most health care settings, with very impressive returns on investments in terms of improving outcomes and lowering costs of care.63 Multidrug Resistance The emergence of multidrug resistant bacterial pathogens poses perhaps the most serious challenge to management of sick infants and newborns with heart disease in LMIC environments Widespread indiscriminate use of broad-spectrum antibiotics in the community and in hospitals has undoubtedly contributed to this unfortunate predicament.64 Antibiotic stewardship initiatives have a role in mitigating the problem in pediatric heart programs They have been shown to substantially reduce the cost of care Other Infections A number of other infections occur in the community in the LMIC setting (see Table 88.4) They have the potential to significantly complicate the management of CHD, and this is particularly true for open heart surgery Delivering Pediatric Heart Care in ResourceLimited Environments It is abundantly clear that the overwhelming majority of the world's children live in parts of the world with substantial limitations in resources and systems to deliver basic pediatric heart care Yet much of the contemporary scientific literature focuses on niche areas and very specific issues that affect the relatively small patient populations in advanced nations.20 Although these issues are of some interest to everyone, the available science does not enable us to satisfactorily address a very fundamental issue: How can we deliver comprehensive quality care for the average child with heart disease living in a resource-constrained environment? In the past 2 decades a number of new pediatric heart programs have been established in LMICs All these programs have to contend with the challenge of delivering pediatric heart care in the face of significant limitations in human and material resources This section will describe the general principles that govern this process General Principles To overcome these challenges it is necessary that all members of the team embrace the philosophy of working to reach out to the largest possible number of affected children with the available resources.20 A list of attributes that is particularly useful toward this end is listed next Pediatric cardiac professionals (cardiologists, cardiac surgeons, intensivists, anesthesiologists, and nurses) who work in resource-constrained environments will need to acquire these attributes in addition to their core clinical skills in order to be effective A deep-rooted desire to reach out to and serve the needs of the average child in the region There is perhaps an even greater need to understand the socioeconomic and cultural background of families, as well as logistic challenges that the families face This enables development of thoughtful and contextually appropriate management strategies recognizing the challenges that individual families face Willingness to multitask The luxury of having specialists with specific domains of expertise in various elements that constitute comprehensive pediatric cardiac care (see Fig 88.4) is not economically viable in resource-constrained environments A wide range of skills may have to be acquired to effectively function in varied situations For example, it may be necessary for the same pediatric cardiologist to do imaging work, perform catheter interventions, assist in intensive care, and interpret common arrhythmias at the bedside Some of these skills are quite complementary and often help to improve overall efficiency Willingness to improvise and innovate A number of innovations in various facets of pediatric heart care from resource-poor environments have enabled cost reductions without compromise in quality Some of these innovations can also be used in advanced nations to help reduce health care costs Table 88.5 lists examples of low-cost innovations in catheter interventions that can be use in low-resource settings without significant compromise in quality Table 88.5 Innovations and Adaptations to Reduce Costs of Pediatric Cardiac Catheterization Source of Expense Expense of Biplane catheterization Low-Cost Solution A single plane cath lab allows safe and effective diagnostic and interventional catheterization in more than 95% of situations Sharing the laboratory Expense of hybrid catheterization laboratory Long procedure times of pediatric catheterization Catheter hardware: Requirement of a large inventory of dedicated hardware for pediatric heart catheterization Cost of occlusive devices General anesthesia cath lab with an adult facility allows substantial reductions in equipment overhead per procedure Liberal use of echocardiography to supplement imaging for catheter intervention helps in overcoming limitations of biplane imaging Given the tiny proportion of cases that truly need hybrid catheterization laboratory it is difficult to justify the overhead expense for cases that do not need them Careful preoperative imaging and planning allows hybrid stenting of branch pulmonary arteries can be performed in the operation room under direct vision without fluoroscopic guidance Meticulous echocardiography before the procedure by the same person doing the catheterization allows focused or targeted procedures that considerably reduce procedure time Improvisations in using adult hardware for pediatric catheterization For example, a number of coronary angioplasty hardware items are actually well suited for newborn interventions such as stenting of the duct and the right ventricular outflow tract Resterilization and reuse of catheters can be safely undertaken in carefully monitored settings Gianturco coils can be used as low-cost alternatives for occlusive devices in selected situations The bioptome-assisted techniques enables simultaneous delivery of multiple coils.78 This can be used for large vessels and selected patent arterial ducts Using carefully implemented sedation protocols and comfortable patient restraints, the majority of catheter interventions can be undertaken with conscious sedation without the need for general endotracheal anesthesia This saves time and resources Develop pragmatic case selection strategies It is an ethical challenge to deny care to an individual patient with a complex condition to preserve the larger interests of a fragile system Examples include prioritizing patients with straightforward lesions correctable through a single operation over complex multistaged procedures such as palliation for the hypoplastic left heart syndrome.65 Willingness to tailor solutions according to the socioeconomic condition of the families Deviations from “standard” practice are common in the face of economic constraints particularly when families have to pay out of pocket For example, the inability to afford a conduit may necessitate palliation with a cavopulmonary shunt in an infant or a young child with transposition, VSD, and pulmonary stenosis Reluctance to accept expensive new technology without proof of incremental benefits Although it is true that technologic advances have contributed substantially toward improving the outcomes of children with heart disease, it is also true that very expensive new technology has often found its way into mainstream practice without any form of audit on cost versus incremental benefit Examples of such high-end ... catheterization laboratory Long procedure times of pediatric catheterization Catheter hardware: Requirement of a large inventory of dedicated hardware for pediatric heart catheterization Cost of occlusive... The luxury of having specialists with specific domains of expertise in various elements that constitute comprehensive pediatric cardiac care (see Fig 88.4) is not economically viable in resource-constrained environments... be acquired to effectively function in varied situations For example, it may be necessary for the same pediatric cardiologist to do imaging work, perform catheter interventions, assist in intensive care, and