Heart Conditions in Kids: What You Need To Know with Dr. Bradley Marino

Podcast Transcript

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Molly Shroades:
Hi, and thanks for joining us for this episode of the Health Essentials podcast. My name is Molly Shroades and I'll be your host. Today, we're talking about congenital heart defects and the impact they can have on a child's life. We're here with Dr. Bradley Marino, a pediatric cardiologist. Thank you for joining us.

Dr. Bradley Marino:
Good morning, Molly. How are you?

Molly Shroades:
Great. Starting off, can you tell us a little bit about the types of patients that you see?

Dr. Bradley Marino:
We're very fortunate here at Cleveland Clinic Children's to see the entire breadth and depth of patients with congenital heart disease. Some of those patients have very mild shock defects, where they don't need any intervention or care, other than just seeing a pediatric cardiologist intermittently over the course of their childhood, adolescence, into adulthood. To children that literally need emergency, life-saving surgeries or cardiac catheterizations in the first 30 days of life so that they can survive.

Molly Shroades:
Can you tell us when you hear the phrase congenital heart defect, what does that exactly mean and how much should a parent worry when they hear that?

Dr. Bradley Marino:
That's a great question, Molly. I think sometimes people get confused by what congenital heart disease means. Simply put, the heart is meant to form in a specific way. We know what normal looks like, in terms of how the chambers, the valves, and the vessels all come together to make your heart. In some children, sometimes it's how the chambers are set up between the atria, which are the filling chambers, and the ventricles, and pumping chambers. Sometimes it's the actual valves between those chambers, the tricuspid valve on the right side of the heart, with the mitral valve on the left side of the heart.

Sometimes it's the vessels that come out of the right ventricle, the pulmonary artery, or out of the left ventricle, the aorta, that is abnormal. Sometimes it's a multitude of issues that encompass both the chambers, the valves, and the vessels. Each type of congenital heart defect or congenital heart disease is different. We, as pediatric cardiologists and pediatric cardiac surgeons, look at every single patient as an individual, identify what the differences are in that child's heart structurally compared to a normal heart.

Then we can with parents and we can explain to them exactly what that structural difference is. Then what we might do to make sure that child does well and again, survives and thrives.

Molly Shroades:
Gotcha. Great. What are a few of the most common heart defects that you might see in children?

Dr. Bradley Marino:
Most common ones are actually fairly simple defects. There's something called a patent ductus arteriosus, which all of us have in utero when we're in our mother's wombs, that sometimes instead of closing at birth stays open. Another very common one is something called an atrial septal defect, which is a hole between the two filling chambers, the right atrium and the left atrium. Another very common one is called a ventricular septal defect, which is a hole between the two pumping chambers, the right ventricle and the left ventricle.

Some of the most common, more complex structural defects. The most common blue baby congenital heart defect is Tetralogy of Fallot, in which there's a combination of both a hole between the right ventricle and the left ventricle, and a problem with the pulmonary valve. There are other defects that are very common, like transposition of the great arteries, where the actual aorta, which comes out of the left ventricle, and the pulmonary artery, which comes out of the right ventricle, actually switched when the heart is created and that requires surgery at birth.

Then there's an entire broad group of congenital heart defects called single ventricle congenital heart defects, where instead of having two pumping chambers, the children are only born with one pumping chamber. Then we have to do some fairly complex surgery multiple times during the first year of life to create a structure in that heart that the child can survive and thrive into adulthood.

Molly Shroades:
Perfect. Dr. Marino, can you tell me a little bit about why these defects happen? I know there's probably a different answer for different conditions, but what's going on that makes this happen?

Dr. Bradley Marino:
For the vast majority of congenital heart defects, we actually don't have currently, a specific genetic cause as to why they occur. But there are over a thousand genetic abnormalities right now that are associated with structurally different hearts or congenital heart defects. We're learning every year about more and more genetically based congenital heart defects. I think in 20 years, the vast majority of the congenital heart defects that we see will likely be from a genetic basis.

Now, there are some congenital heart defects that actually result from exposure to babies of specific medications in utero, in their mother's wombs. There are other congenital heart defects that may result from exposures, environmental exposures that the mother takes into her body that then end up being transmitted to the fetus. We know that there are certain types of nutritional and vitamin deficiencies that can result in, not necessarily congenital heart defects, but specifically, in other malformations in the body like folate.

If you don't take folate, you'll have neural tube defects. We're constantly learning about how the environment in which pregnant women and babies live, and the medications or drugs that mothers may take, and the genetic basis of congenital heart disease that is driving the number of children with congenital heart disease. I think the important thing to know is that there's a specific rate of congenital heart disease in our population but it's pretty consistent right now.

It really has not gone up over time. It's not gone down over time. We continue to learn what the causes are for congenital heart disease, but the amount of congenital heart disease in our general population is pretty stable. I think the other thing that's really important that we talk about is that the most common birth defect in human beings is congenital heart disease. Very few people actually know that the structure of a normal heart is the most common birth defect in all of our human species.

Most people don't know that many of the people that they work with, that they're friends with, in their families, that they have congenital heart disease. Sometimes it's discovered in utero during a fetal ultrasound, sometimes discovered after birth. Sometimes not discovered until childhood, even adulthood, that people have these congenital heart defects, but is the most common birth defect that we see.

Molly Shroades:
Once this defect is found, what's the next step? Is there often immediate action taken or is it a waiting game?

Dr. Bradley Marino:
It really depends. I think the important thing is that over the last decade to 15 years, in most large cities that have major medical centers with birthing hospitals, the majority of babies with congenital heart disease are now being discovered in utero, when these babies are in their mother's wombs. That's very, very different than it was 20 to 25 years ago. The whole field of fetal ultrasound or fetal echocardiography has really exploded.

Now, throughout the United States, there are very, very talented imagers that can now look at a fetus in utero and in the mother's womb, and actually identify that congenital heart defect before the child's born. This is critically important because if a child has a very complex congenital heart defect, we can then have that mother actually deliver at the hospital that the child's actually going to be cared for, which in a lot of times you can maybe save that baby's life. Or minimize a transfer from an outlying hospital to that medical center's that's going to take care of that baby, which could pose that baby a significant risk.

If you're a mother or a father that finds out in utero that your child has a congenital heart defect, there's often a conversation that will happen with the obstetrician, immunohematologist, and the cardiologist sometimes at what's called a fetal care center at some of the major medical institutions nationally, Cleveland Clinic being one of them, that you will get a full briefing on what the child's congenital heart defect is. What's going to happen at the time of birth or the birth plan, and then what you vet your child may require in those first 30 days of life to make sure that they survive and they do well moving forward.

Now, there are still a percentage of babies that are born, parents not knowing that their child has congenital heart disease. Most babies are born, typically those babies present in one of four ways. They either have a situation where they present in shock, meaning maybe a lack of blood flow going through their body. They present being really blue, what we call cyanosis, where the skin looks blue, the lips look blue. They can present with an abnormal heart rhythm, or they can present with a heart murmur. Heart murmur is just a vibration that we can hear with a stethoscope putting that on your baby's chest.

We hear the abnormal blood flow through the heart, and it manifests as a vibration that we call a murmur. Those babies that are diagnosed after birth, typically present one of those four ways. Then you'll have a pediatric cardiologist come chat with you. They'll describe to you what the issue is. Then similarly, you'll then talk with a team about what comes next. If it's a surgical situation, obviously, a surgeon, a cardiothoracic surgeon, who specializes in taking care of babies with congenital heart disease will be intimately involved in that discussion with the pediatric cardiologist to make a determination about what surgeries are required.

Now, there are a small percentage of people that actually they won't know that they have congenital heart disease till literally school age or even young adulthood. May not have been appreciated by the pediatrician and something may occur where a murmur is picked up. Then ultimately, they determine that you have this congenital heart defect and that you have to go ahead and get a appropriate assessment by a pediatric cardiologist or an adult cardiologist, adult congenital cardiologist, and then get the appropriate care. I think one of the key things for people understand is that we don't think about pediatric cardiovascular disease in isolation.

Patients now with pediatric congenital heart disease will survive, the vast majority of them, into adulthood. Now, there's an entire new group of physicians called adult congenital heart disease physicians that care for these patients from literally fetal life, all the way through geriatric life in this congenital heart space. I think as a parent when you start thinking about where do you want to get your care, you want a center that literally can take care of your child, literally from cradle to cane. From fetal life and birth all the way to adult care.

There are great programs nationally, and they all have a different structure. Some of them are freestanding children's hospitals without adult care. Some of them like Cleveland Clinic are fully integrated medical systems. We're very blessed here at Cleveland Clinic. We have the number one adult cardiovascular program in the country for the last 26 years, our Heart, Vascular, and Thoracic Institute, as well as having one of the best pediatric cardiac programs in the country. You want to go to a program that can offer care for your child, not just as a fetus or an infant, but all the way through adulthood.

And in that transition of care during adolescence and young adulthood, it's very critical. A lot of patients get lost to care there. From an integrated medical system, like within the clinic, you just stay within Cleveland Clinic, and we just get you a new doctor to add to your care team as a young adult. Then take on your adult congenital heart care needs.

Molly Shroades:
Wonderful. I'm wondering, you already touched on this a little bit as you were talking, but as you're moving throughout your life, as these patients with congenital heart disease are moving throughout their entire life, what kind of treatment options generally are they going to experience?

Dr. Bradley Marino:
If your child is born, either diagnosed in fetal life or right after birth with a very, complex congenital heart defect, your child's likely to need either a cardiac catheterization procedure or a surgery. Those surgeries today in our current era, across the country, 97% of the individuals that have congenital heart surgery will survive within at least 30 days after their operation. But this is extraordinary and the generation we've gone from over 30% mortality rate, meaning if you had congenital heart surgery, you had a one out of three chance of dying to now where it's literally 97% survivable.

And at the best centers, like here at Cleveland Clinic, our actual mortality rate or likelihood of death, it's less than one percent. More than 99% of the patients that we'll take care of here Cleveland Clinic will actually survive their initial operation. If you need surgery, make sure you're getting into a center that has a very, very, very low death rate. More importantly, has very few complications and then this data is available to most families, when they're making these very, very important decisions for their infants, for their fetuses.

Now, if you don't need surgery when you're first born, you may need surgery later on in childhood or as an adult congenital patient. I think at that point, it's very, very important that you get the right follow-up care and that you're at a place that can make the right decisions about and recommendations to you, as the patient or the parent, as to what you may want to do for your child. Here at Cleveland Clinic, every Monday, our entire team of more than 75 professionals, cardiologists, advanced practice providers, surgeons, anesthesiologists, nursing leaders.

We get together every week and discuss literally, dozens of patients to make sure that as a team, we're giving parents the critical information that they need to make the appropriate decisions for their children. You want to make sure you get a broad based opinion from a leading center when you're making these critical decisions about your child's care, whether they be a baby, or whether they be a child or adult congenital patient, experience matters and outcomes matter. Frankly, reputation is great. Brand is important, but all that matters really is can they assess your child appropriately?

Can they give you the options thoughtfully in a way that you can understand them, and then allow you to make the appropriate decision for your family, and then support you in those decisions to take the best care of your child?

Molly Shroades:
Yeah, it's absolutely a stressful time for many parents when they hear those words together, so it's good to have a team that they can feel comfortable with. Now, you mentioned earlier about how people can have this condition for a long period of time without even knowing it into adulthood. Can it go away on its own sometimes?

Dr. Bradley Marino:
Things like a small, ventricular septal defect, which again, a hole between the two pumping chambers, if it's what we call a muscular ventricular septal defect, upwards of 75% of those holes will actually close in the first several years of life. Patients with atrial septal defects, if they're small, they may also close in the first several years of life. Patent ductus arteriosus, which is the connection between the aorta and the pulmonary artery, which is normally open in utero but then closes in the first several weeks of life.

That may close over the first months to a year or so, if it is not closed right away after birth. Other than those three defects, pretty much everything else is something that you're going to have moving forward in your life. Now, maybe that it doesn't progress or change. For example, you could have some mild narrowing of the pulmonary valve, and you can live with that your entire life and never have anything done. Just follow up with a cardiologist every two or three years just to take a look and make sure it's not changing.

You could have a situation where you have aortic valve stenosis, a minimal amount of stenosis, that doesn't change for decades. Then you may not need something done until your fourth, fifth, sixth decade potentially, and everything in between. I think the key piece of this is whatever the diagnosis is with congenital heart disease, unless it's a patent ductus arteriosus, atrial septal defect, or ventricular septal defect that closes, you're going to need long-term follow-up. Getting the right pediatric cardiologist and team around them and it's obviously a surgical patient, pediatric cardiac surgical team to support your child is critically important.

I think the other thing that we haven't touched on yet, which is really important, is that we know that half of our children that survive the congenital heart surgery will have specific neurodevelopmental, psychosocial, behavioral, and emotional issues that relate to white matter injury or brain injury that occurred during fetal life and then with the first operation as a newborn. We know that babies with congenital heart disease will often have decreased brain growth in the third trimester. That when babies with congenital heart disease are born with those specific congenital heart disease, the brains are literally the size of a 35-week preemie.

We know the brains are less developed. We know that at birth, one-third of these babies with complex congenital heart disease will actually have what we would call paraventricular leukomalacia, which is basically loss of white matter, which are the wires that connect to thinking parts of the brain. Remember from high school biology, there's the gray matter, the outside of your brain, which is the thinking part of your brain. Then there's the inside, the white matter, which connects all the gray matter. Basically, it does all the talking between the different thinking centers of your brain.

If your brain is immature and you have potential damage to that wired connection, and then you go on cardiopulmonary bypass, we know that that impacts the brain in a very specific way as well. One-third of the children, after going on a cardiopulmonary bypass will have new white matter injury. We also know that the inflammation that the brain undergoes from being on the cardiopulmonary bypass machine results in the actual brain cells themselves not proliferating or growing in that first year of life like it normally would, which results in what we call decreased connectivity.

Again, if you think of your brain is as being a computer, there are parts of your computer that are thinking parts of your computer. There are parts of your computer that are basically wires. If the thinking parts of your computer are not connected effectively, that computer doesn't work as well as it might. It's not going to be as efficient. We know that in half the kids that have newborn or infant in the first year of life, congenital heart surgery on the heart-lung machine, cardiopulmonary bypass, that they will have a specific phenotype or specific set of potential issues that we as cardiologists and cardiac neurodevelopmental specialists will treat. They will often have issues with what we call executive functioning, where the ability to make decisions, and do high complex operations or procedures, or to follow a multi-step process may not go with as well, maybe issues with that. That doesn't typically manifest itself in elementary school, where teachers pretty much organize their kids on a daily basis. It will definitely show up in middle school and for sure, in high school/ we know that kids who had heart surgery in the first year of life on the heart-lung machine are more likely to have attention deficit hyperactivity disorder, which many parents are familiar with. There may be issues with processing speed, in terms of how quickly you can think and then process information. There may be issues with what we call working memory.

Think about your computer. Everyone's heard of RAM, or random access memory. RAM is about how many processes or programs you have open at one time on your computer. If you have issues with working memory, it's harder for you to have four or five things that you're thinking about at the same time and utilizing to do your tasks. We know that these kids will have fine motor issues because of the white matter injury. Some of them, some gross motor issues, in terms of the white matter injury. Then importantly, I think parents often ask this question from an intelligence question similar to an IQ standpoint, the majority of children with congenital heart disease will be normal.

The majority of them will also have a normal math and language academic achievement in school. Many of the parents remember from high school, when you took your statistics course, or your math course, we talk about a normal distribution in the population. In a normal population, two and a half percent are low, two and a half percent are high in let's say IQ, then 95% are normal or in the middle. In kids with congenital heart disease, it's actually that curve, which normally looks like this, is shifted to the left.

So that now instead of two and a half percent being low, it's actually 30% are low. And 70% are still normal or high, but 10 times more patients will be low than in the normal population for both IQ, and math, and language achievement. We know that there are psychosocial issues that arise from this brain injury that these babies suffer, both in fetal life and in utero. I'm sorry, then after their cardiac surgery, and there's a much higher incidence of anxiety, depression, post-traumatic stress in both the child and the family.

There can be issues with coping, the child, the family functioning, the parents. As you said earlier, Molly, it's a very stressful time for them raising a child with a chronic disease that requires medications and requires lots of doctor visits can be very stressful for these parents as well. All these factors occur in about half of the patients that we see. As a result, we have set up here at Cleveland Clinic and there are now, many of them across the country, specific cardiac neurodevelopmental follow-up programs.

To basically bring children in as infants, and then toddler, school age, and evaluate them to see what are the specific neuropsychological or psychosocial, behavioral, emotional issues that these kids may face? Then figure out specifically, how can we support these families to allow them to have their children reach their highest potential in school educationally, and obviously, thrive socially and within the context of their family?

Molly Shroades:
There can be a long-term impact to this. It's not just a have a procedure and it's all done and all gone.

Dr. Bradley Marino:
Yeah. Molly, that's really been what we've all learned in our field in the last two decades. When I was a cardiology fellow in the 1990s, I literally used to walk to the family and say, "We're going to take your child to the OR, we're going to fix them, and everything's going to be fine." We didn't know then that actually, that wasn't true. That in half of these children, that they were going to have this white matter injury that would have an impact on them from a neuropsychological, as well as from a psychosocial, behavioral, emotional standpoint.

What I call the grand re-education of healthcare providers, both general pediatricians, family practice docs, internists, pediatric cardiologists over the last 20 years, educating them that if you have congenital heart disease, which is the most common birth defect, and you have surgery, that there is a possibility that there's going to be some longstanding issues from a brain standpoint that we want to make you aware of, and that you need to refer to us for evaluation and management.

This came to a head in 2012, when the American Academy of Pediatrics and the American Heart Association published the first guideline on the evaluation management of these neurodevelopmental, psychosocial issues in kids with congenital heart disease as a major scientific statement. Since that time in 2012, a group called the Cardiac Neurodevelopmental Outcome Collaborative was formed, which has more than 45 participating institutions in the United States, Canada, and Europe, to basically come together to figure out how we're going to best prevent brain injury.

If a child has a brain injury from congenital heart disease, how do we treat that moving forward for the first two decades of childhood, obviously, and then ultimately into the adult congenital heart disease period when they're adults? Both from a research standpoint, clinical standpoint, and quality standpoint, this group is now collecting data internationally and is already starting to put out some of the seminal research in this area. The field has changed dramatically in the last two decades, and I'm very, very excited and proud of where we've come to, but there's so much more work to do.

What I would say to parents are, "We are completely committed, both here at Cleveland Clinic and around the United States, to figure out how we prevent brain injury in kids with congenital heart disease, and then treat it most effectively so that these children cannot just survive, but thrive."

Molly Shroades:
Now, as you're having these conversations with parents about long-term side effects and the impact over time, are there any physical limitations like involving sports or physical activities that you recommend to parents?

Dr. Bradley Marino:
Again, it depends on what this specific congenital heart defect is. There are certain types of congenital heart defects that may require certain therapies that we would say maybe, "You can't play football and contact sports. You can't go on a roller coaster." There are many of them we say you can. A lot of it depends on over time, with the structural abnormalities to the heart that result in the heart muscle itself or the left ventricle having issues. Because if a child then develops heart failure, secondarily to having congenital heart disease, that will specifically change again, what we recommend for that child or that parent.

Many children with congenital heart disease will need what we call bacterial endocarditis prophylaxis at the dentist, that those recommendations have changed over the last 10 years. Now, much fewer of our patients require that. But if a child has congenital heart disease, definitely ask your pediatric cardiologist, whether your child needs bacterial endocarditis prophylaxis, which endocarditis is when you have a bacteria that can get into your blood, and then basically attach itself to your heart or the heart vessels and create an infection.

But as far as limitations to the specific physical activity a child might want to do, it's highly variable. Now, what I will say is this. Pretty much all children are not going to be Olympic athletes. The vast majority of children are actually not going to be college athletes. A few of them will be high school athletes. The vast majority of kids play recreational sports. I think for most pediatric cardiologists with rare exception, the child can self-limit. They can tell you when they need to take a break if they have congenital heart disease, most cardiologists will let them participate in those types of activities without any limitations.

Again, ultimately, it's always whatever the specific defect is that your child has, speak to your pediatric cardiologist. They will specifically let you know what your child can and can't do. But for the vast majority of the patients we take care of, community-based, noncompetitive sports I'll say, are completely appropriate and highly encouraged by pediatric cardiology.

Molly Shroades:
As a child is out there doing activities and getting moving, what are some signs that a parent should keep an eye for, especially if they already have a diagnosis of congenital heart defect?

Dr. Bradley Marino:
I just want to reiterate that if a child is having issues, they will self-limit. It's very, very likely that if your child's congenital heart defect, if they're having issues, they will tell you, and they will tell you early and often. If that's not the case, if they are breathing much harder, if you feel their pulse and they've got a much higher pulse rate than normal that is sustained after activity is completed. If they have chest pain at peak exercise, if obviously, they pass out, these are signs that you want to have your child evaluated immediately, by either their pediatric cardiologist or pediatrician, or emergency department.

When in doubt, take them in for evaluation. Don't wait, don't hesitate. If your child has congenital heart disease and you think there's a problem, take them in for evaluation.

Molly Shroades:
This is rewinding a little bit back to before a child is born, but is there any way a parent can prevent a congenital heart defect? Or is it just so wrapped up in genetics, there's no way to prevent this?

Dr. Bradley Marino:
Yeah, so there's still obviously a lot that we don't know about what causes congenital heart disease. In terms of what we currently know today, getting the best prenatal care you can from an appropriate surgical practice is really the best way to prevent all congenital defects, not just congenital heart disease. There are obviously, as we've talked about before, certain medications that are associated with congenital heart defects. Usually, if that's the case, the mother would have had to have been on those specifically.

If the child is potentially going to get a congenital heart defect from that medication, typically the obstetrician will talk with that parent, that mother and father, about the fact, you need to be on this medication. When you take the medication there is this potential risk for this specific type of congenital heart disease. The parent obviously, has to make that call as to whether they want to take that medication or not. But other than not taking a specific medication that may be associated with congenital heart disease, there's really not much that a mother and father can do, other than just get the appropriate prenatal care.

The genetics are the genetics. There're some lesions that specifically we know are hereditary and can be passed along in families specifically of the left side of the heart. But short of that, not taking medication that may be associated with congenital heart defects and getting good prenatal care. There's really not much that a parent can do to prevent it.

Molly Shroades:
Now, if you have a child in your family who has a congenital heart defect, and you find that you were pregnant a second time, should you have any extra tests done or have any extra concerns?

Dr. Bradley Marino:
I want to reassure the parents that are watching this, that even if your child does have congenital heart disease, the actual risk of the second child having congenital heart disease, while it is higher than the pregnancy where there isn't a child with congenital heart disease in that family, it is not significantly high. If you have now that second pregnancy and your first child has congenital heart disease, the vast majority of obstetricians I know will make sure that child, the second child specifically, gets a fetal echocardiogram just to make sure that there's not congenital heart disease again in the second child.

Now, there are families where I've seen multiple children in the same family have congenital heart disease but it's not always the same congenital heart defect. It may be a much more mild version of it, or maybe a more complex version of it but that's usually pretty rare. I will say in the vast majority of families where I've seen a child with congenital heart disease, they will have multiple children after that, that don't have congenital heart defects. I think the most important thing is if you're a parent that has a child with congenital heart disease, when you get pregnant that second time, make sure that you talk with your obstetrician, get a fetal echocardiogram done so that you can have some peace of mind.

Hopefully that child, which is most likely won't have a congenital heart defect as well.

Molly Shroades:
Wrapping up here today, I just am hoping you could give our listeners a few tips on how to talk to kids about congenital heart defects and what talking points parents should work into the conversation?

Dr. Bradley Marino:
Molly, that's such an important point. I'm glad that we're finishing the conversation this way. We really struggled a generation ago to have the vast majority of these kids survive and we're there now, with a 97% plus survival rate for the vast majority of the kids that have heart surgery now. If you have congenital heart disease, the high likelihood is that you will survive into adulthood. We then over the last 20 years have really now delved into what the specific complications or what the issues that may arise from either having congenital heart disease is or getting treatment for it.

I think we really, really worked very hard to educate our communities and our families over the last 10 years about that. I think really in the next 10 years, it's all about telling these kids with congenital heart disease, that even though you have a congenital heart defect, there's really nothing that you can't do. Building that resilience to make them understand that while they have this congenital heart defect, it does not determine their life. It's not to determine who they are, who they can be, what they can do in their lives.

There are many patients with congenital heart disease, individuals that are incredibly successful doctors, lawyers, business people. There really is no limit to what anyone with congenital heart disease can accomplish in their lifetime. Most importantly, if you get the right care, if you have the right team surrounding you and your child, help guide you through that several decade long process, through childhood, adolescence into adulthood.

And then have your child transition to the right adult congenital care. As long as they're getting the right medical care in the background with their family practitioner, internist pediatrician within that medical home, your child can do anything. I don't think really at this point, this has any limitations to what we can now do as a community to support these children and these families. I'm humbled, frankly, over the last 20 years to see how far we've come as a field and how well all of these children doing now.

If your child has congenital heart disease, it doesn't mean anything other than get the right assessments, get the right team around you and your child. We will help you make sure that they are physically well or as well as they can be. Then as a parent, treat them like a normal child. Listen to your cardiologist, relative to any limitations that they may put on them from physical activities, which frankly, shouldn't be many in most cases. But again, listen to your cardiologist. Then the rest is just up to you as a parent. Your children, they always see themselves through your eyes.

If you see them as this amazing miracle, who is going to impact the world in a positive way and is going to be highly successful, that's who they're going to be. Again, our goal is here to work with parents, make sure kids survive and thrive, and here at Cleveland Clinic, we're here to help every child do that.

Molly Shroades:
Thank you so much for talking to us today and sharing your insights, Dr. Marino.

Dr. Bradley Marino:
Thanks, Molly. I really appreciate the time.

Molly Shroades:
To learn more about heart conditions and heart health, visit clevelandclinicchildrens.org/cardiology.

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