Asian Cardiovasc Thorac Ann 2007;15:320-323
© 2007 Asia Publishing EXchange Ltd
Telecardiology: Effective Means of Delivering Cardiac Care to Rural Children
Prem Sekar, MRCP,
Vairan Vilvanathan, DCh
Department of Pediatrics, Apollo Rural Hospital, Andhra Pradesh, India
For reprint information contact: Prem Sekar, MRCP Tel: 91 44 2656 4224 Fax: 91 44 2656 5150 Email: premsekar{at}yahoo.com, Department of Pediatric Cardiology, International Center for Cardio-Thoracic and Vascular Diseases, R-30-C, Ambattur Industrial Estate Road, Chennai 600 101, India.
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ABSTRACT
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Telemedicine allows face-to-face interaction between the medical specialist and the patient. We present our experience of 102 pediatric telecardiology consultations between a tertiary care cardiac center and a remote rural hospital located 120 miles away, between July 2000 and December 2003. The connection was through a Very Small Aperture Terminal satellite bandwidth provided by the Indian Space Research Organization. An S-video link between the echocardiographic and videoconferencing equipment at the remote center allowed the specialist to view images in real time. Pathology was ruled out in 50 (49%) children by tele-echocardiography. Cardiac problems were diagnosed in 52 children (51%), of whom 30 (29%) required surgery. Successful cardiac surgery following telediagnosis was carried out in 18 patients, 8 are awaiting elective operations, and 4 died before surgical correction. The Very Small Aperture Terminal enabled a higher bandwidth that allowed clear images with no significant diagnostic errors. This study demonstrates that pediatric telecardiology effectively delivers cardiac care in rural centers in developing countries with stretched medical resources, where the specialists are urban centered and the majority of patients are rural based.
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INTRODUCTION
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The availability of pediatric cardiac services, like most super-specialties, is generally confined to the metropolitan areas in India. This is mainly due to the limited number of trained pediatric cardiologists in our country. However, the number of babies born with congenital heart disease in India is estimated at 109,000 per annum, based on the National Census Data 2001 estimate of 27.93 million live births and the incidence of congenital heart disease estimated at 3.9 per 1,000 live births.1 Adding to this problem is the high incidence of rheumatic heart disease in India; with at least 50,000 new episodes every year, it is estimated that there are currently more than one million patients with rheumatic heart disease. Telemedicine appears to be an effective tool in bridging this enormous mismatch between the few available specialists and the vast population of children with heart disease.2 Herein we describe our experience in the diagnosis, management, and follow-up of children with congenital and acquired heart disease who presented at a rural hospital and whose clinical data, including echocardiography, were analyzed in real time by a pediatric cardiologist at a tertiary care referral center 120 miles away.
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PATIENTS AND METHODS
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Children with suspected cardiac problems warranting echocardiography were evaluated between July 2000 and December 2003 using videoconferencing to obtain specialist opinion. The remote center was situated in the rural hospital in Aragonda, a village in the Chittoor district of Andhra Pradesh, while the pediatric cardiologist was based at the tertiary referral center in Chennai. The remote center was equipped with the following hardware to facilitate videoconferencing including viewing of echocardiography in real time: a satellite dish antenna, Demand Assignment Multiple Access (DAMA) equipment to receive signals from the satellite and route it to the videoconferencing equipment, videoconferencing equipment with a high-resolution camera (Polycom) and the capability of handling image transfer at a bandwidth of 512 kilobytes per second, echocardiography equipment with connectivity to the videoconferencing equipment through an S-video cable, a computer with a webcam and 17-inch monitor connected to the videoconferencing equipment, a frame grabber card, Ethernet card, terminal adapter, laser printer, and a scanner. The communication channel was initially through an Integrated Services Digital Network (ISDN) between July 2000 and February 2001, and subsequently through a Very Small Aperture Terminal (VSAT) satellite system provided by the Indian Space Research Organization. The history, clinical findings, and investigations such as blood tests, electrocardiograms, and chest radiographs were sent from the remote center in store-and-forward mode. This involved scanning the radiographs and electrocardiograms, which were then captured and forwarded as image files to the specialist through net meeting using an ISDN dial-up service. S-video connectivity between the echocardiography equipment and the videoconferencing equipment at the remote center enabled the pediatric cardiologist at the referral center to view the pictures in real time and advise the echocardiography technician on adjustments to enable accurate views of the cardiac anatomy. The specialist center was equipped with a satellite dish antenna, DAMA equipment, videoconferencing equipment, and a 28-inch television screen to view the images.
There were 102 pediatric patients aged 3 days to 18 years included in the study between July 2000 and December 2003. Of these, 52 (51%) were found to have cardiac pathology by tele-echocardiography, and 50 (49%) had noncardiac etiology for their symptoms. Of the 52 patients with a heart lesion, 42 (81%) were diagnosed with congenital heart disease and 10 (19%) had acquired heart disease of rheumatic origin (Table 1
). In the congenital heart disease group, 31 (74%) children had acyanotic and 11 (26%) had cyanotic heart disease. Of the 10 children with acquired heart disease, 3 presented with acute rheumatic fever and 7 with rheumatic heart disease. In the other 50 children who underwent tele-echocardiographic consultations, echocardiography confirmed normal cardiac anatomy. Their symptoms were attributed to various causes such as anemia with flow murmur, thyrotoxicosis, clinical Kawasaki disease, clinical rheumatic fever, juvenile rheumatoid arthritis, and neonatal cyanotic episodes of noncardiac etiology. Appropriate treatment was instituted with complete recovery in all of these children. Tele-echocardiography helped to determine the appropriate management in this group by confirming normal cardiac anatomy.
Associated conditions were present in 11 of the 42 children diagnosed by tele-echocardiography to have congenital heart disease: trisomy 18 in 3, neurofibromatosis in 2, and one each with Williams syndrome, Marfan syndrome, Down syndrome, VATER association, microcephaly with mental retardation, and renal tubular acidosis with failure to thrive. This group of children benefited not only from the telecardiology consultation but also from input by other specialists regarding their associated problems. This underlines the role of telemedicine in providing holistic care when required.
Thirty (57%) children required surgery: 18 have been operated on, 8 are awaiting surgery, and 4 died before undergoing surgery. The deaths were predominantly in children who required surgery immediately but it was deferred due to late presentation or associated illness. Tele-echocardiography was repeated in 19 patients including those followed up after open-heart surgery at our tertiary referral center.
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DISCUSSION
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This study demonstrates that it is possible to arrive at an accurate diagnosis of a complex heart problem using telemedicine. The required infrastructure can be assembled in any remote rural center, and any literate person can be trained to operate the connection with no great difficulty. In this series, once the diagnosis was made, appropriate management advice was provided by the pediatric cardiologist, and the patient was transferred to the tertiary center for surgical intervention if required. There was only one error when a patient was diagnosed with an innocent murmur but subsequently found to have a bicuspid aortic valve with mild stenosis on repeat echocardiography at the referral center. No mortality resulted as a consequence of the misdiagnosis. The quality of the echocardiography transmission with the ISDN line during the initial phase was sufficient to establish a conclusive diagnosis, as reported in previous studies.3,4 However, the clarity and frame rate of the live echocardiography transmission improved dramatically with the VSAT link, and when possible, this mode of transmission is recommended.
Telemedicine is particularly suitable for pediatric cardiology because it bridges the gap between the vast number of children seeking specialist help and the few qualified pediatric cardiologists. It enables shared care of the patient by the primary pediatrician and the cardiologist, while also training the primary physician in the specialist management of children with heart diseases. It allows the primary physician to continue to be the principal manager of the case, thus ensuring continuity of care for the patient. In emergency situations where the baby is acutely sick or born blue with a complex heart problem, guidance on management obtained from a pediatric cardiologist through teleconferencing can prove lifesaving, contributing to decreased mortality. One of the most advantageous aspects of connectivity between the videoconferencing and echocardiography equipment is that it enables real-time transmission of echocardiograms from the remote center to the pediatric cardiologist at the referral center (Figure 1). This is important as echocardiography images previously captured and sent as still frames (store-and-forward) may not always convey the information necessary to make an accurate diagnosis. The reason for this is the complexity of pediatric echocardiography and the need for specific experience to perform and interpret pediatric echocardiograms. While viewing a live echocardiography transmission, the pediatric cardiologist is able to direct the technician at the remote site to show the necessary views and measurements, thus obtaining the most relevant information to arrive at an accurate anatomic diagnosis.5 When this is not possible, good quality store-and-forward echocardiography images may have to be relied on to achieve a diagnosis. It is important to realize that accurate diagnosis plays a crucial role in the subsequent management of the cardiac patient by determining the mode of management and timing of interventions, and assessing the final outcome.
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Figure 1. Parasternal long axis view of echocardiography showing a large sub aortic malaligned ventricular septal defect. Active transmission of echocardiography is indicated by camera insignia on the image.
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Telemedicine, by bridging the distance between the rural patient and the urban specialist, offers tremendous solace to the parents. More importantly, it obviates the need for the parents to make a potentially life-threatening journey to a distant specialist clinic with a sick child.6 Furthermore, a family of 4 would have to spend roughly USD 5 for the journey to the tertiary care center, another USD 35 for 4 days’ stay in an urban center, and USD 50 towards investigations. The total expenditure of USD 90 is considerable given that the annual per capita income of this rural population is approximately USD 394. For the same family, the actual total expense incurred in establishing a diagnosis, including investigations and travel to the rural hospital, amounts to USD 19.45. This clearly illustrates why telemedicine is essential and effective in delivering specialist care for the rural populace in developing countries with stretched resources.
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REFERENCES
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- Khalil A, Aggarwal R, Thirupuram S, Arora R. Incidence of congenital heart disease among hospital live births in India. Indian Pediatr 1994;31:519–27.[Medline]
- Finley JP, Sharratt GP, Nanton MA, Chen RP, Bryan P, Wolstenholme J, et al. Paediatric echocardiography by telemedicine—nine years’ experience. J Telemed Telecare 1997;3:200–4.[Medline]
- Grant B, Wallace JG, Hobson RA, Craig BG, Mulholland HC, Casey FA. Telemedicine applications for the regional paediatric cardiology service in Northern Ireland. J Telemed Telecare 2002;8 Suppl 2:31–3.
- Mulholland HC, Casey F, Brown D, Corrigan N, Quinn M, McCord B, et al. Application of a low cost telemedicine link to the diagnosis of neonatal congenital heart defects by remote consultation. Heart 1999;82:217–21.[Abstract/Free Full Text]
- Fisher JB, Alboliras ET, Berdusis K, Webb CL. Rapid identification of congenital heart disease by transmission of echocardiograms. Am Heart J 1996;131:1225–7.[Medline]
- Widmer S, Ghisla R, Ramelli GP, Taminelli F, Widmer B, Caoduro L, et al. Tele-echocardiography in paediatrics. Eur J Pediatr 2003;162:271–5.[Medline]
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ABSTRACT
INTRODUCTION
