Colombian hospital looks to Children's to lift level of care

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Only a few months old, Josell Andres Valencia Micolta has already lost parts of his fingers and his lower right leg to amputation.

But the Colombian child is alive, thanks to a medical team from Children's Hospital.

During a trip to Cali, Colombia, in late November, the team surgically corrected the child's life-threatening heart problems, then worked feverishly with others to find and activate a machine needed to help his heart recover.

But after the group returned to Pittsburgh, blood clots in the child's extremities led to the amputations.

The complication is unusual, but can occur with the assistance technology known as extracorporeal membrane oxygenation or ECMO, said Dr. Victor Morell, the Children's surgeon who performed Josell's operation.

Through an interpreter, Josell's mother, Ana, said she was grateful for the surgery that saved her son's life, though she is concerned about giving him appropriate care at home. She is a single parent, has three older children and works a variety of jobs to support her family.

She said in Spanish that she hopes to "find a good job to support her son and help him live a good life after all he's been through."

Dr. Morell, Children's chief of cardiothoracic surgery, said it is unclear that a different outcome would have occurred in a U.S. hospital.

But he said a planned collaboration with Children's could make the Colombian hospital, the Fundacion Valle del Lili, better prepared to deal with such health problems.

The 310-bed, tertiary-care hospital in Cali, Colombia's third-largest city, provides critical and trauma care, organ transplantation, cardiovascular surgery and neurovascular treatment.

The not-for-profit hospital is a referral center for southwestern Colombia and, for organ transplants, for patients from throughout the country, said Dr. Martin Wartenberg, the hospital's medical director.

Officials there are arranging a multiyear consulting agreement with Children's that focuses on pediatric heart surgery and liver transplants, said Jeanne Casilli, Children's vice president for strategic business development. Plans call for Children's physicians to provide their expertise for travel expenses and a nominal fee.

"Our aim through this project is to improve our results, hopefully to the same standards as Children's Hospital in Pittsburgh," Dr. Wartenberg said.

He said officials hope to expand the agreement with the University of Pittsburgh Medical Center to improve some adult services, such as organ and bone marrow transplants.

Dr. Morell said the relationship with Children's can have a more lasting impact than doctors paying occasional visits to perform a few surgeries, "because there's a time they won't need us."

Discusssions leading to the collaboration arose in part from relationships formed between medical professionals at the two hospitals. Dr. Morell, for example, met one of the Fundacion's physicians at a conference, and some doctors from the hospital have worked at UPMC, Dr. Wartenberg said. Dr. Ricardo Munoz, Children's chief of cardiac intensive care, also has worked with doctors in Colombia to improve pediatric services, and recently won an award from the Colombian government for his efforts.

A team from Children's traveled to the Cali hospital during the last week of November to assess its programs and perform surgeries.

Besides Drs. Morell and Munoz and Ms. Casilli, those from Children's who made the trip included Dr. Rakesh Sindhi, co-director of pediatric transplantation; Dr. Steven Lichtenstein, director of cardiac anesthesiology; interpreter Elizabeth Tassaro; researcher Ana María Manrique; and Kent Kelly, director of perfusion services.

Team members began operating on Josell, then 2 months old, the same day they arrived at the Cali hospital.

The initial diagnosis was truncus arteriosis, a birth defect in which a single vessel arises from the heart's left and right ventricles.

Normally, the pulmonary artery arises from the right ventricle and the aorta arises from the left ventricle and the two vessels are separate.

But in correcting that defect, Dr. Morell, who performed the surgery, encountered another problem: The child had an anomalous coronary artery, arising from the pulmonary artery instead of the aorta. Though the problem was repaired, the heart was weak from insufficient blood flow.

The child needed help from ECMO, probably for a few days, to allow the heart to recover. But doctors soon found the hospital had no machine available.

The team had to temporarily leave the child on a heart-lung machine, tying up an operating room, because the device was too large to move elsewhere, while a search began for an ECMO machine.

Dr. Wartenberg said a machine was located at a hospital in Bogotá that had been used only once before. The government's health ministry helped the Cali hospital arrange for a charter plane to pick it up.

When it arrived in Cali, it was dusty and not in operating condition, Mr. Kelly said. With help from hospital technicians, he was able to get it working, allowing the child to come off the heart-lung machine after 36 hours.

Since the local staff was not familiar with ECMO, Mr. Kelly lived at the hospital for the next day and a half, napping occasionally in a chair, to make sure no problems developed until the child no longer needed help from the device.

Josell's case was believed to be the first successful use of ECMO in Colombia, Dr. Wartenberg said.

While the complications that developed are unfortunate, Dr. Morell said the experience underscores the need for such collaborations.

"There are so many kids dying every day from illnesses that shouldn't be."

Joe Fahy can be reached at or 412-263-1722.


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