ABSTRACT
Women in cardiology have been outnumbered by their male colleagues not only in India but all over the universe. The present review highlights the role of pertinent women who have been instrumental in development of cardiology in India. Their struggle has paved way for several young lady cardiologists who now tread the path with confidence and zeal.
INTRODUCTION
Dr Helen Brooke Taussig, a pediatrician at Johns Hopkins, was the codeveloper of first successful “Blue Baby” operation at Johns Hopkins Hospital. The two great Indian pioneers of pediatric cardiology in India, Dr Kamala I Vytilingam and Dr S Padmavati both were trained in Johns Hopkins hospital, under Dr Helen Brooke Taussig, “Mother of pediatric cardiology.” The journey of cardiology in India started with toddlers steps of pediatric cardiology by women! Thus, it has been truly fascinating and full of challenges, determination, and dedication by many illustrious women. So much so that once great cardiac anatomist and a world authority, Bob Anderson once exclaimed during world congress of pediatric cardiology to Dr IB Vijayalakshmi- “Oh Vijay I thought you were a man!!. We have laid the solid foundation for structural heart diseases, now it is to the young Indian pediatric cardiologist to build it further.” The remarkable journey of cardiology in India has many women luminaries who have brightened the path of future cardiologists.
HISTORY OF BEGINNING OF CARDIOLOGY IN INDIA
The first formal department of cardiology in India was started in Christian Medical College (CMC) Hospital, Vellore in 1957 by Dr Kamala I Vytilingam, after training at Johns Hopkins Hospital, Baltimore. The DM cardiology training course was initiated in CMC in 1965. The birth of the specialty of pediatric cardiology in India took place at Vellore under Dr Reeve Betz who started the first cardiothoracic surgery department at Vellore in 1949. Dr T Thomas and Dr Gopinath joined Dr Betz subsequently and initiated the first open heart surgery program in 1960. Late Dr Vytilingam established one of the 4earliest cardiac catheterization laboratories in India. Butreal interventional cardiology started only in 1985.
PIONEERS IN CARDIOLOGY
Dr S Padmavati
Dr Sivaramakrishna Iyer Padmavati, widely regarded as the doyenne of cardiology in India. She is India's first woman cardiologist and woman of many firsts! The first Indian doctor who completed training in pediatric cardiology is Dr S Padmavati who studied CHD as a fellow with Dr Helen Taussig from 1948 to 1951 and subsequently in pediatric cardiology department in Boston at the Massachusetts general hospital. She had rare privilege of publishing a paper “Results of Operation for Pulmonary Stenosis and Atresia Transactions” with Dr Helen Taussig in Association of American Physicians in 1951. On her return to India, she was amazed to find the wards full of young women and children with acute rheumatic fever (ARF) and rheumatic heart disease (RHD). As she did not have access to surgical management of pediatric cardiac patients, she had to predominantly look after adults. She opened a cardiac clinic in Lady Hardinge hospital where there were a lot of children with CHD. In 1980, she published her paper “Congenital Heart Disease in Delhi School Children.”
Dr Kamala I Vytilingam
The first formal Department of Cardiology in India, was started in Christian Medical College (CMC) Hospital, Vellore in 1957, by Dr Kamala I Vytilingam, who brought modern cardiology to India after a period of training at Johns Hopkins Hospital, Baltimore in the early 1950s. She did a year's training with Dr Helen Taussig in 1961. The availability of surgical help allowed her to look after both adult as well as pediatric patients. She established one of the earliest cardiac catheterization laboratories in India.
Dr Savitri Shrivastava
Professor Savitri Shrivastava did her MBBS from GRM College, Gwalior, Agra University in 1957 and MD (Medicine) at GRM College, Vikram University in 1961. She did her DM (Cardiology) at All India Institute of Medical Sciences, Delhi, India in 1971. Subsequently between 1975 and 1976, she did her fellowship in pediatric cardiology at University of Minnesota, Minneapolis, USA. She came back to AIIMS. Her special achievement in field of interventional cardiology described for the first time in the world was an original technique of balloon dilatation of the atrial septum (static balloon) in transposition of great vessels. This was published in Indian Heart Journal in 1988. She also reported for the first time in the world “Percutaneous catheter commissurotomy in rheumatic mitral stenosis” in the New England Journal of Medicine in 1985. She was also instrumental in doing a lot of procedures for the first time in India at AIIMS. The procedures were balloon valvuloplasty for pulmonary valve, aortic valve, balloon dilation of aortic coarctation, aortoarteritis, peripheral pulmonary arteries, coil occlusions of BT Shunt, coronary AV fistula, and aortopulmonary collaterals. She was awarded “PICS Achievement Award” at the Annual PICS (Pediatric Interventional Cardiology Symposiums) meeting held in Miami, Florida on January 21, 2013. This is a great honor for an Indian. After her retirement from AIIMS, the good work is being continued at present by Dr Anitha Saxena who did school surveys for RHD disease with mobile echo machine and Dr Shyam Kothari who has worked on pulmonary hypertension.
Dr (Mrs) Ramesh Arora (Fig. 1)
She established a registry of transcatheter noncoronary interventional procedures in the country and was awarded with national interventional council of CSI award for development of noncoronary interventional cardiology in India (1999). She started nonsurgical (device) closure of patent ductus arteriosus (PDA) in 1987 by using Rashkind umbrella device for the first time in the country.
For valvular lesions specially percutaneous transvenous mitral commissurotomy (PTMC) in children was done in 1987 by her using double Mansfield balloon technique and in 1990 with Inoue balloon. Nonsurgical closure of atrial septal defect (ASD) was first time attempted in the country by using various sizes of Sideris devices (1993), followed by Starflex, Cardioseal, and Amplatzer devices (1998). She started devices closure of ventricular septal defect (VSD), both perimembranous and muscular by using Rashkind umbrella device in 1995 and this was replaced by muscular Amplatzer VSD device in 1999. First human use of specially designed perimembranous VSD device was done in 6December 2000 by Dr Ramesh Arora. Various other rare cardiac lesions were attempted like coronary arteriovenous (AV) fistula, ruptured sinus of valsalva pulmonary AV fistula, PA to LA fistula, etc. She made all Indians proud by having done the highest number of PTMC and perimembranous VSD closure by device in the world, at a particular time! She is a bundle of energy and enthusiasm for innovations. So much so when Dr IB Vijayalakshmi showed her the booklet with the diagram of Amplatzer device drawn by Kurt himself she had jumped with joy!
Dr Lekha Pathak
Dr Lekha Pathak is the Director and Head of the Cardiology Department at Nanavati Super Speciality Hospital, Mumbai, India. She completed MBBS from Netaji Subhash Chandra Bose Medical College, Jabalpur in 1965, and MD-General Medicine from Netaji Subhash Chandra Bose Medical College, Jabalpur in 1968, DM-Cardiology from King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College in 1971. She has done over 10,000 interventional procedures for past 10 years. Dr Lekha Pathak has been awarded with Lifetime Achievement Award by Ex-President APJ Abdul Kalam for outstanding contribution in the field of cardiology 2008, Priyadarshini award in 2008, Doctor of Science (DSc) by University of Loyola, Chicago, USA in 2012 and many more. She is a member of Maharashtra University of Health Sciences, Padmashree Dr D Y Patil University-Member Management Council, Association of Physicians of India (API) and Indian College of Physician. Some of the services provided by the doctor are carotid angioplasty and stenting, coronary and noncoronary interventions, angioplasty and stenting, interventional procedures and minimally invasive cardiac surgery. She is the second woman to be president of CSI after Dr Padmavathi. She is a cardiologist in Vile Parle West, Mumbai and has an experience of 47 years in this field.
FIG. 1: Dr Ramesh Arora is seen presenting on rheumatic fever and rheumatic heart disease (RHD) in June 1980 in London in the first world congress of pediatric cardiology.
Dr Anitha Saxena
She was born in November 1956, presently serving as full professor of cardiology since 1998, at the All India Institute of Medical Sciences, New Delhi, a very high volume tertiary care public hospital catering primarily to northern, central, and eastern parts of India. Her responsibilities include teaching, research, and patient-related clinical work. She is regularly teaching postgraduate fellows and residents who are undergoing 3 years structured training programs in cardiology and has served as guide/co-guide for thesis for over 50 postdoctoral students.
She completed her education with MBBS, MD, and DM degrees, all from University of Delhi, and has been a gold medalist throughout the academic carrier. She has over 33 years of experience in the subspecialty of pediatric cardiology and adults with CHD. She has many publications with over 312 research articles in reputed national and international journals. Some of the landmark articles are frequently cited in literature and textbooks. She has been the principle investigator for a number of community-related research projects on public health issues related to cardiology. Some of her publications on community research, related primarily to rheumatic and CHD, have been widely cited.
She is actively engaged in the formulation of national guidelines for the management of CHD and RHD and has published extensively on status and management of CHD in India. She is also a member of several international groups dealing with global burden of RHD and the co-chair of the Working Group of Task Force on Rheumatic Heart Disease, set up by the World Heart Federation, Geneva. She is frequently invited as an expert group member by the Ministry of Health and Family Welfare, Government of India, for formulation of policies and guidelines related to the specialty of cardiology. The Indian Council of Medical Research has also been regularly inviting her as one of the experts for evaluation of research projects and for policymaking decisions, related to the specialty of cardiology.
She has held important positions in several national and international academic organizations including President of Asia Pacific Pediatric Cardiac Society, Pediatric Cardiac Society of India, and National Rheumatic Heart Consortium. She has been awarded Fellow of American College of Cardiology.
On November 14, 1998 for the first time in South India government set up pediatric cardiology department was started in Sri Jayadeva Institute of Cardiology. Dr IB Vijayalakshmi, first lady cardiologist of Karnataka, who headed the department, was the first one to use Amplatzer septal occluder and Amplatzer duct occluder (ADO) on January 27, 1999 in South India. Thanks to Children's Heart link, Minnesota, she was trained in four best centers in USA: (1) Fairview University Children's Hospital (Minneapolis), (2) St. Mary's Hospital (Rochester), teaching hospital of Mayo Clinic Medical School, (3) Children's Hospital Medical Centre (Boston, Massachusetts), teaching hospital of Harvard University in 1998, and later was (4) trained at Children's Hospital at Chicago University in 2002 under Dr Ziyad Hijazi.8
Thanks to the excellent training that she received, she went on to do several interventions for the first time in the world. One such case was a 4-year-old child with noncompaction of left ventricle with the aorto-left ventricular tunnel (ALVT) closed with Amplatzer device in 2001. When the first ALVT was closed surgically by Evalon plug from aortic end by Dr Lillehei Minnesota, Dr Kurt Amplatz was part of that great team! So Kurt was excited about the ALVT being closed by his device. He donated three devices to be tried for this case and wrote “Nobody can advise you, as no one has any experience, use your clinical acumen and all the best.” True to his words, the two sizes of VSDs were too big and compressing on the aortic valve, the third, 16 × 14 largest ADO was a bit small to block the aneurysmally dilated extra cardiac portion of the tunnel, leading to hemolysis for 5 days. This case was presented at 37th Annual Scientific meeting and AGA Medical 4th International Symposium at Porto, Portugal, on 15 May, 2002 and published in pediatric cardiology journal. And also in the same meeting, the first case of isolated dextrocardia with mid-muscular VSD closed through the jugular approach with 16 mm Amplatzer device was presented by her.
FIG. 2: From left to right Dr IB Vijayalakshmi with her source of inspiration Dr S Padmavati, Dr Kurt Amplatz, Dr Richard Van Praagh, and Dr Fontan.
FIG. 3: Dr IB Vijayalakshmi is seen putting the red pin on Bengaluru to mark the centers using Amplatzer device. Dr Kurt Amplatz and his son-in-law watching the global map in the head office of AGA in 1998.
When it was explained to Dr Kurt, that the available Amplatzer devices require larger French sheaths to introduce and hence it was difficult to do the device closure in emaciated low-weight Indian children, he came out with innovative “modified Amplatzer device” in which only one layer of polyester material was stitched, instead of three layers! Thanks to this alteration, a large PDA in a 3.9 kg infant was closed with 10 × 8 ADO in 2002 and was presented in PICS-VI at Chicago, USA in September, 2002 and initial experience in 10 infants was published in 2006. This was done when nobody was doing device closure in children weighing <6 kg. When the angiogram of a PDA larger than aorta in a 4.5 kg infant was mailed to Dr Kurt, he came out with the custom made angled PDA device which had no polyester material at all in it! These custom made angled devices became the prototype for ADO II additional size (ADO II AS) which were used in infants and newborns later! For the first time in the world, a case of sickle cell anemia with ASD was closed with device closure in 2005. This was presented in World Congress in Buenos Aires, Argentina. Thanks to the low profile and easy trackability of ADO II, first time in the world a case of left coronary cameral fistula to RV was closed with ADO II in 2011, which topped the top 20 publications in noncoronary section in 2013. For the first time in the world, a case of aorto-right ventricular tunnel (ARVT) (only the 17th case) was closed with ADO II in 2013. For the first time in India, the workshop of PDA closure with Nit Occlud was done in 2002 with Dr Lee. For the first time, ADO II was used to close Gerbode defects with no complete heart block.
Dr IB Vijayalakshmi has written four textbooks for the cardiologists, (1) A monogram on “Acute Rheumatic fever and Rheumatic heart Disease,” (2) “Step by Step to Echo in Congenital Heart Disease,” (3) Chief editor of a textbook “A Comprehensive Approach to Congenital Heart Disease” for which the book review has been written by Dr Crystal R Bonnichsen of Mayo clinic and published in European Heart Journal. Dr Crystal writes “As stated in the epilogue, the editors used the approach of “A Lifelong Journey” to describe the management of congenital heart disease through the various stages, often called the “womb to tomb” approach. The editors undertook a formidable challenge by covering all aspects of congenital heart disease at all stages of life”. For the first time in the world, she has proposed and published “Vijaya's Echo criteria” for diagnosis of carditis in ARF. In the recently revised Jones criteria, her two studies are cited and echo features are incorporated. Her study has been quoted in latest editions of standard pediatric cardiology textbooks like Heart Diseases in Infants and Children by Moss and Adams’ and Park's Pediatric Cardiology for Practitioners.10
Dr Suman Rao
Dr Suman Rao, the first cardiologist of Himachal Pradesh, born on May 3, 1946, did her MD (medicine) as well as DM in cardiology from PGIMER, Chandigarh. She is a WHO fellow from cardiovascular institute, Mount Sinai, New York, USA. She worked as professor and head of the department of cardiology at IGMC Shimla for 12 years. She held post of director of medical education in the state of Himachal Pradesh and has been advisor to the state government. She is principal of Tanda Medical College. She has number of publications in national journals on cardiac status at high altitudes. In addition, she has a number of publications in national and international journals of cardiology. She is the recipient of DP Basu Complimentary Award at CSI Conference and has taken active part in national and international conferences of cardiology.
JOURNEY OF CATHETER-BASED INTERVENTIONS BY WOMEN
The various pediatric cardiac catheter interventions initiated in India are:
- Rashkind balloon septostomy in d-TGA in early 1970s—CMCH, Vellore.
- Balloon pulmonary valvotomy in 1985 by Dr M Khalilullah and Dr Ramesh Arora at GB Pant Hospital, New Delhi.
- Balloon aortoplasty of coarctation of the aorta (CoAo) 1985 by Dr M Khalilullah and Dr Ramesh Arora, New Delhi.
- The first PTMC in rheumatic mitral stenosis was done in 1985 by legendary Dr Savitri Shrivastava.
- Balloon aortic valvuloplasty in 1986 by Dr M Khalilullah and Dr Ramesh Arora, New Delhi.
- Procedure of balloon dilatation of the atrial septum in transposition of great vessels by static balloon was introduced in 1988 by Dr Savitri Shrivastava and followed by Dr Ramesh Arora.
- Dr Ramesh Arora started nonsurgical (device) closure of PDA in 1988 by using Rashkind umbrella device for the first time in the country.
- Device closure of PDA in 1988 by Dr Ramesh Arora at GB Pant Hospital, New Delhi and subsequently by using Amplatzer devices (1998).
- Nonsurgical transcatheter closure of ASD was first time attempted in the country by using various sizes of Sideris devices (1993), followed by Starflex, Cardioseal by Dr Ramesh Arora.
- Dr Ramesh Arora also did the first device closure of VSD, both perimembranous and muscular by using Rashkind umbrella device in 1995 and this was replaced by muscular Amplatzer VSD device in 1999.
- Later for the first time in India, various Amplatzer devices were used to close ASD and PDA by Dr Ramesh Arora in North India and Dr IB Vijayalakshmi in South India in January 1999.
- The valvular lesions, especially PTMC in children, was done in 1987 by using double Mansfield balloon technique and in 1990 with Inoue Balloon by Dr Savitri Shrivastava, Dr Satyvan Sharma, and Dr Ramesh Arora.
- First human use of specially designed perimembranous VSD device was done in December 2000 by Dr Ramesh Arora.
- Along with Dr Ramesh Arora, Dr IB Vijayalakshmi did the first PDA closure with specially designed angled device in neonates (2003). Incidentally, this was the first case in the world in whom 8.6 mm PDA larger than aorta (8.2 mm) was closed in 4.5 kg infant.
Various other rare cardiac lesions were attempted like coronary AV fistula, ruptured sinus of valsalva pulmonary AV fistula, PA to LA fistula, etc., by Dr Ramesh Arora and Dr IB Vijayalakshmi.
For the first time in the country, a national policy for CHD was proposed by Dr IB Vijayalakshmi in 2004. Since then many centers started coaching fellows in pediatric cardiology. Now, DNB itself has identified 11 centers training 22 fellows in pediatric cardiology and two centers in India offering DM in pediatric cardiology.
CONCLUSION
The situation is not very different in India from west where 20% of cardiologists are women, though there is no compiled data available. More women are now heart specialists in India. The journey of cardiology started virtually with only three centers having just M-mode echocardiograms in India. But the cardiac catheterization laboratory has clearly transformed from a diagnostic facility to a place for providing definitive treatment to nearly 65% of simple CHDs without scar on the chest. So fascinating is the history of interventional cardiology. Many surprises are bound to come as gifted minds toil night and day to make this world a better place with less suffering. Thanks to medical tourism, today India is the destination for interventions in cardiology and women are contributing a great deal in taking care of hearts of ailing patients.
“One hundred years from now, it will not matter what kind of car I drove, what kind of house I lived in, how much was my bank account, nor what my clothes looked like. BUT the world may be a little better because I was important in the life of a child”— Anonymous
SUGGESTED READING
- Tandon R. Development of Pediatric Cardiology in India.
- Taussig HB, King JT, Bauersfeld R, Padvamati-Iyer S. Results of operation for pulmonary stenosis and atresia; (report of 1000 cases). Trans Assoc Am Physicians. 1951;64:67–73.
- Shrestha NK, Padmavati S. Congenital heart disease in Delhi school children. Indian J Med Res. 1980;72:403–7.
- Shrivastava S, Radhakrishnan S, Dev V, Singh LS, Rajani M. Balloon dilatation of atrial septum in complete transposition of great artery--a new technique. Indian Heart J. 1987;39(4):298–300.
- Lock JE, Khalilullah M, Shrivastava S, Bahl V, Keane JF. Percutaneous catheter commissurotomy in rheumatic mitral stenosis. N Engl J Med. 1985;313:1515–8.
- Arora R, Jain P, Rajagopal S, Nair M, Keane JK, Khalilullah M. Transcatheter closure of patent ductus arteriosus: preliminary experience with five patients. Indian Heart J. 1988;40(4):253–7.
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- Arora R, Nair M, Kalra GS, Sethi KK, Mohan JC, Nigam M, et al. Non-surgical mitral valvuloplasty for rheumatic mitral stenosis. Indian Heart J. 1990;42:329–34.
- Kalra GS, Verma PK, Dhall A, Singh S, Bhardwaj S, Arora R. Transcatheter closure of secundum atrial septal defect with atrial septal defect occlusion system (ASDOS): initial experience and short-term follow-up. Indian Heart J. 1998;50(4):409–13.
- Kalra GS, Verma PK, Dhall A, Singh S, Arora R. Transcatheter device closure of ventricular septal defects: immediate results and intermediate-term follow-up. Am Heart J. 1999;138(2 Pt 1):339–44.
- Bass JL, Kalra GS, Arora R, Masura J, Gavora P, Thanopoulos BD, et al. Initial human experience with the Amplatzer perimembranous ventricular septal occluder device. Catheter Cardiovasc Interv. 2003;58(2):238–45.
- Vijayalakshmi IB, Chitra N, Prabhu Deva AN. Use of an Amplatzer duct occluder for closing an aortico-left ventricular tunnel in a case of noncompaction of the left ventricle. Pediatr Cardiol. 2004;25:77–9.
- Vijayalakshmi IB, Chitra N, Rajasri R, Vasudevan K. Initial clinical experience in transcatheter closure of large patent arterial ducts in infants using the modified and angled Amplatzler duct occluder. Cardiol Young. 2006;16(4):378–84.
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- Vijayalakshmi IB, Narasimhan C, Agarwal A. Transcatheter closure of left coronary cameral fistula With Amplatzer Duct Occluder II. J Invasive Cardiol. 2013;25:265–7.
- Vijayalakshmi IB, Narasimhan C, Agarwal A. Closure of aorto-right ventricular tunnel with Amplatzer Duct Occluder II. J Invasive Cardiol. 2013;25(4):E75–7.
- Vijayalakshmi IB, Natraj Setty HS, Chitra N, Manjunath CN. Amplatzer duct occluder II for closure of congenital Gerbode defects. Catheter Cardiovasc Interv. 2015;86(6):1057–62.
- Vijayalakshmi IB, Narasimhan C, Singh B, Manjunath CN. Treatment of congenital non-ductal shunt lesions with the Amplatzer duct occluder II. Catheter Cardiovasc Interv. 2017;89(6):85–E193.
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- Vijayalakshmi IB, Chitra N, Rajasri R, Prabhudeva AN. Amplatzer angled duct occluder for closure of patent ductus arteriosus larger than the aorta in an infant. Pediatr Cardiol. 2005;26:480–3.
- Vijayalakshmi S, Prabhudev N. Coronary heart disease in Indian women—change the gender bias. In: Rao GH, Kakkar VV (Eds). Coronary artery disease in South Asians. New Delhi: Jaypee Brothers Medical Publishers Pvt Ltd; 2001. p. 92.