Surprise Heart Defect Diagnoses at Birth: Noah’s Story

When Noah was born last May, his parents Lauren and John were expecting a healthy baby boy. They were shocked to learn that prenatal ultrasounds had missed his pulmonary atresia with intact ventricular septum (PA-IVS), a condition where the right side of the heart is underdeveloped, and there is no connection from the heart to the lung, compromising blood flow to the lungs and other parts of the body.

Noah’s pulmonary and tricuspid hypoplasia means that he was born with birth defects of the pulmonary and tricuspid valves, which control blood flow to the right side of the heart and eventually to the lungs. He was also diagnosed with a right coronary artery fistula, an abnormal connection between the coronary artery carrying oxygen-rich blood to the heart.

“When I was pregnant, I did everything I was supposed to do to grow a healthy baby. I gave up caffeine, ate well, and took the stairs every day to the ninth floor until I was 33 weeks pregnant,” says Noah’s mom Lauren, who is an occupational therapist at CHOC Children’s.

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Noah and his mom Lauren, who is an occupational therapist at CHOC Children’s.

The evening Noah was born, he had low oxygen and platelet levels and was brought to the neonatal intensive care unit within the hospital where he was born. Dr. James Chu, a CHOC Children’s pediatric cardiologist who was making rounds that evening, suspected Noah had a heart defect and ordered a cardiac ultrasound, or echocardiogram, a non-invasive procedure used to assess the heart’s structure and function.

Dr. Chu returned to Lauren’s room as soon as he had a better idea of Noah’s diagnoses, even though it was 3:00 a.m. He knew Noah’s parents wanted to know what was wrong as soon as possible.

“He drew us diagrams and gently explained Noah’s exact heart defects, their severity, and detailed the surgeries he would have to endure,” Lauren recalls.

Dr. Chu told Lauren and John their son needed a higher level of care.

“He gave us a few options of where we could transfer Noah, and when I told him I really wanted to go to CHOC, he reaffirmed my choice,” Lauren recalls. “Once we arrived at CHOC, another cardiologist, Dr. Ahmad Ellini, confirmed the diagnoses, explained everything again, and answered all of our questions.

“We didn’t have a lot of time to think about a game plan immediately after he was born,” Lauren says of Noah’s surprise heart conditions. “But I knew that CHOC was the best place for him to be.”

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As an occupational therapist at CHOC, Lauren has been caring for patients for years. She never imagined her son would become a CHOC patient shortly after he was born with surprise heart defects.

Surgery for PA-IVS

Noah spent a week in CHOC’s NICU before undergoing his first in a series of three heart surgeries. That first week was an emotional rollercoaster, Lauren recalls. Noah’s team of neonatologists, Dr. Amir Ashrafi, Dr. John Cleary and Dr. John Tran, helped his parents remain calm.

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Noah’s dad reads him his favorite book as he recovers from surgery to repair heart defects in the CVICU.

“The team of neonatologists were great. They answered all my questions, spent lots of time with us, and were super available― even if I had a question at 2:00 a.m. Everyone on his care team was very collaborative,” Lauren recalls, adding that she found the attention to detail and calm nature of Dr. Richard Gates, director of cardiothoracic surgery and surgeon-in-chief at CHOC, very comforting. “Dr. Gates knows his patients through and through. Even though I have a medical background, I’m still a parent. He describes things in a way my husband and I understand, especially when we’re sleep deprived and scared.”

Babies with PA-IVS typically undergo three procedures:

  • Blalock-Taussig (BT) shunt: a surgeon inserts an artificial tube to aid blood flow to the lungs. This procedure is usually done in the first week of life.
  • Glenn procedure: Usually done between 4–6 months of age, this operation allows blood returning from the upper part of the body to flow directly to the lungs without passing through the heart. Now the left ventricle only has to do one job, pumping blood to the body.
  • Fontan procedure: Typically occurring between 2 and 4 years of age, this surgery connects the pulmonary artery and the inferior vena cava (vessel returning oxygen-poor blood from the lower part of the body to the heart), allowing the blood coming back from the lower body to go to the lungs. Once this procedure is complete, oxygen-rich and oxygen-poor blood no longer mix in the heart. The surgeon may leave a small connection between the oxygen rich and oxygen poor chambers (a fenestration).

Lauren describes Noah’s surgeries to her family as a “miracle bandage” since they will not make PA-IVS go away. Noah may need a heart transplant someday.

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When Noah was recovering from surgery, his CVICU nurses helped him get ready for visitors by dressing up his bandages.

“When Noah was born his heart was the size of a walnut. Each of these surgeries are temporary, and it’s Noah’s job to keep growing, and eventually, to outgrow each of these repairs and need the next one,” she explains.  “Unfortunately, these surgeries cannot make his heart “normal” and he’ll always have serious heart disease, but we’re so grateful we have these operations to give him the best chance possible.”

After his first surgery, Noah spent five weeks in the cardiovascular intensive care unit (CVICU) at CHOC. For the first 48 hours of his recovery, he required extracorporeal life support (ECLS) (also known as extracorporeal membrane oxygenation or ECMO), a special procedure that takes over the heart’s pumping function and the lungs’ oxygen exchange until a patient can recover from injury or illness.

“I knew there was a possibility he’d need to be on ECMO after surgery, but it wasn’t something I allowed myself to think about,” Lauren says. “It was hard to see him hooked up to so many machines and be so fragile. Dr. Joanne Starr did an extraordinary job managing Noah’s care while he was on ECMO and she also cared for us as his parents too. She checked on Noah at all times of the day and night, and even ordered me to go take a walk in the butterfly garden to get a break from being at his bedside 24/7.”

Dr. Starr, director of ECMO and medical director of cardiothoracic surgery at CHOC, has long been committed to caring for a patient’s entire family.

“In caring for children and teens, it’s vital that we as physicians remember we are not only taking care of the patient, but the parents as well. Parental stress and anxiety may have an effect on the patient and the healing process. If parents aren’t practicing self-care, they might not have a clear enough mind to be able to understand their child’s condition and make decisions on their behalf,” explains Dr. Starr. “Having a family’s full support is an important part of the healing process, and something that goes a long way in ensuring a positive long-term outcome for my patients.”

After five weeks in the CVICU, Noah’s parents were thrilled to be able to bring their baby home for the very first time. But a mere 30 hours later, they were readmitted to CHOC as Noah fought a central line infection.

Things calmed down a few weeks later. He went home, continued growing, and started hitting developmental milestones and developing a big personality. During the next few months, the family was still coming to CHOC as frequently as a few times per week for blood and platelet transfusions. Ever since Noah had a low platelet count at birth, his parents knew that he would need transfusions― they just didn’t know how many. That turned out to be as many as three transfusions per week.

Lauren and her dad had a history of donating blood. For instance, if they were at a hospital visiting a family member, they would always go find the blood donor center and give “because it was easy and it was just the right thing to do,” she says.

“I always knew that donating blood and platelets was important, but having a baby who needed blood and platelets changed my respect for what a gift it really is,” Lauren says. “When my baby needed to go on oxygen, and then they gave him a red blood cell transfusion and all of a sudden, he doesn’t need supplemental oxygen anymore, it’s a game changer. To literally watch a kid who couldn’t oxygenate well on his own, suddenly not need help breathing because of a blood transfusion, is amazing.”

Over the past several months, Noah has been able to meet several of the donors who have given him much-needed blood and platelets.

“It is so humbling to meet his donors. Whenever we come to the Orange campus for appointments, we visit the blood donor center and have gotten to meet and thank some of his donors,” Lauren says. “The people who give regularly are my heroes. Being helpless and not being able to cure your child is heartbreaking. We rely on these strangers and their generosity. They don’t know us but they help us.”

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Noah meeting one of his platelet donors Kathleen, a CHOC staff member.

The need for regular donors ―platelets especially― is so great because the shelf life on blood products is not long. Red blood cells have shelf life of 42 days, but platelets only have a shelf life of 5 days, half of which is taken up by necessary safety testing before a patient can receive the donation. That means there is a window of about 48 hours where patients can receive donor platelets before they expire.

Direct donations, when blood and platelet donations are earmarked for specific patients, are an important way to safeguard patients who need ongoing transfusions, as they help minimize the number of different types of blood products they are exposed to during treatment. This will also help to improve Noah’s chances of being matched for a heart if he needs one in the future. Lauren outlined the ways donors helped her son in handwritten thank you notes she asked the Blood & Donor Services staff to distribute to his directed donors.

When Noah was about five months old, he underwent a cardiac catheterization procedure to determine if his heart was ready for the next surgery. This was standard protocol before part two in his series of surgeries, the Glenn procedure.

“It never crossed my mind that more bad news was coming because he looked ok. We thought he was doing fine,” Lauren says.

During Noah’s cardiac catheterization, his team noticed that the fistula in his heart had grown significantly in size. Noah’s “lucky fin” (as Lauren refers to his right ventricle) grew, which wasn’t good news for the left, healthy side of his heart. The weaker side of his heart was stealing space, blood and other resources from his stronger side. The discovery prompted the question, “Do we rush him into the Glenn procedure or go straight to a heart transplant?” ― a conversation his parents were not prepared for at the time.

“I didn’t even know what to hope for. Do we hope for the Glenn, or do we hope we find a new heart and a transplant goes well?” Lauren recalls. “His team told us to hope that his heart lasts as long as possible.”

His cardiology and hematology teams at CHOC rushed to help the family coordinate second opinions at other institutions within just a few days. They also helped the family coordinate a transplant evaluation, a three-part process to determine if the patient is medically qualified and the family emotionally prepared to care for a transplant patient.

“With invaluable input from a Southern California pediatric transplant team, and after multiple phone and in-person conferences amongst all his caregivers and his family, it was decided that Noah’s best chance at a positive outcome would be to have his Glenn procedure at CHOC,” recalls Dr. Ellini. “I have never worked at an institution that can so quickly mobilize to make sure that patients obtain the best care possible. It is even more amazing that our team at CHOC has the ability to use its regional resources to optimize the care of our complex patients like Noah.”

The consensus was clear―Noah needed a second surgery, and he needed it to go perfectly, or else he would need a heart transplant.

“That week rushing to get second opinions was a whirlwind,” Lauren recalls. “My husband and I were basically looking for any reason to stay at CHOC for surgery. Not only did we have complete confidence in Dr. Gates, but Noah’s entire care team has always treated him like he was their own child. There were so many people at CHOC totally invested in his care― everyone from cardiology, hematology, blood and donor services, the CVICU, everyone.”

After surgery, which went well, Noah stayed in the CVICU for 10 days before going home.

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With every appointment at CHOC comes a special visit to the Blood & Donor Services Center to thank blood and platelet donors for helping kids like Noah.

“I didn’t realize how hard he was working to just survive until after his second surgery,” Lauren says. “I couldn’t see how hard his heart was working to do anything because he was still happy, growing and meeting developmental milestones. But now I can just tell he feels so much better. He has more energy to play and skills are coming to him more easily now. It’s really amazing to see.”

The reason why Noah required platelet transfusions for the first few months of life remains a mystery. Thankfully, he hasn’t required platelets since his second surgery, when he was almost six months old, and his care team remains hopeful this is something he’ll grow out of.

The reason his platelets continue to be low remains a mystery, but Noah is slowly improving under the close watch of his hematology team, including Dr. Diane Nugent, Dr. David Buchbinder, Dr. Arash Mahajerin, Dr. Amit Soni, Dr. Victor Wang and Dr. Geetha Puthenveetil. Noah has an affinity towards Dr. Puthenveetil, whose last name means ‘Newhouse’ (Noah’s last name) in her home language. His family remains hopeful Noah won’t need any more transfusions, and his directed donors can now donate to help other CHOC patients in need.

Noah’s third open heart surgery, the Fontan procedure, will happen in a couple years.

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At a recent appointment, Noah’s fan club at CHOC welcomed him with a special message on the exam table.

Even though Lauren has been a valued CHOC employee for over four years, she knows the high level of care her son has received isn’t due to special treatment.

“We are treated like family here not because I work here, but because that is how CHOC treats all patients.”

Today, one-year-old Noah is “defying all odds in terms of cardiac babies,” his mom says. He is very curious, always alert, and loves flirting with his favorite nurses.

Learn more about the Heart Institute at CHOC Children's

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CHOC Recognized as Leader in Critical Care

CHOC Children’s has again been recognized by an international consortium for its excellence in extracorporeal life support (ECLS), a special procedure that takes over the heart’s pumping function and the lungs’ oxygen exchange until a patient can recover from injury or illness.

The platinum-level Extracorporeal Life Support Organization (ELSO) Award of Excellence in Life Support recognizes programs worldwide that distinguish themselves by having evidence-based processes, procedures and systems in place that promote excellence in ECLS. As a recipient of a platinum designation, CHOC is among the highest scoring institutions.

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As an award recipient, CHOC has also earned another three-year designationas an ELSO Center of Excellence. CHOC is the only Orange County hospital offering ECLS, also known as extracorporeal membrane oxygenation (ECMO).

“This award validates CHOC’s efforts and commitment to providing exceptional, state-of-the-art critical care to patients and families, and can provide families with added assurance that CHOC is the right place to receive this special type of care,” said Dr. Joanne Starr, CHOC’s ECLS director and medical director of cardiothoracic surgery.

The ELSO Award of Excellence demonstrates an assurance of high-quality standards, collaboration, specialized equipment and supplies, defined patient protocols, and advanced education of all staff members. Additionally, the award is recognized by U.S. News & World Report and Parents magazine as one criterion for top institutions.

ELSO is an international consortium of health care professionals and scientists dedicated to the development and evaluation of novel therapies for support of failing organ systems.

Learn more about CHOC’s extracorporeal life support program

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CHOC Children’s Physicians, Staff Share What They’re Thankful For This Thanksgiving

In celebration of Thanksgiving, members of the CHOC Children’s family express what they’re most grateful for this year.

thanksgiving at chocMary Green 

Registered nurse in the Hyundai Cancer Institute at CHOC Children’s

“I could list 100 reasons why I am thankful for CHOC. I’m thankful to work at a place with such visible growth: in the number of available treatments, in the percentage of children that are surviving cancer, in relationships between patients, family members and staff; and growth visible in children as they begin to believe how strong they truly are. Even more so, I am thankful that CHOC is passionate about celebrating growth and takes pride in celebrating all of the little things.”

thanksgiving at chocDr. Joanne Starr

Medical director, cardiothoracic surgery

“I’m grateful to be part of an innovative pediatric hospital and for CHOC’s commitment to providing patients and families with access to the best neonatal and open-heart surgery in Orange County.”

thanksgiving at chocDana Sperling

Social worker, NICU

“I am thankful for two amazing teams I am privileged to be a part of:  the social services team and the Neonatal Intensive  Care Unit (NICU) team.  The compassion and dedication of both teams makes me proud to work along side them day after day, delivering outstanding care to patients and families.”

 

thanksgiving at chocDr. Kenneth Grant

Chair of gastroenterology 

“I am thankful to be working for an organization that creates an environment where our patients become our family. I am also grateful that CHOC Children’s has the foresight to invest in the innovative ideas we have to improve the health care we provide. ”

thanksgiving at chocDr. David Gibbs

Medical director of trauma services

“I am thankful for the trust of our patients and families. With the strong support of the hospital and the community, our Level 2 Trauma Center is proud to care for children in Orange County.”

thanksgiving at chocJoani Stocker

Volunteer

“I am so thankful for the opportunity to bring smiles and laughter to our patients through Turtle Talk and the playrooms. Laughter is medicine to the bones, and I am humbled to be a part of the healing. My cup is overflowing with joy when I see a patient giggle and play.”

thanksgiving at chocDr. Daniel Mackey

CHOC Children’s pediatrician

“I am thankful for the opportunity to be partnered with an excellent children’s hospital. I am also thankful for the pleasure of working with other positive people who provide outstanding care to the children of Orange County. Together we work to improve the care and services we deliver to our most important resource…our children.”

thanksgiving at chocDr. Gary Goodman

Medical director of the Pediatric Intensive Care Unit, CHOC Children’s at Mission Hospital

I am most grateful to the people behind the scenes at the hospital that do all the invisible jobs that are so important to keep CHOC Children’s running: the housekeepers, lab and x-ray technologists, bio-medical engineers, pharmacy technicians, scrub technicians, security guards and maintenance staff that work tirelessly, 24-hours a day.”

thanksgiving at choc

Dr. Raymond Wang

Metabolic disorders specialist

“I am thankful that CHOC cares for families and children with rare disorders by supporting clinical trials and translational research, and the staff who care for these families, to find treatments and cures for their conditions.”

thanksgiving at chocEric Mammen

Lead music therapist

“I am grateful that I get to witness the transformative powers of music with amazing patients and families everyday here at CHOC. So very grateful for the generous donors that continue to support our growing music therapy program. Without them we would not be able to impact the families and help them face incredible challenges with courage, smiles, and a song. Super grateful to be apart of writing a powerful song with a patient in response to his medical diagnosis- “To Life Live To The Fullest!” Happy Thanksgiving and I hope you get to spend some extra time with your loved ones around you.”

Matt Gerlachwhat choc is thankful for

Executive vice president and chief operating officer

“At this time of Thanksgiving, I am thankful for CHOC Children’s and the wonderful service we are privileged to provide for the communities we serve. I am thankful for the dedication and commitment of our physicians, associates and volunteers, who give the very best they have to give— their knowledge, skills, abilities, care and compassion— to make CHOC’s mission to nurture, advance and protect the health and well-being of children a reality for so many in need, every day. I am also thankful for those that stand behind our physicians, associates and volunteers— their loved ones, who support our CHOC Children’s team to be the best that they can be, both at work and at home. I wish all of our CHOC Children’s family a happy and healthy Thanksgiving.”

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