Congenital cardiac surgery: Innovations from India

ABSTRACT

Innovation in congenital cardiac surgery took its roots in the 1960s with the development of indigenous heart–lung machines. Over the years, many pioneering advancements showcasing solutions that combine cutting-edge technology with cost-effective approaches have happened in India. Indian surgeons have made significant contributions, including developing tissue-engineered patches, handmade conduits, and indigenous devices for surgical closure of multiple ventricular septal defects. Several new surgical techniques have been described, and Indian surgeons have described some new anatomical entities. Development of frugal technologies has been the game-changer for resource-limited environments. Innovations in imaging, including three-dimensional printing and virtual reality, are transforming preoperative planning and surgical education. Artificial intelligence and machine learning are beginning to influence decision-making and predictive modeling in pediatric cardiac care. Funding initiatives, including government support, public–private partnerships, and philanthropic funding, are making congenital heart disease surgery accessible to a broader population. India’s contributions to innovations in congenital cardiac surgery exemplify the spirit of resilience and ingenuity, offering solutions that are impactful locally and inspiring globally.

INTRODUCTION

Innovation, defined as the process of bringing about new ideas, methods, products, services, or solutions that have a significant positive impact and value, is the key to the progress of any medical specialty.[1,2]

India has made significant advancements in the field of congenital cardiac surgery, with several innovations and contributions to improving the outcomes for children with heart defects. Over the years, Indian surgeons and institutions have revolutionized congenital cardiac care by integrating state-of-the-art technologies, cost-effective treatments, and patient-centered approaches.[3,4]

With a huge disease burden of approximately 200,000 children born every year with congenital heart disease (CHD), Indian centers have been actively contributing to research, training programs, and global collaborations, positioning the country as a hub for medical excellence. This wave of innovation continues to save countless lives, offering hope to children and families.[5,6]

This narrative review article will focus on the key innovations from India in the field of congenital cardiac surgery [Table 1]. The methodology and disclaimer are described in Appendix 1. All the innovations mentioned in the article are important contributions from India; however, some innovations have found widespread usage by others while some have not. It is also important to note that many innovations and improvisations happen daily in pediatric cardiac surgery. Many of these are not necessarily documented through publications and often stay unnoticed.

Table 1.

Congenital cardiac surgery innovations from India

Innovations in devices

Indigenous CPB machine

Devices for apical muscular/multiple VSD

Handmade conduits for RVOT reconstruction

Tissue-engineered patches

ECMO improvisations

Stabilizing devices in Fontan surgery

Innovations in surgical techniques

Unidirectional Valved patch

TAPVC repair: Posterior approach, dual pathway repair

TOF: Transatrial approach, Transatrial – transventricular approach, fixed versus dynamic gradients, simplified double barrel

TGA: Arterial switch without coronary transfer, criteria for LV preparedness, extended CPB ECMO, closed technique for coronary transfer, simplified modified Senning for TGA-TAPVC

Single-stage unifocalization

Variations in papillary muscles of mitral valve and their surgical relevance

PA band: Adjustable PA band, Modified PA band by interposition graft

Fontan: Beating heart Fontan, unusual fenestration technique

Arch repair: Midline off pump coarctation repair

Atrial switch: Modified in situ pericardial technique in “small pulmonary venous presence”

Anomalous coronaries: Unroofing technique for ARCAPA

Nonsternotomy/minimally invasive approaches: Left/right thoracotomy, left vertical axillary thoracotomy

ASD: Right atrial wall patches

Bentall procedure: Modified medial trapdoor technique for pediatric Bentall

Ross procedure: Modified Ross by Dacron valved conduit in RVOT

Innovations in frugal technologies

Use of CPB machine for ECMO

Use of blood bag/Esmarch bandage for open chest

Use of drainage tubing with multiple side holes from the vaccum-assisted closed wound drainage system for peritoneal dialysis

Intraoperative epicardial echocardiography

Electrocautery maze

Innovations in use of technology, AI, and ML

Use of 5G telecommunication

Use of data analytics, AI, ML for predictive models in CHD

Use of indigenous robots, telesurgery

Innovations in imaging

Use of 3D imaging, virtual reality, augmented reality, 3D printing

Innovations in funding for CHD surgery

Government funding

Public–private partnerships

Philanthropic funding

CPB: Cardiopulmonary bypass, VSD: Ventricular septal Defect, RVOT: Right ventricular outflow tract, ECMO: Extracorporeal membrane oxygenation, TAPVC: Total anomalous pulmonary venous connection, TGA: Transposition of great arteries, PA: Pulmonary artery, ASD: Atrial septal defect, 5G: Fifth generation, AI: Artificial intelligence, ML: Machine learning, CHD: Congenital heart disease, 3D: Three dimensional, ARCAPA: Anomalous origin of the right coronary artery from the pulmonary artery

INNOVATIONS IN DEVICES

Innovation in devices for congenital cardiac surgery started in the 1960s. Over the years, many such innovations have become part of daily surgical practice.

Cardiopulmonary bypass

From the early days of development of cardiac surgery, the first series of “open-heart” surgery was done in Mumbai by Dr. KN Dastur using an indigenous heart–lung machine.[3,7] In co-ordination with engineers of National Steel Company, Mumbai, Dr. Dastur made the country’s first totally indigenous roller pump with disc oxygenator in 1959 and did a series of successful dog experiments and closed an atrial septal defect (ASD) in a 19-year-old girl in 1961.[7]

During the same time, Dr. Saibal Gupta in Kolkata was working on improving the Lillehei model of the heart–lung machine with changes in the cooling-heating, oxygenator, filter components, followed by experiments on dogs. In 1962, along with Dr. AK Basu, he performed nine successful ASD closures using this machine, which was called the Calcutta heart–lung machine.[8] These two are probably the earliest innovations in congenital cardiac surgery in India, which paved the way for further developments. Over a period of time, however, these indigenously made machines were replaced by foreign ones mainly due to availability and production issues.

Some notable improvisations were done later to use the cardiopulmonary bypass (CPB) machine as a way to provide temporary extracorporeal support with some innovative changes in circuitry. Bisoi et al. successfully showed the use of integrated extracorporeal membrane oxygenation-CPB (ECMO-CPB) circuit for left ventricular re-training after arterial switch in late presenting transposition of the great arteries (TGA) with intact ventricular septum with modifications in the conventional CPB machine.[9] Typically, this has been done by incorporating a closed bladder and closing the line to the cardiotomy reservoir.[9] The described closed bladder is, however, not widely available.

We reported the use of the conventional CPB circuit as temporary mechanical circulatory support in the short term.[10] George et al. described a technique that involves completely bypassing the reservoir and connecting the roller pump directly to the venous limb.[11] These innovations have mainly been driven by the need to provide temporary mechanical circulatory support in resource-limited environments as a cost-saving measure.

Shivaprakasha et al. described an innovative right heart bypass circuit utilizing autologous lung as an oxygenator, offering a simple, safer, and less expensive alternative to conventional CPB for Glenn shunts, central aortopulmonary shunts, and pulmonary artery (PA) reconstructions.[12] Bypass circuit consisted of a reservoir and a roller pump along with a cardiotomy sucker. The left and main pulmonary arteries were used for arterial return, and venous drainage was achieved with innominate vein cannulation. Inferior vena cava (IVC) cannulation was performed when needed.

Devices for closure of apical muscular ventricular septal defect/multiple ventricular septal defects

The difficulty of access and clear identification of apical muscular ventricular septal defect (VSD) makes it a challenging surgical entity. Mishra et al. described their innovative and simple surgical technique for closing apical VSD using a cost-effective, custom-made low-profile single-disc polytetrafluoroethylene (PTFE) device.[13] This innovative VSD closure device utilizes a three-fold approach to prevent left-to-right shunting. First, the graft, precisely sized to match the defect, directly seals the VSD. Second, a disc on the left ventricular side covers the defect and the surrounding septal area, providing additional reinforcement. Third, the graft is secured on the right ventricular side with pledgeted stitches to the septal muscles, preventing any residual shunting around it. Additionally, as multiple apical VSDs often converge into a single left ventricular opening, closing the primary apical VSD effectively addresses all associated defects. The disc also seals any additional defects near the main VSD, making this device highly effective for complex anatomies. It is easy to make and cost-effective at $ 100 per device. The author has patented the device (Mishra, A [2013]. A device and method for closure of Apical Muscular VSDs [Indian Patent Number 399543, Government of India]).

Salve et al. described an intraoperative customized double-patch device technique in various situations in multiple muscular VSDs with satisfactory immediate and short-term results.[14] Muscular VSDs were mapped through enface reconstruction (EFR) by echocardiography and closed using an intraoperative customized double-patch device technique, with patches on the left ventricle (LV) and right ventricle (RV) side. The authors concluded that echocardiographic EFR of multiple muscular defects helps in accurate profiling and closure of most of these VSDs. EFR also helps customize the devices that are prepared on the table. The double-patch concept results in secure closure of the bigger VSD, besides closing the smaller defects in the vicinity. This “sandwich technique” was first described by Kapoor et al. in 1999.[15]

Handmade conduits for right ventricular outflow tract reconstruction

RV to PA connections with conduits are integral to CHD surgery. Availability issues with homografts and expenses associated with commercially available xenografts like Contegra have paved the way for innovative handmade conduits. Iyer and Sharma published one of the earliest reports of handmade pericardial valved conduits highlighting this necessity in the resource-limited environments.[16] Kasturi and Prabhu demonstrated the details of making handmade, trileaflet, valved expanded PTFE conduit, where the valve is made of 0.1 mm PTFE membrane.[17] Malankar et al. published the short-term results of such a PTFE-valved conduit in various anatomical subsets with good results.[18]

Tissue-engineered patches

Dr. Soma Guhathakurta was instrumental in developing SynkroScaff^®, a tissue-engineered pericardial patch for clinical use. Recently, Tiwari et al. conducted an observational study on SynkroScaff^®, a tissue-engineered decellularized bovine pericardium developed in India for CHD repair, demonstrating its effectiveness as a prosthetic material. The study highlighted the material’s excellent intraoperative handling, particularly in complex patchwork areas due to its flexibility and manageability. Its nonglutaraldehyde-based decellularization eliminates the need for intraoperative rinsing, while a proprietary process prevents calcification by removing the open carboxyl moiety. With a tensile strength of 18 MPa and a burst strength of 64 kPa, SynkroScaff^® offers durability and retains an intact extracellular matrix, promoting autologous cell adhesion and integration with host tissue. These features make it an indigenously developed, safe, cost-effective, and promising option for surgical repairs of CHD.[19]

Extracorporeal membrane oxygenation improvisations

In addition to using a CPB machine for extracorporeal mechanical circulatory support, as mentioned earlier in this review,[9,10,11] India has introduced some unique innovations in the field of ECMO.

The integrated ECMO-CPB circuit developed at the All India Institute of Medical Sciences (AIIMS) significantly contributed to the growth of the institute’s ECMO program and improved patient survival rates. This circuit incorporates a slight modification to the conventional CPB setup by using the ECMO oxygenator instead of the standard CPB oxygenator, which typically has a shorter lifespan. This innovative approach optimizes resource utilization and enhances the efficiency of the ECMO-CPB circuit during procedures.[20]

Cost of ECMO and the hardware is a major issue in India. The medical device market often faces cross-compatibility barriers, as manufacturers design their equipment to work exclusively with their own solutions and repair kits. Sai Sree Ram and Manoj addressed this issue for ECMO machines, specifically focusing on the centrifugal pump, which often requires multiple replacements during the device’s lifetime.[21] Their study involved designing and developing a functional ECMO machine capable of accommodating existing models of centrifugal blood pumps, focusing on simplifying the replacement process so that any healthcare provider within the hospital can perform it. As proposed in this paper, the primary design of the centrifugal blood pump holder is universally compatible with all current pumps on the market. Additionally, the system allows for the creation of adaptable components to ensure compatibility with newer pump designs in the future. This approach addresses logistical challenges and eliminates the need for specialized service personnel outside the hospital-manufacturer ecosystem, creating a more efficient and versatile solution for ECMO machine usage. This innovation ensures that any widely available centrifugal pump can be used in emergencies or logistical delays, overcoming original equipment manufacturer-imposed limitations and making the system more practical and versatile.

ECMO Society of India was established in 2010 to improve the awareness and practice of ECMO in India. The platform was used to enhance knowledge about the practice of ECMO, arrange training programs, and hold annual conferences within India.[22]

Use of heart stabilizing devices in Fontan surgery

Das et al. reported using a heart positioning device (Starfish^®, Medtronic Inc., USA) during the extracardiac Fontan procedure to safely retract the ventricular mass and facilitate IVC anastomosis.[23] Traditionally used in off-pump coronary artery bypass, such devices prove particularly beneficial in Fontan procedures, which are often redo surgeries with significant intrapericardial adhesions. Retracting the ventricular mass, especially near the IVC, typically requires retraction sutures or assistance from a surgical assistant. The heart positioning device simplifies and secures ventricular retraction and frees the surgical assistant’s hands for other tasks during the procedure. This approach is especially valuable in cases of apicocaval juxtaposition, where the ventricular apex is directly over the IVC, enhancing access and ease of anastomosis.

Simple innovation to make epicardial pacing wires safe

Mishra et al. described a simple innovation to make epicardial wires safe and to prevent injury to cardiac structures during removal.[24] They proposed removing a part of the insulation near the end of the pacing wire after cutting the needle off and retaining the distal insulated portion of the wire. The covered, insulated portion of the end of the pacing wire makes it a safer device with a simple innovation.

INNOVATIONS IN SURGICAL TECHNIQUES

A host of surgical innovations have been described and published from India, mainly tailored to the unique surgical challenges that we face here.

Unidirectional valved patch

The high prevalence of late-presenting CHD lesions and their unique challenges have prompted the development of many innovative approaches from India.[25] Talwar et al. summarized several surgical strategies to deal with CHD and severe PA hypertension in low/middle-income countries.[26] The AIIMS group described a modification of the unidirectional valved patch closure of VSDs with a single, folded patch with a fenestration.[27] The “AIIMS technique” offers several advantages. It is straightforward, cost-effective, and easily reproducible. Unlike other methods, it does not require the use of two patches, pericardium, or homograft for preparation. Additionally, it is quicker to prepare, significantly reducing ischemic arrest time during procedures.

Total anomalous pulmonary venous connection repair

Venugopal, Iyer, Sharma, Bhan et al. described the “posterior” approach for repair of total anomalous pulmonary venous connection (TAPVC) for the first time by dislocating the heart into the right pleura.[28] This approach became very popular worldwide for its simplicity, although the term “lateral” approach was also used to describe it. A video article from India nicely depicts the nuances of this approach.[29] Shivaprakasha, Koshy et al. described a novel repair for obstructed TAPVC to the coronary sinus.[30] Salve et al. described innovative technical steps in dual-pathway repair of congenital pulmonary vein stenosis using autologous left atrial appendage as a pedicled tube for left inferior pulmonary vein stenosis.[31]

Tetralogy of Fallot

Indian authors have described numerous surgical innovations for repair of tetralogy of Fallot (TOF).

Dr. KM Cherian first popularized transatrial repair for TOF in an era when transventricular repair was the common approach. The trend rapidly became common in most surgical units in India.

Venugopal, Iyer, Sharma, Kaushal et al. published the first Indian randomized controlled study comparing transatrial-transpulmonary approach versus the more common transventricular approach in 1997, showing lesser global hypokinesia of RV in the transatrial-transpulmonary group.[32] The transatrial-transpulmonary approach gradually became the norm for TOF repair.

Iyer, Kaushal et al. described for the first time the concept of “fixed versus dynamic gradient” in immediate postoperative assessment after total repair for TOF to reduce unnecessary revisions.[33]

Shivaprakasha simplified the “double-barrel” technique for use in TOF repair with important coronary artery crossing the right ventricular outflow tract (RVOT), where a conduit is not available, and also as a cost-effective surgical solution by using autologous pericardial patch.[34]

Jhajhria, Banday et al. described a modification in the intraoperative technique for assessing the adequacy of infundibular muscle resection through transatrial technique on the cardioplegic arrested heart and have named the modification as Jhajhria Infundibular Resection Adequacy Assessment Technique.[35] In this technique, the surgeon inserts the index finger of the right hand into the RVOT while placing the thumb on the anterior aspect of the RV, enabling tactile assessment of residual muscle bundles between the finger and thumb. The evaluation is performed systematically, starting from the pulmonary valve annulus and progressing toward the base of the anterior tricuspid leaflet, ensuring any obstructive muscle bands are identified.

Recently, Benedict et al. described a novel method of monocusp reconstruction of the pulmonary valve using autologous pericardium in children requiring transannular patch (TAP).[36] Unlike the already described conventional monocusp techniques mainly with 0.1 mm PTFE membranes, the authors preferred using untreated native pericardium for monocusp reconstruction and have had good results and found less early calcification.

Transpositions of great arteries

Murthy and Cherian described a novel technique in TGA that achieved anatomic correction for TGA without coronary artery translocation by creating flaps in the proximal great arteries.[37]

Iyer et al. published one of the first series delineating the serial echocardiographic criteria for rapid two-stage arterial switch operation (ASO) in 1995.[38] An increase in left ventricle (LV) mass, LV posterior wall thickness, and LV end-diastolic internal diameter toward normal combined with a circular LV configuration with the interventricular septum contracting in synergy with the LV mass showed the preparedness of LV to take on the systemic circulation. The criteria described in the article later became the factors used liberally for establishing candidacy for arterial switch in late presenters with borderline LV.

Bisoi et al. showed in a large series from India that primary ASO can be done safely in children beyond the neonatal age group. They demonstrated that primary ASO can be performed with acceptable surgical mortality and early postoperative morbidity in infants more than 6 weeks old, with a preparedness for supporting on mechanical circulatory support if needed.[9]

Rao et al. described a modified “closed” technique for coronary transfer that emphasizes accurate coronary placement by considering the anatomy of a distended aorta and coronary transfer after the neo-aortic anastomosis.[39] This approach incorporates anterior interrupted sutures, which minimizes the purse-string effect, ensures even tension distribution, and reduces the risk of bleeding. Additionally, it facilitates smoother reconstruction in cases of size mismatch and has better growth potential.

Mishra et al. innovated with a modified Senning procedure for late presenting TGA associated with TAPVC.[40] It is a simple solution for a complex anatomical subset of TGA treated by a modified Senning procedure, for which minor modifications were made to unroof the common chamber. The same lead author described another modified technique for a complex subgroup of TGA with aortopulmonary window.[41] The standard technique of an ASO operation with minor modification in the excision of branch pulmonary arteries was proposed, and good results were obtained.

Although root translocations of all forms have gained popularity, in unusual circumstances, two papers from India have described neo-aortic valve replacement with ASO in selected cases of dextro-TGA, VSD, and valvar pulmonary stenosis.[42,43]

Pulmonary artery band

Choudhary, Talwar, Airan , Venugopal et al. have described a percutaneously adjustable PA banding (PAB) technique.[44] This inexpensive, simple innovation allows easy band adjustments without requiring multiple reoperations.

Salve et al. published a novel technique of modified PAB that effectively restricts pulmonary blood flow with transposition physiology after an ASO while avoiding complications of standard PAB by using a PTFE interposition graft.[45] A patch of pulmonary homograft, autologous pericardium, or bovine pericardium with a central fenestration was used to close the opening at the pulmonary confluence.

Innovations in Fontan

Iyer, Kaushal et al. published the first report of extracardiac Fontan on beating heart in 1998, which soon was adapted by many other surgical units as a standard way of performing a Fontan completion.[46]

Shivaprakasha, Salve et al. described unusual fenestration in a primary Fontan between left PA and adjacent left juxtaposed right atrial appendage due to complex anatomy, making conventional fenestration difficult.[47]

Arch repair

Iyer, Dutta et al. published a new technique of off-pump repair of coarctation of the aorta through midline sternotomy when associated with intracardiac defects to be repaired in a single stage.[48]

Atrial switch

The Senning procedure remains relevant to our part of the world due to the late presentation of TGAs with completely regressed LV. The surgical modifications of this procedure, with video illustrations, were published by Iyer, describing the surgery’s nuances.[49]

Dutta Baruah and Sharma described a previously unreported anatomical variation in pulmonary vein anatomy in hearts with D-transposition or congenitally corrected TGA. In this variant, the inferior right pulmonary vein lies posterior rather than inferior to the superior right pulmonary vein, a condition referred to as a “small pulmonary venous presence.” This anomaly prevents the right inferior pulmonary vein from contributing to the pulmonary venous outlet, potentially leading to pulmonary venous pathway obstruction following a Senning operation. To address this, the authors propose modifying the in situ pericardium technique, utilizing the opening in the inferior pulmonary vein to establish a reliable pulmonary venous outflow during the procedure.[50]

Anomalous coronaries

Mishra reported the surgical experience for the rare anomalous origin of the right coronary artery from a PA. The authors found that the unroofing technique they used was simple and reproducible.[51] The unroofing procedure would seem superior to reimplantation because it can normalize virtually the entire course of the left coronary artery (LCA) without leaving the intramural segment, which could eliminate a potential nidus for lethal events. It is technically simple, too.

Nonsternotomy/minimally invasive approaches

Nonsternotomy/minimally invasive approaches have been innovative approaches for pediatric cardiac surgery for quite some time. These procedures, however, should be called “minimal access” rather than “invasive,” as the invasiveness of the procedure remains the same. Some useful innovative articles from India establish the advent and progress of these procedures in India.

Shivaprakasha et al. published one of the earliest reports from India describing limited posterior thoracotomy as a viable alternative for midsternotomy and submammary thoracotomy. The approach has the advantage of a scar in the back that does not impede the future growth of the breast tissue and the pectoralis major without needing any special instruments.[52]

Shivaprakasha, Salve et al. described a case of large ostium secundum ASD, pulmonary valvar stenosis, absent right superior vena cava (SVC), and isolated left SVC draining to the right atrium via coronary sinus by a right posterior thoracotomy.[53] Iyer, Ramman et al. reported a new technique of pulmonary valve replacement (PVR) in repaired TOF through limited left anterolateral thoracotomy as an alternative to repeat sternotomy.[54] Malankar et al. showed that PVR and left pulmonary arterioplasty in repaired TOF through left vertical axillary thoracotomy achieved a better cosmetic result.[55]

Recently, Sargar et al. published a series of 63 patients with simple congenital cardiac lesions, safely and effectively repaired by a minimally invasive approach, with good results and without compromising the surgical techniques.[56]

Other innovations

Victor and Nayak described the variations in the papillary muscles of the normal mitral valve and their surgical relevance.[57]

Murthy, Cherian et al. described single-stage unifocalization through median sternotomy for pulmonary atresia, major aorto-pulmonary arteries, and VSD.[58]

Iyer et al. described a series of seven patients with the ventriculo-arterial connection best described as a “double outlet of both ventricles.” They showed good early and midterm results of surgical repair using two patches for interventricular septation.[59]

Iyer, Kalita et al. reported the surgical management of extremely rare Uhl’s anomaly by surgical exclusion of the RV with an individualized approach to each patient.[60]

Kumar, Talwar et al. showed for the first time the use of an autologous, free, right atrial wall as a patch for ASD closure, which has several advantages.[61] Lahiri and Gaur modified this technique using a vascularized pedicled right atrial wall flap, a mechano-physiologically active patch for ASD with its own set of merits.[62]

Manohar, Hiremath, Amboli et al. reported an innovative surgical approach with three cases of high partial anomalous pulmonary venous connection to SVC using the azygos vein into the Warden anastomosis for a tension-free suture line.[63]

Salve et al. reported a novel modification for a pediatric Bentall procedure with medial trap-door technique for coronary reimplantation.[64]

Chatterjee, Sankhyan et al. devised a novel technique for RVOT reconstruction by preparing indigenous Dacron valved conduit in 40 consecutive cases of “modified” Ross procedure with a median patient age of 12 years.[65]

Recently, a surgical technique, documented in the article “Bhende Pathak Hernia” by Bhende et al., offers valuable insights into unique approaches to congenital diaphragmatic hernias.[66]

INNOVATIONS IN FRUGAL TECHNOLOGIES

Innovations in frugal technologies have been necessary in a resource-limited country like India. The use of CPB machine for ECMO and handmade conduits for RVOT repair has been discussed before.[9,10,11]

Leaving a chest open temporarily is a well-established operative strategy, especially in neonates. In place of expensive PTFE membranes, Talwar et al. described using blood bags safely.[67] We have used patches from Esmarch bandages, commonly used in orthopedic surgeries, for the same purposes in our unit.

Based on personal communication, several units use Gore-Tex/Felt as annuloplasty ring material instead of commercially available rings with good results. CPB cannulas have been reused safely all over India after proper reserialization.

Iyer, Kaushal et al. and Iyer, Awasthy et al. from the same center reported using epicardial echocardiography for intraoperative assessment after CHD surgery.[68,69] This avoids purchasing expensive transesophageal echocardiography (TEE) probes and the availability of a sonographer trained in intraoperative TEE.

Rheumatic heart disease leading to mitral valve pathologies in young children/adolescents is still common in the developing world, and sometimes, they do have concomitant atrial fibrillation. Modified maze procedures with alternative cheaper energy sources like electrocautery have been published from India.[70,71,72]

Another popular frugal innovation, although unpublished, is the use of drainage tubing with multiple side holes from the vacuum-assisted closed wound drainage system (Romo Vac Set®, Romsons, Agra, India) as a substitute for the costly Tenckhoff catheter for peritoneal dialysis. The team at Escorts Heart Institute, New Delhi, propagated this innovation.

INNOVATIONS IN THE USE OF TECHNOLOGY, ARTIFICIAL INTELLIGENCE, AND MACHINE LEARNING

Use of fifth-generation technology, robotics, and telesurgery

Doddamane and Kumar illustrated the advent and use of fifth-generation telecommunication technology in India. The innovative use of 5G technology in cardiothoracic surgery mainly in bridging gaps in perioperative care, outreach, education, research, and much more has been well decribed.[73]

Indigenously made Robotic System SSI Mantra is already used in adult cardiac surgery and will soon be used in CHD surgery as well.[74] Recently, a telesurgery (remotely done coronary artery bypass grafting) was performed in India using this system.

Use of artificial intelligence, machine learning, and data analytics

The modern tools of AI, machine learning, and data analytics have made their inroads into pediatric cardiac sciences in a big way, and India is no exception.[75,76,77] In the future, pediatric cardiac professionals will greatly benefit from structured training in artificial intelligence (AI) and data science and stronger collaborations with data scientists and computer scientists. These efforts will facilitate the development and implementation of AI models in mainstream pediatric cardiac care.

INNOVATIONS IN IMAGING

Three-dimensional imaging, printing, and use of immersive virtual reality and augmented reality techniques

Advances in imaging, including virtual reality and three-dimensional (3D) imaging technology and printing, have added a new dimension of preoperative understanding for congenital heart surgeons. Immersive 3D visualization can significantly improve spatial comprehension of complex CHD morphology, addressing limitations in spatial intelligence, experience, and expertise. These technologies have the potential to serve as powerful clinical and educational tools in the field of CHD surgery.[78,79]

In the current era, professional societies like the Pediatric Cardiac Society of India and the Society of Paediatric and Congenital Heart Surgeons have used 3D-printed heart models for hands-on operative training of young surgeons in India.

INNOVATIONS IN FUNDING FOR CONGENITAL HEART DISEASE SURGERY

Funding for CHD surgery remains a real challenge in India.[80] With non-existent insurance coverage and out of pocket expenditure not being a sustainable solution for most parents of children with CHD, it is challenge to run CHD programs in India. However, various innovations from the government, to provide funds, public–private partnership models, philanthropic funding have helped thousands of children surmount this challenge.[81,82,83,84] The overall numbers and the results of surgery for CHD are in the right direction if funding sources continue to support in a meaningful way.[85] A philanthropy-based collaborative model called “GIVE” gave a new insight into the sustainability of CHD surgical programs.[86]

CONCLUSIONS

Innovations have continued and supported the growth of CHD surgery in India, with a focus on special approaches for late-presenting lesions and the development of frugal technologies driven by economic need, in addition to the overall growth of scientific and evidence-based surgical practices. Most of these innovations have been positively regarded worldwide and adopted in many other parts of the world.

Conflicts of interest

There are no conflicts of interest.

APPENDIX 1

METHODOLOGY

I used a comprehensive approach to collect and collate the information on innovations in congenital cardiac surgery from India.

Searching the databases

I searched the PubMed database for the relevant studies originating from India (from inception to December 2024). The search terms included "congenital heart disease" OR "congenital heart defect," OR "surgery" OR "new surgical approaches" OR "indigenous" OR "devices" AND "India."

I specifically looked for the earliest publication on any surgical technique. The reference list of relevant articles was manually checked. Any landmark or prominent surgical series was also checked for use indigenous methods.

Email

An email/personal message asking about their own innovations in congenital cardiac surgery was sent to all the members of the Society of Paediatric and Congenital Heart Surgeons.

DISCLAIMER

I have made every effort to ensure that the list is as comprehensive and accurate as possible. However, despite my best intentions, some important innovations may have been unintentionally overlooked or omitted for various reasons. I sincerely regret any such inadvertent errors or omissions.

Funding Statement

Nil.