition. Soon you will be an expert in your own right. Be sure the material you read is reliable. Ask your child’s doctor or other heart families for recommendations of sources of information.

 

*Please note the information in this post is not meant to be a substitute for medical advice.

New Diagnosis – Pulse Oximetry

This week we will hear two perspectives on the benefits of pulse ox and the effort to make this non-invasive test a standard screening of newborns. Pulse Ox screening has made it possible to detect CHD in many newborns that would have otherwise gone home undiagnosed. This week’s contributions were provided by Dr. Gerard Martin, a pediatric cardiologist, and Ms. Lisa Wandler, a pediatric nurse, from the  Children’s National Heart Institute and  Dr. Matt Oster, MD, MPH , a pediatric cardiologist at Sibley Heart Center Cardiology at Children’s Healthcare of Atlanta.

 

 

Dr. Gerard Martin, a pediatric cardiologist, and Ms. Lisa Wandler, a pediatric nurse, from the  Children’s National Heart Institute discuss with us how pulse oximetry screening works , as well as its benefits and limitations. 

Screening infants for Critical Congenital Heart Disease (CCHD) using pulse oximetry is recommended in the United States, but this was not always the case!  As of this summer, all 50 states and the District of Columbia will be screening for CCHD.  In many countries, this important life-saving screen is not yet standard for every newborn.  

How CCHD pulse oximetry screening works:

CCHD screening is simple, painless and takes only a few minutes to perform.  It typically takes place around 24 hours after birth either in the newborn nursery or in the mother’s room.  A sticker with a special light probe is placed on the baby’s right hand and either foot.  The measurement that the light probe takes helps the medical team determine whether the baby may have CCHD and require further assessment and testing.

How it has changed standard screening for newborns:

Prior to the implementation of CCHD screening, as many as 50% of infants with CCHD were being discharged from the hospital without anyone knowing of their heart problem.  Without CCHD screening using pulse oximetry, routine newborn screening could help identify hearing and other rare but serious conditions in babies just after birth but not heart defects.  

Benefits/importance of screening:

An undetected heart problem in a baby can lead to severe health problems for the baby and even death.  This newborn screen has helped to decrease the number of babies lost to undiagnosed heart defects and saved many lives.  The CDC continues to investigate the impact CCHD screening has had in the U.S., but an early estimate is that the number of deaths due to CCHD has gone down by 33% in states requiring this important newborn screen.

Limitations of screening using pulse oximetry:

Screening improves the detection of CCHD, however, not all types of CCHD are able to be detected using this screening method.  It remains important to follow the instructions of a baby’s pediatrician and other doctors as newborn assessment and pre-natal ultrasound remain important other ways CCHD can be identified.

Early symptoms of CCHD can include rapid breathing, difficulty feeding and bluish skin.  If your baby has these symptoms, tell the baby’s doctor.

 

The Critical Congenital Heart Disease Screening Program at Children’s National Heart Institute is composed of Dr. Gerard Martin, a pediatric cardiologist and Ms. Lisa Wandler, a pediatric nurse.  The team at Children’s National has worked on implementation, education and CCHD screening advocacy for over ten years and has provided guidance at the local, state and international levels to those interested in CCHD screening using pulse oximetry.  The team can be contacted at pulseox@cnmc.org

Gerard Martin headshot, cardiologist, children’s national heart institute

 

 

 

Dr. Matt Oster, MD, MPH  discusses the progress brought by pulse ox and the distance yet to go. 

 

In my medical career, I’ve been able to see what was once just a promise or an idea be transformed into reality – the ability to screen well-appearing newborns for critical congenital heart disease. While a baby may appear completely well by anyone who sees her, lurking beneath the surface could be subtle hypoxemia – an abnormally low concentration of oxygen in the blood.- secondary to a congenital heart defect. The application of pulse oximetry to detect such hypoxemia has thus allowed clinicians to detect many previously undiagnosed cases sooner, a change
that has led to decreased infant mortality from critical congenital heart disease.

This dramatic change in the care of newborns did not come easily. It took scientists studying the issue to determine whether this could work. It took policy makers the vision to implement this change in their regions. And, most importantly, it took the tireless advocacy of parents and others to call for, and when needed essentially demand, such change.

The application of pulse oximetry to screen for critical congenital heart disease is a true public health success story. And, it has even seen spillover effects in that many children with hypoxemia due to causes other than heart disease are being detected and treated. However, there is still much work to be done. We need to figure out the best way to implement this screening in special settings such as the neonatal intensive care units, home births, or areas of high altitude. We need to improve the quality of the program so that it is implemented consistently and correctly for all newborn. We need to help public health agencies monitor and track the success of this program.

But the biggest change we need to make is figure out a way to increase the sensitivity of the screening. Yes, the program has detected thousands of babies that may have previously gone undetected. But there are still many newborns with critical congenital heart disease that are being missed, even newborns with hypoplastic left heart syndrome. This is typically due to the fact that hypoxemia may not yet be present. We need improved diagnosed methods beyond pulse oximetry to help detect these children. This is not an easy task, but scientists are indeed working on it. And when it’s ready, we’ll need the help of advocates and policymakers to make it a reality.

 

Dr. Matt Oster, MD, MPH is a pediatric cardiologist at Sibley Heart Center Cardiology at Children’s Healthcare of Atlanta, and he holds Emory appointments of Associate Professor of Pediatrics in the School of Medicine and Associate Professor of Epidemiology in the School of Public Health. He earned his MD at the University of Pennsylvania School of Medicine and his MPH in epidemiology at Emory University Rollins School of Public Health. After completing residency training in pediatrics at the University of California-San Francisco, he did fellowship training in pediatric cardiology at Emory University. When not seeing patients, he serves as director of the Children’s Cardiac Outcomes Research Program at Sibley Heart Center. His research interests include newborn screening for congenital heart disease, the epidemiology of congenital heart disease, and long-term outcomes for patients with congenital heart disease.

 

 

 

New Diagnosis – Fetal Echo

More often now, than a generation ago, babies born with CHD are being diagnosed prenatally. This week, Dr. Sheetal Patel, from Lurie Children’s Hospital of Chicago and Assistant Professor of Pediatrics, Northwestern University Feinberg School of Medicine, explains the role prenatal echocardiography plays in diagnosing CHD and the benefit of that early diagnosis.   

 

 

Congenital Heart defects (CHDs) are among the most common birth defects, affecting 1 out of every 110 babies born. Each year nearly 40,000 babies are born in the United States with CHD, ranging from simple lesions that may not need any interventions to complex CHDs that can be fatal if appropriate treatment is not provided soon after birth. Research shows that prenatal diagnosis and early detection of these complex CHDs is associated with improved surgical outcomes. With improvement in diagnostic technology with Fetal echocardiogram today, about 70% of complex CHDs are detected prenatally. Goals for detection are targeted at 100%, and we are aiming to reach there with improved awareness and better screening techniques.

A fetal echocardiogram is an ultrasound test performed during pregnancy to evaluate the heart of the unborn child and can be performed as early as 18 weeks gestation. Diagnostic accuracy for detecting complex CHD with a fetal echocardiogram is as high as 95%. It is a non-invasive procedure performed with an ultrasound probe placed over mother’s belly. Generally, the pain or discomfort that results from the probe pressure on the mother is minimal. It involves detailed evaluation of baby’s cardiac structures including cardiac chambers, valves and major blood vessels. It also evaluates fetal heart rate and rhythm. This test can detect CHDs such as missing heart chambers (such as hypoplastic left heart syndrome, hypoplastic right heart syndrome, and many other variations), abnormal great arteries (such as transposition of the great arteries, truncus arteriosus, interrupted aortic arch, etc), abnormal cardiac valves (such as atrioventricular septal defect, pulmonary valve atresia), or large hole between cardiac chambers (such as a large ventricular septal defect). There are limitations of fetal echocardiography that it may not detect minor cardiac valve abnormalities, small holes between cardiac chambers or coarctation of aorta that develops after birth.

Early detection of CHD before baby’s birth has many advantages.

Prenatal diagnosis of CHD allows for necessary preparation to provide highly specialized care that the baby will require soon after the birth and prevents the hemodynamic compromise that can result if this CHD was undetected. This preparation involves coordinated care by multiple teams with expertise in pediatric cardiology, neonatology, pediatric cardiac intensive care and pediatric cardiovascular surgery. In addition, social worker, child life specialists, and palliative care teams may be available to help parents cope with the diagnosis and treatment. An important aspect of early detection is to provide expectant parents the opportunity to have detailed counselling.  This counselling helps parents to better understand their unborn child’s heart condition and interventions that might be needed.  This aids parents in their research to choose a center of excellence for their baby’s care. The goal of this prenatal counselling is for parents to be armed with knowledge, process the information over time, and maximize the family’s preparedness for the journey and transition to a birth of their new baby. Research shows that those mothers who knew about their baby’s heart condition prior to the birth were less anxious once the baby was born as compared to mothers who found out about the defect after baby was born.

There are some standard indications for fetal echocardiography during pregnancy.

Not every expectant mother needs to have a fetal echocardiogram. However, if the risk of having CHD in the unborn child is expected to be higher than general populations, a fetal echocardiogram is indicated. These risk factors include having a prior child with congenital heart defects, maternal diabetes, maternal infections during pregnancy known to affect baby’s heart, etc. Mother should discuss with her obstetrician if a fetal echocardiogram is indicated based on the family history and her own medical history. If indicated, a fetal echocardiogram should be arranged to be performed between 20 to 24 weeks gestation which is an ideal time for accurate diagnosis of CHD. Other indications for fetal echocardiogram include abnormal findings on obstetrical screening test such as increased nuchal thickness, abnormal cardiac images during the level II anatomy scan, chromosomal abnormalities (such as trisomy 21, trisomy 18, trisomy 13, Turner syndrome, etc) detected during the prenatal genetic testing, or other organ malformations noted during the anatomy scan. These abnormal screening tests indicate higher risk of CHD in the fetus and therefore, a fetal echocardiogram is indicated.

What happens after a fetal echocardiogram detects CHD in fetus?

A pediatric cardiologist performing the fetal echocardiogram will discuss the findings of CHD in details with the expectant parents. Tailoring the counselling to the parent’s needs over time is critical as parents can be very overwhelmed during the initial hearing of a diagnosis of CHD. Counselling should include discussion about implications of this CHD on baby during the pregnancy, what support and care this baby would need soon after the birth, what interventions, procedures and surgeries would be necessary during neonatal period, and what other procedures or surgeries would be needed later in life and what is expected overall prognosis with this CHD. The goal of this counselling process is to provide information to parents that would help them with their decision making to choose their options. The options are described in details that include preparing them for this journey to have child with CHD, palliative care or other family planning options.

Each Fetal Cardiac Program have unique set up to provide this detailed counselling. At Lurie Children’s Hospital; these services are provided through our fetal cardiac program at The Chicago Institute for Fetal Health. Following the initial consultation, parents have a “Comprehensive Fetal Cardiac Consultation” which includes a follow up fetal echocardiogram to assess the evolution of the CHD (if any), consultation with a fetal cardiology team composed of a pediatric cardiologist, neonatologist, cardiac intensivist, cardiovascular surgeon, social work, and other specific team pertinent to the diagnosis. For example, a consultation for prenatal diagnosis of HLHS would include a specialist for “Single ventricle Program”. Parents may also choose to meet with “cardiac neurodevelopment team” and “Child life Specialist” if they are interested in learning more about these important aspects of their child’s quality of life in future.  The number of partners at the table during this meeting can seem overwhelming to some parents and modifications are made to this process to meet each family’s needs.  

Our goal as a comprehensive fetal cardiology team is to arm families with information, answer questions, form a united care team to provide cohesive CHD care pre and post-natally, and optimize the chances for the most successful outcome and quality of life throughout a lifetime.  

 

References:

Fetal Echocardiogram: https://www.luriechildrens.org/en-us/care-services/specialties-services/medical-imaging-radiology/diagnosis-services/heart-evaluation-testing/Pages/fetal-echocardiograms.aspx)

CDC: https://www.cdc.gov/ncbddd/heartdefects/data.html

 

Dr. Sheetal Patel is Associate Director of Fetal Cardiac Program at Ann & Robert H Lurie Children’s Hospital of Chicago and Assistant Professor of Pediatrics at Northwestern University Feinberg School of
Medicine. Her clinical interest lies in fetal, neonatal and pediatric cardiology. She is passionate about prenatal diagnosis of congenital heart defects. Her research interests are in evaluating outcomes in
congenital heart defects, with special focus on single ventricle heart defect and Fontan palliation.

Zipperstrong Project

As we continue through heart month, one amazing program, called Zipperstrong, helps honor families affected by CHD and their stories. The work done by photographer SheRae Hunter helps remind us all that even our scars can be beautiful. 

 

 

 

“I am the mommy of a child who is different.   All I ever want and need is for others to understand. To understand my family, to understand my son, to understand the hours of therapy, the meltdowns, and the uncertainty that we live with daily. To listen and not judge, not offer advice, and not extend pity, but to try understand us,” SheRae Hunter explains.  With her work on the Zipperstrong Project, she helps  other families, families affected by CHD, accomplish this very thing.

 

Ainsley – 2 Years Old – 2 Ventricular Septal Defects closed with open heart surgery at 3 months. ​

 

On the first day of Congenital Heart Disease Awareness Week, the Pediatric Congenital Heart Association of Virginia (PCHA-VA), in partnership with the Zipperstrong Project, shared a set of powerful images capturing the strength, vitality, and hope of children fighting congenital heart disease (CHD), as well as the reality that many CHD warriors sadly lose this battle each year.

 

Blake – Two years on Earth. Forever in our hearts.Transposition of the Great Arteries, AV Canal Defect, Pulmonary Artesia, Heterotaxy

 

Every year, 40,000 infants are born in the United States with a congenital heart defect. It the most common birth defect, yet many people are unaware. Through Zipperstrong, Winchester, Virginia Photographer SheRae Hunter helps raise awareness of congenital heart disease by giving outsiders a glimpse into the CHD world. Hunter started Zipperstrong in 2015 after becoming intertwined in the lives local CHD families and wanting to make a difference.

 

Finn – 2 1/2 Years Old – Heterotaxy, Double Outlet Right Ventricle, Total Anomalous Pulmonary Venous Return and other cardiac issues.

 

“In my photography, I see these children’s personalities shine through, despite their physical and emotional scars. Their vitality and courage is something to be admired and that is what I hope to capture through the Zipperstrong Project. That is what I want the world to see!” says Hunter. “This year’s Zipperstrong class is truly special. Many of these kids have grown up before my eyes, while others I’ve met for the very first time. All of their stories are so deep and profound that I wish I could share every word. Year after year I am reminded of how extraordinary these kids are.”

The 2018 Zipperstrong Class includes children  from across the Commonwealth, from the Shenandoah Valley and neighboring West Virginia regions to Richmond, Fredericksburg, and Alexandria. Their ages  range from newborn to 11 years old. In all, 15 children were photographed and a handful participated for the first time this year. Most of the children have multiple heart defects, and many have gone through numerous surgeries, with more in their future.

 

Jade – 11 Years Old – 2 Ventricular Septal Defects & Double-Chambered Right Ventricle

 

“Through Zipperstrong, SheRae offers the perspective of an outsider and her own artistic vision to tell the story of children living with hearts that have complex structural or functional problems hidden in plain sight,” says PCHA-VA President Laura Carpenter. “Her Zipperstrong Project has moved and captivated all of us at PCHA-VA, and so many more who have never heard of CHD. She has done a great service to the CHD community and we are thrilled to have her as a partner.”

PCHA extends great affection and gratitude to Zipperstrong founder and photographer, SheRae Hunter. Her portraits capture the incredible strength of CHD Warriors in Virginia and allow us to share that with the world!

The Zipperstrong Project kicked off CHD Awareness Week 2018 in Virginia, and we are excited to announce Zipperstrong as a program of the Pediatric Congenital Heart Association!

View this year’s Zipperstrong Project photos at www.zipperstrong.org. The photos will be shared through social media throughout Heart Awareness Month and on display at various events across Virginia, including The Hope Marietta Foundation’s Casino Night in Washington, D.C., on February 24. Arrangements can be made to connect with certain Zipperstrong families and reproduce imagery by contacting PCHA-VA Communications Director Renée Lang at rlang@conqueringchd.org.

 

New Diagnosis – Jaclyn’s Story

This week, PCHA-OH Board Member, Jaclyn Frea shares the story of her miracle baby’s diagnosis with Tetralogy of Fallot.


My husband Bryan and I were married on March 5, 2011 and we knew that immediately we wanted to start a family. Little did we know, getting pregnant would be a lot more difficult than we thought and tragedy would strike two fold. Five months after we were married, I lost my Dad to cancer and, a year and a half later, in 2014, I lost my Mom to a different form of cancer. I am an only child, so losing both my parent was a devastating loss, but we didn’t want to give up at trying to have the family we had always wanted.

Along with the loss of my parents, Bryan and I tried and tried to get pregnant with no luck, each month we thought, maybe this month will be our month, then nothing. We then decided to go through a fertility doctor, only to find out that pregnancy probably wasn’t in our future. At that time, there was no explanation why! We wanted so badly to be parents. We decided to look into the adoption process and were approved; the only thing we needed to complete the adoption process was to find a birth Mom. After 5 years of unsuccessfully trying to get pregnant and just being approved to adopt, I found out I was pregnant!!!

My pregnancy with Paul was amazing. Yes, I had morning sickness, a lot of morning sickness, but I was carrying the baby I had always wanted. I was pregnant with a miracle baby, and I was incredibly grateful and I loved every single minute of being pregnant with this child! From hearing the first heartbeat, to seeing our baby in the ultrasounds and seeing my belly grow, feeling the baby kick and being incredibly active, and then finding out that we were going to have a little boy. God had answered my prayers!

The day arrived when Paul wanted to make his debut and everything seemed to be going pretty smoothly, until, his 36 hour check up. I remember the nurse coming in and telling Bryan and I that she was going to take Paul to the nursery to complete his check up and feeling so blissful about everything being absolutely perfect. A little while later, the doctor came into tell us that they could still hear a murmur in Paul’s heart, and they wanted to send him down to the NICU to conduct an echocardiogram on his heart just to make sure everything was alright. I hadn’t been released from the hospital yet, so we were going between floors being with our son and waiting on me to be discharged.

Bryan and I walked into the NICU, and I remember being greeted at the entrance with our nurse immediately informing us that they were going to be conducting an arterial blood draw on Paul. I remember that my heart sank. I knew in my gut that something was wrong with my baby boy, and the next hour we were waiting on the NICU doctor to come and tell us that our son was born with a Congenital Heart Defect, Tetralogy of Fallot!

How could this be happening, after everything we had been through, a CHD???? Neither Bryan, nor I were prepared, let alone even thought about a CHD! I remember sitting in the chair, sobbing, and the only words I remember hearing were Tetralogy of Fallot, open heart surgery necessary; if he didn’t have the surgery, he wouldn’t survive to be a teenager…..what???!!!

My husband is a Firefighter and Paramedic, and I thank God that he was there because he was so strong and he understood everything the doctor was saying. Paul was considered a pink tet baby, as his O2 saturation remained near 100. Looking at him, one wouldn’t even know that he was sick. In a normal case of Tetralogy of Fallot, the heart shunts blood from the right side to the left side, sending oxygen poor blood to the body. Paul instead shunted blood from the left to right, keeping his oxygen levels very high, but causing constriction of the pulmonary blood vessels and risking permanent lung damage due to this increased blood flow.

Paul was released from the NICU later that day, and that is when the litany of doctor’s appointments and preparations began. Bryan and I kept Paul quarantined pretty much until his surgery, because we wanted to try and keep him as healthy as possible. When he was 4 1/2 months old, he had his complete repair via open heart surgery in 2016 by Dr. Toshiharu Shinoka. Paul is followed closely by Nationwide Children’s Hospital, but now only requires yearly echocardiograms and check ups.

Paul is now 22 months old and he is doing phenomenally well; exceeding every milestone set before him.  Paul is a happy, mellow baby (toddler), who loves the water and can’t get enough of the bathtub and the swimming pool. He is always smiling, beginning to talk, and using lots of sign language (we began to teach Paul sign language when he was 6 months old).  He LOVES music, dancing and trying all kinds of foods.  He is very compassionate with a strong love for animals (he loves to give kisses and hugs where ever he goes). He is an only child, a total flirt
(who no doubt will use his scar to flirt with the ladies in the future).  Paul is a dynamic young man, who is also a giant book worm (he gets to go through about 25 to 30 books each day), walking and running everywhere, is super chatty, and is climbing on and into everything.

All who hear about him are inspired by his story and genuine passion for life.  Paul is, without a doubt, our miracle baby. I had to have an emergent hysterectomy 6 months after Paul was born, only to find out that I had severe endometriosis. The doctors said there is no scientific or medical reason why I should have ever gotten pregnant. Paul is a miracle, and is meant for great things in his very bright future!

Jaclyn Frea  is a wife, to Bryan, and a Mom, to Paul her heart warrior. She loves her family, animals and OSU Buckeye Football. She is a PCHA – Ohio Board member, as well as the Communications Coordinator for Congenital Heart Network of Central Ohio.  Jaclyn also volunteers as a wish grantor for the Make-A-Wish Foundation.  In her spare time, she loves to spend time at the zoo, with her family, coloring, and Jaclyn loves makeup and all things beauty related.

New Diagnosis – Prenatal Conquering CHD Kits

This week, our State Chapter Coordinator, Melanie Toth, shares her experience with us as  a new mom finding out her son would be born with a congenital heart defect and how PCHA helps to make sure other families don’t have to go through what Melanie’s did alone.

 

Like many heart families, when diagnosed with their child’s heart defect, your world is flipped upside down. It was no different for our family. I remember us walking out of the room not really understanding or knowing what just happened. We had only walked into the doctors office for our 20 week ultrasound, and left finding out our child would be born with a heart defect, that I couldn’t even pronounce. While I have always had a love and hate relationship with congenital heart disease, over the past decade I have learned a lot. I can’t change the diagnosis we were given that day, but I did wish I could change the information that our family was given when we left the doctors office.

We weren’t aware that CHD was the #1 birth defect or that too many families walked in similar shoes as us. We left feeling hopeless and alone, with a paper that said, “Tetralogy of Fallot”. My husband and I went online to get more information on our son’s diagnosis and, to say the least, were completely overwhelmed. There was different information on various websites, and we just felt more hopeless.

If 10 years ago our doctors would have handed us a PCHA Prenatal Conquering CHD Kit, life would have been just a little easier. From resource cards to navigate important CHD information, to guided questions on what to ask your medical team, and most importantly, how to connect with other heart families, the prenatal kit is like a life raft for new families. Through PCHA State Chapters and working with hospitals, prenatal kits have offered the much needed information and personal connection that every heart family deserves. If 10 years ago our family was given a prenatal kit, instead of walking out with our sons defect written down, our family would not have felt so alone in our heart journey, during a difficult first year with our son’s surgeries.

I feel honored and blessed to help our PCHA State Chapters as National State Chapter Coordinator. Personally helping heart families and helping set up chapters to empower families, is the best pay it forward our family can offer.

 

Melanie’s heart journey began in June 2008, during a routine 20 week ultrasound. She and husband were devastated by the news that their unborn son Luke would be born with a congenital heart defect (Tetralogy of Fallot) and required heart surgery at a week old and again at 9 months old. Feeling very scared and alone during the roller coaster ride of a CHD journey, Melanie decided that no other heart family should feel alone. In 2010, she has started a support group for heart families in Chicago. Working nationally and locally with various CHD organizations. In 2016, she began volunteering with PCHA’s new state chapters, to offer families more than just support. She is currently the State Chapter Coordinator for PCHA National helping to develop state chapters.

 

Recap – Arrhythmias and Cardiac Devices

Complications from surgery, scar tissue left behind, and an underlying disease can bring about arrhythmias in CHD patients and lead to need for a cardiac device. Gathered here are the contributions and resources from PCHA’s Arrhythmia Blog Series. 

 

Jarvik: For Smaller Hearts

PCHA’s next series introduces the various Cardiac Devices involved in the treatment of Congenital Heart Disease and the associated conditions. In the first post, Dr. Adachi tells us about the Jarvik for small hearts, a ventricular assist device used to help pump blood through the body.

 

Terri’s Story

Often times, CHD patients face issues with the rhythm of their hearts. In some patients, this can mean additional treatment is necessary, with either medication or a cardiac device. In this week’s post, Terri Elliott, an adult CHD patient, shares her experience with an arrhythmia that led to her receiving an implantable cardioverter defibrillator. or ICD.

 

The Elephant in the Room

With each CHD, there is no certain path, no one course looks like the next, and complications vary widely. Though a patient may have a specific structural diagnosis, different arrhythmias may develop over time, however patients and families are not always made aware of this possibility immediately. That’s why the diagnosis of an arrhythmia may surprise parents and send them for a loop, just when they think they’ve seen it all.  This also makes it difficult for parents to know just how much to share with teacher and other adults in their children’s lives, just as Alison Connors shares with us this week.

 

Bradycardia Explained (Part One)

This week former Cardiac Nurse, Carol Raimondi, provides us with the first of a two-part resource on arrhythmia and the various diagnosis and treatment. Up first: Bradycardia.

 

Tachycardia Explained (Part Two)