Caring for the Tiniest Hearts

A healthy newborn’s heart is about the size of a walnut, but these minute hearts can have a multitude of life-threatening abnormalities in the arrangement of the vessels, valves, and chambers. Each year Columbia surgeons repair congenital heart defects in almost 150 newborns. These patients, who weigh as little as 500 grams (1.1 pounds), benefit from the Columbia surgery team’s expertise in intricate and complex cardiac procedures. The Vivian and Seymour Milstein Family Infant Cardiac Unit at NewYork-Presbyterian Morgan Stanley Children’s Hospital, a state-of-the-art, 17-bed unit dedicated solely to cardiac care for infants up to three months old, has further expanded the scope of care the medical center provides.

“The cardiac neonatal intensive care unit (NICU), the first of its kind in the world, allows specialists in neonatal cardiac intensive care to work closely with pediatric cardiologists and cardiothoracic surgeons to enhance the outcomes of infants having surgery for complex congenital heart disease,” says Ganga Krishnamurthy, MD, medical director of the unit.

From the beds to the medical and surgical equipment, everything is designed for the tiniest newborns. The unit offers specialized modes of hemodynamic support such as ECMO (extracorporeal membrane oxygenation), cardiac assist devices that replace the function of the heart such as the Berlin Heart, and 3-D printing, enabling surgeons to examine precise replicas of each infant's heart prior to surgery.

CUIMC surgeons are extraordinarily skilled at repairing a range of complex congenital heart disease (CHD), for instance transposition of the great arteries, hypoplastic left heart syndrome, tetralogy of Fallot, total anomalous pulmonary venous connection, and truncus arteriosus. Many of these conditions are identified prenatally by specialists in CUIMC’s Carmen & John Thain Center for Prenatal Pediatrics (CPP) or at other centers, and are then referred to CUIMC for care. Lynn Simpson, MD, director of the CPP, says “A third of patients seen in the CPP are diagnosed with fetal heart defects, and I know our patients appreciate the specialized care their infants receive in the cardiac NICU.”

Dr. Krishnamurthy notes that it’s important to operate on many infants with CHD as soon as possible after birth, despite their low birth weight or early delivery. Waiting has not only been shown to be of no benefit, she says, but can increase babies’ risk of infection as they wait in the ICU—so surgeons prefer to operate when the risk is lowest. As a result, cardiac surgeons are operating on smaller and smaller infants. “If surgeons are moving in this direction we need to adapt the way we take care of these babies before and after surgery,” she says.

A 2022 article from our team in The Journal of Thoracic and Cardiovascular Surgery demonstrates that this dedicated care makes a difference: infants cared for in our infant cardiac unit had outcomes superior to those cared for at peer institutions, and to other pediatric critical care registry databases. (The paper’s lead author, Nimrod Goldshtrom, MD, recently provided commentary on the neonatology-focused podcast, “The Incubator” (listen from 45:35-1:14:15).)

At NYP, the largest CHD referral center in the region, our team performs about 600 surgeries every year in older children and in a growing number of adults who have survived to adulthood with CHD because of improvements in care. Emile Bacha, MD is director of congenital and pediatric cardiac surgery at the hospital, and chief of cardiac, thoracic and vascular surgery at CUIMC. “Not only do we have outstanding surgeons who can perform complicated open-heart surgeries on a three-pound baby, but we have a comprehensive multidisciplinary team who are all experts in neonatal care,” he says.

Infants with CHD are generally cared for in a general pediatric ICU or a cardiac ICU. Columbia has not only created a separate dedicated unit, but is providing dedicated services, since the expertise needed to care for these babies is uniquely specialized. Every doctor who cares for babies in the new unit is board-certified in both neonatology and in cardiac intensive care. “That differentiation matters and I don’t think that level of specialization exists anywhere else,” Dr. Krishnamurthy says.

Learn more about the pediatric heart surgery program and team at Columbia here, and about our pediatric cardiology program and team here.