Dr. Kirk Milhoan, IMA Senior Fellow in pediatric cardiology, traces what changed for children with heart defects over America’s 250 years. He starts with a nine-year-old in Baja California, the daughter of migrant farm workers, who couldn’t walk 20 feet and had been told she would not live past 10. A portable echocardiogram found a stiff pulmonary valve. A balloon catheter opened it, and she was running by her follow-up visit.

He walks the timeline from the wooden stethoscope in 1816 to the first echocardiogram performed on a child in 1969. He lingers on Johns Hopkins, where Vivien Thomas taught Alfred Blalock the operation that saved blue babies while standing on a stool behind him, barred from the OR because he was Black. Work that once meant opening a child’s chest now runs through a catheter in the leg, and the newest frontier is repairing a valve before birth. Dr. Milhoan’s argument for IMA is that the ethics have to keep pace with the technology: patient autonomy and honest consent belong in the cardiac ICU, not only the primary care office.

Check out these related resources from IMA below, followed by the full video transcript.

Transcript

Dr. Kirk Milhoan: I’m Dr. Kirk Milhoan. I’m a Senior Fellow for the Independent Medical Alliance, specifically in pediatric cardiology. What I would like to reflect on is what has happened with the care of children with heart defects since the start of our country, and what we are able to do now.

We’re celebrating 250 years as a country, and really in that time we’ve gone from having no pediatric cardiology to an incredibly robust practice of medicine on a very specific and very complex patient, which is the child with heart defects.

I wanted to start with just why this is so important to me, and that’s because of L.E. When I was a pediatric cardiology fellow, I met this nine-year-old child from a poor family in Baja California. Her parents were migrant farm workers in Mexico, so you can imagine how poor they were. Her father had been told at birth that if she didn’t get heart surgery by age 10, she would be dead.

I was asked to see her when she was nine and a half. Every day, her father prayed that someone would come and help. I was able to use one of the portable echocardiograms to confirm a diagnosis that she had a very stiff pulmonary valve, and I was able to get her to come up to San Diego. We went to the cardiac catheterization lab and did a balloon, and you can see the picture of her pulmonary valve.

This is a girl who couldn’t really walk more than 20 feet. She was very, very blue, and she couldn’t play. After this procedure, she was able to go home the next day. She went back to Mexico, and when I saw her in follow-up she was running like never before. That all came through an enormous amount of change in technology that allowed me to take down a portable echocardiogram machine and then be able to perform really a heart surgery on her without ever opening her chest.

So with that as “wow, how far we’ve come,” I wanted to take you through from the very beginning.

The stethoscope was invented in 1816, so still within the 250 years. It was this wooden tube that people would hold up to the chest, and now we have stethoscopes that are electronic. You can put it on the chest and it gives you an EKG as well.

The EKG, the first time they tried it, was in 1846, and you can see the picture of this man sitting at this giant machine. The first time they did one on a child was 1960. And now you can see that you can hold one in your pocket and it talks to your iPhone. We’ve come an enormous way in really just about 180 years, to be able to do things that used to take a whole room and now it fits inside your pocket.

But probably the main thing that has happened is the birth of being able to look at the heart from the outside with ultrasound, so we didn’t do anything invasive to the child. This all started back when da Vinci looked and found that there’s an abnormal valve in about 1% of the population. Then people started doing more and looking at more, and looking at sound, and looking at all this different physics.

In 1937, Sokolov used ultrasonic pulse echo to detect flaws in metal. In 1953, someone in Sweden decided we could look at the heart with this. And in 1969, Lundström was the first person ever to put this device on a child to diagnose heart defects. You can see from these pictures this giant machine that was used to just get basic pictures. And here I am in Nepal, using this little echo machine that’s by my right hand, on a baby, making a diagnosis with a handheld machine that’s probably a thousand times more accurate than the one on the left.

That was very important, because before echocardiograms we had to do a lot of invasive stuff. A lot of it was basically what was clinically available and how the baby looked.

The start of children’s heart surgery really comes from Johns Hopkins, and I love this story because it’s what America is all about: all the different people coming together, having to overcome stereotypes.

There was Alfred Blalock, who was a surgeon. There was Helen Taussig, who was one of the first female pediatric cardiologists. And there was Vivien Thomas, who was a Black veterinary assistant.

Helen Taussig is seeing these kids who are really, really blue, and she realizes, after doing autopsies and everything, the problem was they didn’t have enough blood flow to their lungs. That was because the blood flow to the lungs was very obstructed. So she figured out, she said, there needs to be some way we can get more blood to the lungs.

When she was down at Johns Hopkins, she’s talking to Blalock about it. Blalock had Vivien Thomas in his lab doing experiments, and they said, oh, we’ve already done this on some of the animals. So they all got together and talked about it, and Vivien Thomas, the veterinary assistant, was the one who did all the heart surgeries.

They come up with the plan that they have this blue child that they’re going to do this exact procedure on, and they’re going to give it more blood flow by putting in a shunt, taking a vessel that goes to the right arm and plugging it right into the right pulmonary artery. But Blalock had really never done that many. Vivien Thomas had done all of them, but he was a Black man and he wasn’t allowed in the OR back then.

It was a big thing whether they should do heart surgery on children at all. But when Blalock saw what Vivien Thomas had done, and his beautiful surgical techniques, he said in a beautiful Southern accent, “Boy, this looks like something the Lord made.” There’s a movie that talks about all that called Something the Lord Made.

You see this picture in the operating theater at Johns Hopkins, and standing behind on a stool is Vivien Thomas, and he is coaching Blalock how to do the surgery. And it was a successful surgery. It used to be called a Blalock-Taussig shunt, a BT shunt. Just recently we’ve changed it to a Blalock-Thomas-Taussig shunt to honor this man.

The next thing we started doing is figuring out, okay, what are other ways that when we need to get more blood, especially if we have significantly blue children, how do we get blood to their lungs, especially if they only have one pumping chamber and not two?

In 1958, Glenn, a surgeon, came up with the idea that we could attach the blue blood directly to the pulmonary artery without a pump. That worked, and we’re still using it today. We have kids in the CICU where I work right now that have this procedure. We have kids who still have a BTT shunt.

But that wasn’t perfect, and so we still had these kids who were blue. We would eventually come up with another surgery, but we were waiting for real pioneers.

In the meantime, we had kids whose great vessels were switched, or crossed, and they needed to be switched back. That was very complex, and so what they decided to do is switch how the blood flowed in the collecting chambers of the heart. That’s called an atrial switch operation. Dr. Senning was the first one who did that, in 1959, and then Dr. Mustard came along in 1963.

Then what happened is Rashkind figured out how to use live x-ray and put a catheter inside the baby’s heart, blow up a balloon on one side, and pull it apart to make a hole in the heart so the blood would mix in these kids who had transposition of the great arteries. He was making holes in babies’ hearts to save lives, and that happened in 1966.

Eventually, for the single ventricles, and this is a child who really has like a three-chamber heart or even a two-chamber heart, Dr. Fontan in France came up with a way of bringing all the blue blood to the lungs so these kids would no longer be blue. We do that operation very frequently here at our children’s hospital.

The atrial switch operation was okay, but long term they didn’t do well. So Dr. Jatene, in 1975, decided to switch the arteries back, which was very complex and had a very high mortality. The atrial switch had a mortality of less than 10%. When they started doing the arterial switch, which is a great operation and we’re so thankful for it now, they had only a 25% survival. So these were people who were willing to be very brave, knowing what needed to be done, but it took them a while to learn how to do it properly.

Continuing on, we now do pediatric heart transplants, but the first one that was done in a child was in 1984, not that long ago. The first time it was done in an infant was in 1985, for a child who had half of a heart, only two chambers, and that first one was done in Loma Linda.

A lot of the things that used to be done with surgery, open chest, cutting through the sternum, we now do through the leg. We have devices that we can put up through the leg in a catheter and then release them. We can coil vessels that shouldn’t be there, like a patent ductus arteriosus, a vessel that should have closed when the baby was first born but didn’t. We can also close holes within the heart, an atrial septal defect or a ventricular septal defect. These kids used to need surgery, and now I do these procedures with one of the interventionalists all around the world. I’ve done it in Iraq, I’ve done it in Nepal, I’ve done it in Papua New Guinea, I’ve done it in Mongolia, I’ve done it in Tanzania and Zambia, all over the place, with amazing abilities to change kids’ lives even if they live in very, very poor countries.

Probably one of the most exciting things is that we’ve been able to now, through the leg, give a child a new valve. This was first done in 2000, in a 12-year-old. You can see there’s this stent that has valve tissue inside of it, and it goes into a little catheter, and then the catheter is put up and a balloon is blown up and it puts it where it’s supposed to be, and the kid doesn’t need to have heart surgery. We continue to do those, and it’s very exciting not to have to do heart surgery where we actually open the chest. We can do this through the legs, and that’s one of the really exciting things that we’re seeing now.

The echocardiogram has come a long way as well. We now have 3D echocardiogram, where we can look in real time and see all the different components, especially when we’re planning surgeries. We can even do this in the operating room while the surgeon is operating, to see and guide what kind of repairs need to be done.

We also have an amazing ability to do CT angiography, where we can look at all the vessels. We inject some dye, we do a CT at the same time, and we can see elaborate anatomy that we wouldn’t otherwise know. Now we can use 3D printing as well, and we also have the ability to use cardiac MRI. These are live, and it’s dramatically increased what we’re able to diagnose without ever cutting a child.

Actually, the frontier for a lot of these defects that we see is fetal interventions. Sometimes, if the valve is small and we don’t make it bigger soon enough, then the chambers or the vessels will never grow. Just a few years ago, Boston Children’s did the first fetal intervention, where they actually ballooned a valve in a baby by going through the mom’s abdomen, into the amniotic sac, into the heart, and then ballooned the valve. The child was protected from ending up with a heart that only had two chambers. These fetal interventions are very exciting, especially as we can change the course of a baby’s life before they take their first breath.

I wanted to say that at the Independent Medical Alliance, we look at all types of medicine. We’re not just relating to primary care or things that we do as outpatient. We want to care about the whole patient, and there’s very sophisticated medicine and treatments that require hospitals and require ICUs. All of us at the Independent Medical Alliance are striving to have excellent centers that respect patient autonomy and are using the very best practices. So it’s not just about primary care. We need to bring this to places where the very highest technology is being used, and one of those places is in pediatric cardiology and pediatric heart surgery.

The lovely Dr. Mellon is a pediatric cardiac anesthesiologist. We work in very highly intensive places, and we need that same ethical care that we extend to the general population in primary care to extend into the most sophisticated branches of medicine, because the ethics are so complex.

I’m thankful to be a part of IMA, and I look forward to continuing to push the envelope for increased patient autonomy and ethical care even in the most sophisticated environments.

Thank you very much.

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