Collaborative effort involving milestone procedure saves premature baby with complex heart disease

Baby Hope looked into her mother’s eyes and gurgled.

Four days short of turning 9 months old, wearing a white onesie with the words “Best Gift Ever” on the front, she made more baby talk.

“You’re always a big chatterbox – what are you saying?” her mother, Elizabeth “Becca” Wyneken, said as she smiled and stared into Hope’s blue eyes.

Becca and Hope endured a lot to get to where they are now — a happy and very grateful mom and a relatively healthy 9-month-old baby girl whose light-brown hair is just starting to fill in.

The odds were stacked against Hope when she was born prematurely at 31 weeks and five days, weighing just 2 pounds, 3 ounces. Today, Hope is alive thanks to a team of doctors, nurses and others who cared for her throughout a four month stay on CHOC’s neonatal intensive care unit (NICU) and cardiovascular intensive care unit (CVICU).

Born with a complex heart disease, as well as only one kidney and defects on her right leg and foot, Hope’s cardiac neonatologist, Dr. Amir Ashrafi, pegged her chances of survival at between 20 and 30%.

When Becca first set eyes on Hope a couple of days after she was born, she was very concerned about her baby’s health.

“Don’t worry, Mom,” Dr. Ashrafi told Becca that day. “I think we can help her.”

It would take an extensive collaboration between highly regarded cardiovascular interventionalists, some of whom were consulted at hospitals as far away as London, to do so.

And it would involve a high-risk procedure never performed on a baby so small at CHOC.

Dr. Amir Ashrafi, neonatologist at CHOC

Grim news at 20-week scan

At 18 weeks pregnant, Becca, a teacher’s aide, went in for a checkup. Blood tests showed her baby had a high risk for Down syndrome and spina bifida.

Two weeks later, a scan of her baby’s anatomy revealed other potential problems.

Her baby had no kidneys, Becca was told. She appeared to have no bladder, no right leg, no lungs, issues with her bowels, and a heart defect.

“I don’t think I stopped crying for the rest of the day,” Becca recalls. “It was horrible.”

She couldn’t drive home from the clinic. A friend had to pick her up. That night, Becca had dinner with her mother and aunt.

Later, lying beside her mother, Becca cried.

“I can’t believe this is happening,” she said.

She felt a poke in her belly.

“Over and over again, when I got upset, she would poke me,” Becca said.

At that moment, she decided on a name for her baby.

“Hope,” Becca told her mother.

Second opinion reveals true complications

Becca got a second opinion about her unborn baby’s condition.

Her baby was missing a kidney and had a leg defect, she was told. Most seriously, Becca was told, she had a defect on her right ventricle, the chamber within the heart responsible for pumping oxygen-depleted blood to the lungs.

Hope’s aorta and pulmonary artery that carry blood away from the heart hadn’t developed properly. She had a hole in her heart as well as one in her left superior vena cava, a vein that helps circulate deoxygenated blood back to the heart. These holes caused blood to drain incorrectly; Hope would need a team of doctors to correct the blood flow.

“Being very small with complex heart disease, your options are very limited with what you can do and the timing of any procedures,” said Dr. Ahmad Ellini, Hope’s primary pediatric cardiologist.

There were lots of sleepless nights as Hope’s team of doctors and nurses monitored her closely. Becca was beside her nearly every night.

Dr. Ashrafi and Dr. Ellini consulted with two outside experts, San Francisco-based Dr. Mohan Reddy, who specializes in complex heart disease in small newborns, as well as renowned thoracic and cardiac surgeon Dr. Glen Van Arsdell of Ronald Reagan UCLA Medical Center on the best course of action.

The team of physicians determined that a stent needed to be inserted under a pulmonary artery that was becoming too narrow, making it hard for blood to flow through it. Such a procedure is risky, especially on a baby so small.

“In Hope’s case, the idea was if we could open up the area below the valve while not injuring the valve, that would be a home run,” said Dr. Sanjay Sinha, a CHOC pediatric cardiologist who put the stent in Hope’s heart. “Two things made this difficult: she was very small, and we had no stents this size.”

A vendor was able to secure the small stent needed a day before Hope’s surgery.

Assisting Dr. Sinha during the procedure was Dr. Michael Recto, medical director of CHOC’s Cardiac Catheterization Lab.

Observing the recently developed procedure, known as valve-sparing RVOT (right ventricular outflow tract) stent placement, were several cardiologists, from CHOC and other pediatric hospitals.

“In some patients, there is very little room for a stent. Hope had just enough room for the stent to be placed,” Dr. Sinha explained, “We knew we had the technical skills and ability to do this, but this had never been done before at CHOC on a baby this size.”

A very scary moment

After the surgery, Hope got seriously ill with a viral infection. At one point, Dr. Ashrafi said, her heart stopped but the team was able to revive her.

In cases like Hope’s, where a newborn’s state of health is fragile, members of her clinical team often must pivot in an instant, making their work schedules long and unpredictable.

Hope was at CHOC for four months before she was able to go home. After that, physicians at another hospital removed the stent, closed the hole in her heart, and corrected her left superior vena cava.

Dr. Ellini, who continues to see Hope at her check-ups, is very pleased with her progress.

“She basically has a normal circulation,” he said. “She needed a pacemaker. Overall, she’s doing great. She’s only on one medication and is gaining weight.”

In fact, she’s up to 13 pounds.

Baby Hope

Dr. Ellini said he’s proud of the extensive collaboration that was involved in Hope’s care at CHOC.

“We try to really foster a collaborative team approach in our interventional lab, and this is a great example of that,” he said. “Having a dedicated neonatal cardiac intensive team of physicians and nurses who are really experts in what they do really was paramount in making sure she did well.”

Becca can’t praise Hope’s team at CHOC enough. “They’re totally lifesavers,” she said. “It was a roller coaster — heartbreaking and exiting. I was pretty much afraid all the time, but they treat you like you are family.”

In the Spotlight: Robert B. Kelly, M.D.

A board-certified physician in pediatrics and critical care with clinical interests in pulmonary hypertension, ECMO, pediatric transport, global health, outreach and business has joined CHOC Children’s.

Dr. Robert Kelly is medical director of the cardiovascular intensive care unit (CVICU) and associate division chief and director of research and academics for the division of critical care at CHOC.

In his role, Dr. Kelly enjoys working in the pediatric intensive care unit (PICU) and CVICU, as well as supporting one of CHOC’s goals in guiding research and educational opportunities for physicians and trainees.

“What makes our division special is our incredible diversity,” Dr. Kelly says. “Our group has an excellent mix of new and seasoned physicians from various training programs and prior experiences. From special interest and experience in CVICU and palliative care, to community PICU care and hospital administration, we are a varied group.”

Dr. Kelly attended medical school at Georgetown University School of Medicine, in Washington, D.C. He completed his pediatric residency at Penn State Milton S. Hershey Medical Center, in Hershey, Penn.; and completed his pediatric critical care fellowship at UCLA Mattel Children’s Hospital.

This dedicated physician has been fascinated with science and biology since he can remember, but he found his passion for pediatrics while in medical school.

“Taking care of children is the most rewarding aspect of my job because the challenges of dealing with patients who often cannot communicate their symptoms pushes me to constantly think, question and re-evaluate,” Dr. Kelly says. “I cannot think of anything more satisfying than being able to form a therapeutic relationship with a family, have a direct hand in the progression of their child’s recovery and then see so many of our patients return to visit the unit after discharge.”

One of Dr. Kelly’s goals is to help expand the capacity and capabilities of the CVICU to handle more complex surgical cases. The team recently added an expert CVICU nurse practitioner with excellent leadership and educational experience. Additionally, the team is working on protocolizing sedation and analgesia practices.

“I’m really excited about one of our latest projects, where we will be revamping daily bedside rounding to begin with nurse-led presentations,” Dr. Kelly says. “We believe this practice will make our care even more family-centered, while also empowering nurses to take a larger role in the care of their patients.”

Through the David Geffen School of Medicine at UCLA, Dr. Kelly has participated in several global health missions, including a recent trip to a tertiary academic PICU in Maputo, Mozambique, which he has been working with for many years to bring pediatric resuscitation training to its physicians, nurses and students.

“On the latest trip, I traveled to two referring hospitals to begin instruction on building a local pediatric transport system,” he says. “We plan on future trips to begin analyzing the demographics of pediatric transport among those three hospitals in order to measure the success of our interventions.”

Dr. Kelly is a fellow of the American Academy of Pediatrics and a member of the Society of Critical Care Medicine.

In his spare time, Dr. Kelly likes to spend time with his wife and daughter. He enjoys playing golf and taking vacations with his family to Hawaii, as well as watching the New York Mets and New York Giants.