TMC PULSE

t m c » p u l s e | j a n / f e b 2 0 1 6 17 the critical component—we want them to know what normal looks like, and when it doesn't look like that, to send us the images so that we can evaluate them and determine whether or not we need to see the patient," explained Anthony Johnson, D.O., co-director of The Fetal Center at Children's Memorial Hermann Hospital and McGovern Medical School at UTHealth. "I'd rather see a dozen cases that might be some- thing that turn out to be fine than have one case be missed because someone didn't know what they were looking at." Texas Children's has deployed their clinical expertise across the greater Houston commu- nity as well by creating a network of pediatric, maternal and fetal clinic locations to assist community physicians and obstetricians in the detection of fetal anomalies, including congen- ital heart. Over the past year, Texas Children's Maternal and Fetal Center conducted more than 41,000 ultrasounds and fetal echocardiograms across the Houston area and beyond. The major- ity of these patients were evaluated and cared for in their own community, however, for the most complex cases, a higher level of care was necessary and 120 mothers with complex cardiac babies were transferred to Texas Children's to gain the comprehensive expertise needed immediately after delivery. Management plans for CHD depend on the type and severity of the malformation. Unfortunately, survival depends on something else entirely: location, location, location. The importance of the where alongside the what underlies Memorial Hermann's and Texas Children's efforts to improve detection of fetal anomalies throughout Texas. As Gardiner pointed out, many of these conditions require careful, expert management; if an obstetrician knows his or her patient's baby has CHD, it is often crucial that delivery takes place at a hos- pital that specializes in pediatric cardiology and cardiovascular surgery. Troublingly, not all of these centers are created equal. "The most important thing is getting the patients to the right hospital at the right time," said Charles Fraser, M.D., Texas Children's Hospital surgeon-in-chief and chief of congen- ital heart surgery and professor of surgery and pediatrics at Baylor College of Medicine. "That affects more lives than all of the advancements in our field combined. There is an enormous disparity in outcomes if you compare centers in this country and that is a tragedy; despite how far we've come, it can still be an accident of birth—that where you happen to be born will have a direct impact on your prognosis." The numbers don't lie. Although the majority of pediatric heart centers do not publicly release their mortality profiles, most confidentially report their results to the national database managed by the Society of Thoracic Surgeons. Just last year, a composite of this data was made publicly available in a report published by CNN, which revealed that surgical death rates ranged from 1.4 to 12.1 percent, depending on the hos- pital. That's an astronomical difference when it comes to life and death. "If our society was really aware of this issue, I don't think any of us would accept it," Fraser said. "Your mortality profile could be 10 times worse depending on where you are born in the United States. Ten times worse. Can you imag- ine that? That's not what we as a society believe in, but it's a fact. It's an unarguable fact." Fraser and colleagues from around the country are becoming increasingly vocal about this disparity in hopes of raising awareness and ultimately fostering change. To turn a mediocre center great, however, first requires an under- standing of the numerous and varied compo- nents that contributed to the overall decrease in mortality rates in the first place. In a single lifetime, we've gone from being unable to offer anything to approaching 100 percent survival. — CHARLES FRASER, M.D. Texas Children's Hospital's Surgeon-in-Chief and Chief of Congenital Heart Surgery and Professor of Surgery and Pediatrics at Baylor College of Medicine "We have 21 children in our dedicated car- diovascular ICU this morning," Fraser said. "I don't believe there is a child in there who would have been alive when I was a baby. Not a single child. And almost every single one of these children will survive and move on from the hos- pital with an acceptable prognosis. In a single lifetime, we've gone from being unable to offer anything to approaching 100 percent survival. It's astonishing, and you honestly couldn't point to just one thing to explain it. It's a concert of having a dedicated children's hospital, focused children's care, the development of all the sub- specialties that are around us as well as general advancements in cardiology and cardio-sur- gery, intensive care, neonatology, anesthesia, pharmacology and physiology. On top of that, our focused surgical teams and specialists don't work on anything else but the heart. That's all we do, that's all everybody in this heart center does—our anesthesia team, our ICU—we don't do anything else." Daniel Penny, M.D., Ph.D., and Charles Fraser, M.D. (Credit: A. Kramer/Texas Children's Hospital)

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