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Griffeth EM, Stephens EH, Dearani JA, Shreve JT, O'Sullivan D, Egbe AC, Connolly HM, Todd A, Burchill LJ. Impact of heart failure on reoperation in adult congenital heart disease: An innovative machine learning model. J Thorac Cardiovasc Surg 2024; 167:2215-2225.e1. [PMID: 37776991 PMCID: PMC10972775 DOI: 10.1016/j.jtcvs.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/09/2023] [Accepted: 09/20/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVES The study objectives were to evaluate the association between preoperative heart failure and reoperative cardiac surgical outcomes in adult congenital heart disease and to develop a risk model for postoperative morbidity/mortality. METHODS Single-institution retrospective cohort study of adult patients with congenital heart disease undergoing reoperative cardiac surgery between January 1, 2010, and March 30, 2022. Heart failure defined clinically as preoperative diuretic use and either New York Heart Association Class II to IV or systemic ventricular ejection fraction less than 40%. Composite outcome included operative mortality, mechanical circulatory support, dialysis, unplanned noncardiac reoperation, persistent neurologic deficit, and cardiac arrest. Multivariable logistic regression and machine learning analysis using gradient boosting technology were performed. Shapley statistics determined feature influence, or impact, on model output. RESULTS Preoperative heart failure was present in 376 of 1011 patients (37%); those patients had longer postoperative length of stay (6 [5-8] vs 5 [4-7] days, P < .001), increased postoperative mechanical circulatory support (21/376 [6%] vs 16/635 [3%], P = .015), and decreased long-term survival (84% [80%-89%] vs 90% [86%-93%]) at 10 years (P = .002). A 7-feature machine learning risk model for the composite outcome achieved higher area under the curve (0.76) than logistic regression, and ejection fraction was most influential (highest mean |Shapley value|). Additional risk factors for the composite outcome included age, number of prior cardiopulmonary bypass operations, urgent/emergency procedure, and functionally univentricular physiology. CONCLUSIONS Heart failure is common among adult patients with congenital heart disease undergoing cardiac reoperation and associated with longer length of stay, increased postoperative mechanical circulatory support, and decreased long-term survival. Machine learning yields a novel 7-feature risk model for postoperative morbidity/mortality, in which ejection fraction was the most influential.
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Affiliation(s)
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | | - Alexander C Egbe
- Division of Structural Heart Disease, Mayo Clinic, Rochester, Minn
| | - Heidi M Connolly
- Division of Structural Heart Disease, Mayo Clinic, Rochester, Minn
| | - Austin Todd
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - Luke J Burchill
- Division of Structural Heart Disease, Mayo Clinic, Rochester, Minn.
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2
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Akiyama N, Ochiai R, Nitta M, Shimizu S, Kaneko M, Kuraoka A, Nakai M, Sumita Y, Ishizu T. In-Hospital Death and End-of-Life Status Among Patients With Adult Congenital Heart Disease - A Retrospective Study Using the JROAD-DPC Database in Japan. Circ J 2024; 88:631-639. [PMID: 38072440 DOI: 10.1253/circj.cj-23-0537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND The end-of-life (EOL) status, including age at death and treatment details, of patients with adult congenital heart disease (ACHD) remains unclear. This study investigated the EOL status of patients with ACHD using a nationwide Japanese database. METHODS AND RESULTS Data on the last hospitalization of 26,438 patients with ACHD aged ≥15 years, admitted between 2013 and 2017, were included. Disease complexity (simple, moderate, or great) was classified using International Classification of Diseases, 10th Revision codes. Of the 853 deaths, 831 patients with classifiable disease complexity were evaluated for EOL status. The median age at death of patients in the simple, moderate, and great disease complexity groups was 77.0, 66.5, and 39.0 years , respectively. The treatments administered before death to patients in the simple, moderate, and great complexity groups included cardiopulmonary resuscitation (30.1%, 35.7%, and 41.9%, respectively), percutaneous cardiopulmonary support (7.2%, 16.5%, and 16.3%, respectively), and mechanical ventilation (58.7%, 72.2%, and 75.6%, respectively). Overall, 70% of patients died outside of specialized facilities, with >25% dying after ≥31 days of hospitalization. CONCLUSIONS Nationwide data showed that patients with ACHD with greater disease complexity died at a younger age and underwent more invasive treatments before death, with many dying after ≥1 month of hospitalization. Discussing EOL options with patients at the appropriate time is important, particularly for patients with greater disease complexity.
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Affiliation(s)
- Naomi Akiyama
- Department of Nursing, School of Medicine, Yokohama City University
| | - Ryota Ochiai
- Department of Nursing, School of Medicine, Yokohama City University
| | - Manabu Nitta
- Department of Cardiology, Yokohama City University Graduate School of Medicine
- Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital
| | - Sayuri Shimizu
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University
| | - Makoto Kaneko
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University
| | - Ayako Kuraoka
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center
- Clinical Research Support Center, University of Miyazaki Hospital
| | - Yoko Sumita
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center
| | - Tomoko Ishizu
- Department of Cardiology, Institute of Medicine, University of Tsukuba
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Ladouceur M, Bouchardy J. Epidemiology and Definition of Heart Failure in Adult Congenital Heart Disease. Heart Fail Clin 2024; 20:113-127. [PMID: 38462316 DOI: 10.1016/j.hfc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Adults with congenital heart disease (ACHD) are facing lifelong complications, notably heart failure (HF). This review focuses on classifications, incidence, prevalence, and mortality of HF related to ACHD. Diagnosing HF in ACHD is intricate due to anatomic variations, necessitating comprehensive clinical evaluations. Hospitalizations and resource consumption for ACHD HF have significantly risen compared with non-ACHD HF patients. With more than 30% prevalence in complex cases, HF has become the leading cause of death in ACHD. These alarming trends underscore the insufficient understanding of ACHD-related HF manifestations and management challenges within the context of aging, complexity, and comorbidity.
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Affiliation(s)
- Magalie Ladouceur
- Department of Cardiology, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, Geneva 1211, Switzerland; Centre de Recherche Cardiovasculaire de Paris, INSERM U970, 56 rue Leblanc, Paris 75015, France.
| | - Judith Bouchardy
- Department of Cardiology, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, Geneva 1211, Switzerland
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4
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Dehghani P, Srivatsav V, Vardeny O, Grewal J, Opotowsky AR, Muhll IV, Keir M, Ducas R, Singh J, Kim K, Joseph J, Aboulhosn J, Havighurst T, Hegde SM, Bhatt DL, Solomon S, Farkouh M, Goodman SG, Moe TG, Udell JA. Feasibility and Findings of Including Self-Identified Adult Congenital Heart Disease Patients in the INVESTED Trial. JACC. ADVANCES 2024; 3:100897. [PMID: 38939662 PMCID: PMC11198655 DOI: 10.1016/j.jacadv.2024.100897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/12/2023] [Accepted: 09/28/2023] [Indexed: 06/29/2024]
Abstract
Background Adult congenital heart disease (ACHD) patients have significant morbidity and rise in cardiac admissions. Their outcome with high-dose influenza vaccination is unknown in comparison to those without ACHD. Objectives The purpose of this study was to compare all-cause mortality or cardiopulmonary hospitalizations in self-identified ACHD versus non-ACHD patients receiving high- or low-dose influenza vaccination within the INfluenza Vaccine to Effectively Stop cardioThoracic Events and Decompensated heart failure trial. Methods We prospectively included ACHD patients in the INVESTED (INfluenza Vaccine to Effectively Stop cardioThoracic Events and Decompensated heart failure) trial. The primary endpoint was all-cause death or hospitalization for cardiovascular or pulmonary causes. Results Of the 272 ACHD patients, 132 were randomly assigned to receive high-dose trivalent and 140 to standard-dose quadrivalent influenza vaccine. Compared to the non-ACHD cohort (n = 4,988), ACHD patients were more likely to be younger, women, smokers, have atrial fibrillation, and have a qualifying event of heart failure. The primary outcome was 49.8 events versus 42.8 events per 100 person-years (adjusted HR: 1.17; 95% CI: 0.95-1.45; P = 0.144) in the ACHD group and non-ACHD group, respectively. The interaction between ACHD status and randomized treatment effect was not significant for the primary outcome (P = 0.858). Vaccine-related adverse events were similar in both groups. Conclusions Patients who self-identify as being ACHD had similar primary outcome of all-cause death or hospitalization for cardiovascular or pulmonary causes compared to non-ACHD cohort. High-dose influenza vaccination was similar to standard-dose influenza vaccination on the primary outcome in patients who self-identify as ACHD.
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Affiliation(s)
- Payam Dehghani
- Division of Cardiology, Department of Medicine, Prairie Vascular Research Inc, Regina, Saskatchewan, Canada
| | - Varun Srivatsav
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jasmine Grewal
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander R. Opotowsky
- Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Michelle Keir
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Robin Ducas
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jyotpal Singh
- Division of Cardiology, Department of Medicine, Prairie Vascular Research Inc, Regina, Saskatchewan, Canada
| | - KyungMann Kim
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jacob Joseph
- Cardiology Section, VA Providence Healthcare System, Providence, Rhode Island, USA
| | - Jamil Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Center, Ronald Reagan/UCLA Medical Center, Los Angeles, California, USA
| | - Tom Havighurst
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sheila M. Hegde
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Scott Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Farkouh
- Academic Affairs, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Shaun G. Goodman
- Division of Cardiology, St. Michael's Hospital, Unity Health Toronto, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Tabitha G. Moe
- Arizona Cardiology Group, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - Jacob A. Udell
- Faculty of Medicine, Division of Cardiology, Department of Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
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Agasthi P, Van Houten HK, Yao X, Jain CC, Egbe A, Warnes CA, Miranda WR, Dunlay SM, Stephens EH, Johnson JN, Connolly HM, Burchill LJ. Mortality and Morbidity of Heart Failure Hospitalization in Adult Patients With Congenital Heart Disease. J Am Heart Assoc 2023; 12:e030649. [PMID: 38018491 PMCID: PMC10727341 DOI: 10.1161/jaha.123.030649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Little is known about outcomes following heart failure (HF) hospitalization among adults with congenital heart disease (CHD) in the United States. We aim to compare the outcomes of HF versus non-HF hospitalizations in adults with CHD. METHODS AND RESULTS Using a national deidentified administrative claims data set, patients with adult congenital heart disease (ACHD) hospitalized with and without HF (ACHDHF+, ACHDHF-) were characterized to determine the predictors of 90-day and 1-year mortality and quantify the risk of mortality, major adverse cardiac and cerebrovascular events, and health resource use. Cox proportional hazard regression was used to compare ACHDHF+ versus ACHDHF- for risk of events and health resource use. Of 26 454 unique ACHD admissions between January 1, 2010 and December 31, 2020, 5826 (22%) were ACHDHF+ and 20 628 (78%) were ACHDHF-. The ACHD HF+ hospitalizations increased from 6.6% to 14.0% (P<0.0001). Over a mean follow-up period of 2.23 ± 2.19 years, patients with ACHDHF+ had a higher risk of mortality (hazard ratio [HR], 1.86 [95% CI, 1.67-2.07], P<0.001), major adverse cardiac and cerebrovascular events (HR, 1.73 [95% CI, 1.63-1.83], P<0.001) and health resource use including rehospitalization (HR, 1.09 [95% CI, 1.05-1.14], P<0.001) and increased postacute care service use (HR, 1.56 [95% CI, 1.32-1.85], P<0.001). Cardiology clinic visits within 30 days of hospital admission were associated with lower 90-day and 1-year all-cause mortality (odds ratio [OR], 0.62 [95% CI, 0.49-0.78], P<0.001; OR, 0.69 [95% CI, 0.58-0.83], P<0.001, respectively). CONCLUSIONS HF hospitalization is associated with increased risk of mortality and morbidity with high health resource use in patients with ACHD. Recent cardiology clinic attendance appears to mitigate these risks.
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Affiliation(s)
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
- OptumLabsMinnetonkaMNUSA
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
- OptumLabsMinnetonkaMNUSA
| | - C. Charles Jain
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | - Alexander Egbe
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | - Carole A. Warnes
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
| | | | - Shannon M. Dunlay
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo ClinicRochesterMNUSA
| | | | - Jonathan N. Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children’s CenterRochesterMNUSA
| | | | - Luke J. Burchill
- Department of Cardiovascular Medicine, Mayo ClinicRochesterMNUSA
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6
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Iyengar A, Weingarten N, Herbst DA, Helmers MR, Kelly JJ, Meldrum D, Dominic J, Guevara-Plunkett S, Atluri P. Waitlist Trends in Heart-Liver Transplantation With Updated US Heart Allocation System. Ann Thorac Surg 2023; 116:1270-1275. [PMID: 35987345 DOI: 10.1016/j.athoracsur.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/10/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In October 2018, the United States implemented a change in the donor heart allocation policy from a three-tiered to a six-tiered status system. The purpose of the current study was to examine changes in waitlist patterns among patients listed for concomitant heart-liver transplantation with implementation of the new allocation system. METHODS Patients listed for heart-liver transplantation between January 1, 2012, and June 30, 2021, were identified from the United Network for Organ Sharing database. Patients were grouped by era according to initial list date before or after October 18, 2018. Competing risks regression for mortality, transplantation, removal from waitlist due to illness was performed according to the method of Fine and Gray. Waitlist data were censored at 3 years from initial listing. RESULTS Overall, 523 patients were identified, of whom 310 were listed before (era 1, 59%) and 213 after (era 2, 41%) allocation change. Patients in era 1 were older, had more restrictive cardiomyopathy, and more preoperative inotrope use (all P < .05). However, patients in era 2 has longer ischemic times (3.5 ± 1.1 vs 3.1 ± 1.1 hours, P < .01) and more intraaortic balloon pump use (8.9% vs 3.9%, P = .016). Era 2 was associated with lower subdistribution hazard for death (hazard ratio 0.37; 95% CI, 0.13-1.02; P = .054) and increased transplantation (hazard ratio 1.35; 95% CI, 1.06-1.72; P = .015). CONCLUSIONS The implementation of the US donor heart allocation policy was associated with more preoperative intraaortic balloon pump use for patients listed for heart-liver transplantation. Despite that, the modern era was associated with lower waitlist mortality and more frequent transplantation, without increased risk of delisting due to illness.
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Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Herbst
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Danika Meldrum
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica Dominic
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara Guevara-Plunkett
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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7
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Krishnathasan K, Dimopoulos K, Duncan N, Ricci P, Kempny A, Rafiq I, Gatzoulis MA, Heng EL, Blakey S, Montanaro C, Babu-Narayan SV, Francis DP, Li W, Constantine A. Advanced heart failure in adult congenital heart disease: the role of renal dysfunction in management and outcomes. Eur J Prev Cardiol 2023; 30:1335-1342. [PMID: 36974357 DOI: 10.1093/eurjpc/zwad094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/13/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
AIMS Previous studies in adult congenital heart disease (CHD) have demonstrated a link between renal dysfunction and mortality. However, the prognostic significance of renal dysfunction in CHD and decompensated heart failure (HF) remains unclear. We sought to assess the association between renal dysfunction and outcomes in adults with CHD presenting to our centre with acute HF between 2010 and 2021. METHODS AND RESULTS This retrospective analysis focused on the association between renal dysfunction, pre-existing and on admission, and outcomes during and after the index hospitalization. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2. Cox regression analysis was used to identify the predictors of death post-discharge. In total, 176 HF admissions were included (mean age 47.7 ± 14.5 years, 43.2% females). One-half of patients had a CHD of great complexity, 22.2% had a systemic right ventricle, and 18.8% had Eisenmenger syndrome. Chronic kidney disease was present in one-quarter of patients. The median length of intravenous diuretic therapy was 7 (4-12) days, with a maximum dose of 120 (80-160) mg furosemide equivalents/day, and 15.3% required inotropic support. The in-hospital mortality rate was 4.5%. The 1- and 5-year survival rates free of transplant or ventricular assist device (VAD) post-discharge were 75.4% [95% confidence interval (CI): 69.2-82.3%] and 43.3% (95% CI: 36-52%), respectively. On multivariable Cox analysis, CKD was the strongest predictor of mortality or transplantation/VAD. Highly complex CHD and inpatient requirement of inotropes also remained predictive of an adverse outcome. CONCLUSION Adult patients with CHD admitted with acute HF are a high-risk cohort. CKD is common and triples the risk of death/transplantation/VAD. An expert multidisciplinary approach is essential for optimizing outcomes.
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Affiliation(s)
- Kaushiga Krishnathasan
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Neill Duncan
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Piera Ricci
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
| | - Alexander Kempny
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Isma Rafiq
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ee Ling Heng
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Sarah Blakey
- Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Claudia Montanaro
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Sonya V Babu-Narayan
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London, UK
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, Imperial College London, London, UK
| | - Wei Li
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Andrew Constantine
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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Dhingra NK, Mazer CD, Connelly KA, Verma S. Chronic heart failure management in adult patients with congenital heart disease. Curr Opin Cardiol 2023; 38:82-87. [PMID: 36656602 DOI: 10.1097/hco.0000000000001011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW A growing number of adult patients with congenital heart disease (ACHD) are entering the healthcare system as a result of advances in the diagnosis and management of congenital heart defects. Heart failure is a common final pathway for this diverse patient population, representing the leading cause of mortality in ACHD patients. Herein, we review present guideline-directed management of heart failure in ACHD patients. RECENT FINDINGS There exists a dearth of data to guide management of ACHD-related heart failure. Given this gap, recent guidelines have been limited in the recommendations they can provide for this patient population, with practitioners being consequently forced to generalize findings from studies of acquired heart disease patients based on mechanistic plausibility. The small number of studies directly assessing ACHD patients have been largely limited in their clinical relevance through being negative, small, observational, limited to specific subsets of ACHD patients or assessing nonvalidated outcomes. SUMMARY Despite the prevalence and impact of ACHD-related heart failure, there are limited evidence-based therapies for its management. Given the rising burden of this clinical problem, definitive trials assessing newer therapies are required to establish their potential role in heart failure amongst ACHD patients.
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Affiliation(s)
| | - C David Mazer
- Department of Anesthesia
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kim A Connelly
- Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Massarella D, Alonso-Gonzalez R. Updates in the management of congenital heart disease in adult patients. Expert Rev Cardiovasc Ther 2022; 20:719-732. [PMID: 36128784 DOI: 10.1080/14779072.2022.2125870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Adults with congenital heart disease represent a highly diverse, ever-growing population. Optimal approaches to management of problems such as arrhythmia, sudden cardiac death, heart failure, transplant, application of advanced therapies and unrepaired shunt lesions are incompletely established. Efforts to strengthen our understanding of these complex clinical challenges and inform evidence-based practices are ongoing. AREAS COVERED This narrative review summarizes evidence underpinning current approaches to congenital heart disease management while highlighting areas requiring further investigation. A search of literature published in 'Medline,' 'EMBASE,' and 'PubMed' using search terms 'congenital heart disease,' 'arrhythmia,' 'sudden cardiac death,' 'heart failure,' 'heart transplant,' 'advanced heart failure therapy,' 'ventricular assist device (VAD),' 'mechanical circulatory support (MSC),' 'intracardiac shunt' and combinations thereof was undertaken. EXPERT OPINION Application of novel technologies in the diagnosis and management of arrhythmia has and will continue to improve outcomes in this population. Sudden death remains a prevalent problem with many persistent unknowns. Heart failure is a leading cause of morbidity and mortality. Improved access to specialist care, advanced therapies and cardiac transplant is needed. The emerging field of cardio-obstetrics will continue to define state-of-the-art care for the reproductive health of women with heart disease.
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Affiliation(s)
- Danielle Massarella
- Department of Cardiology, University Health Network, Peter Munk Cardiac Centre, Toronto ACHD program, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- Department of Cardiology, University Health Network, Peter Munk Cardiac Centre, Toronto ACHD program, Toronto, Ontario, Canada
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Kartas A, Papazoglou AS, Kosmidis D, Moysidis DV, Baroutidou A, Doundoulakis I, Despotopoulos S, Vrana E, Koutsakis A, Rampidis GP, Ntiloudi D, Liori S, Mousiama T, Avramidis D, Apostolopoulou S, Frogoudaki A, Tzifa A, Karvounis H, Giannakoulas G. The Adult Congenital Heart Disease Anatomic and Physiological Classification: Associations with Clinical Outcomes in Patients with Atrial Arrhythmias. Diagnostics (Basel) 2022; 12:diagnostics12020466. [PMID: 35204557 PMCID: PMC8870966 DOI: 10.3390/diagnostics12020466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022] Open
Abstract
The implications of the adult congenital heart disease anatomic and physiological classification (AP-ACHD) for risk assessment have not been adequately studied. A retrospective cohort study was conducted using data from an ongoing national, multicentre registry of patients with ACHD and atrial arrhythmias (AA) receiving apixaban (PROTECT-AR study, NCT03854149). At enrollment, patients were stratified according to Anatomic class (AnatC, range I to III) and physiological stage (PhyS, range B to D). A follow-up was conducted between May 2019 and September 2021. The primary outcome was a composite of death from any cause, any major thromboembolic event, major or clinically relevant non-major bleeding, or hospitalization. Cox proportional-hazards regression modeling was used to evaluate the risks for the outcome among AP-ACHD classes. Over a median 20-month follow-up period, 47 of 157 (29.9%) ACHD patients with AA experienced the composite outcome. Adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for the outcome in PhyS C and PhyS D were 1.79 (95% CI 0.69 to 4.67) and 8.15 (95% CI 1.52 to 43.59), respectively, as compared with PhyS B. The corresponding aHRs in AnatC II and AnatC III were 1.12 (95% CI 0.37 to 3.41) and 1.06 (95% CI 0.24 to 4.63), respectively, as compared with AnatC I. In conclusion, the PhyS component of the AP-ACHD classification was an independent predictor of net adverse clinical events among ACHD patients with AA.
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Affiliation(s)
- Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Andreas S Papazoglou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Diamantis Kosmidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Amalia Baroutidou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Ioannis Doundoulakis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Stefanos Despotopoulos
- Department of Pediatric and Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Elena Vrana
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Athanasios Koutsakis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Georgios P Rampidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Despoina Ntiloudi
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Sotiria Liori
- Second Department of Cardiology, Attikon University Hospital, 12462 Athens, Greece
| | - Tereza Mousiama
- Department of Congenital Heart Disease, Mitera Childrens' Hospital, 15123 Athens, Greece
| | - Dimosthenis Avramidis
- Department of Congenital Heart Disease, Mitera Childrens' Hospital, 15123 Athens, Greece
| | - Sotiria Apostolopoulou
- Department of Pediatric and Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Alexandra Frogoudaki
- Second Department of Cardiology, Attikon University Hospital, 12462 Athens, Greece
| | - Afrodite Tzifa
- Department of Congenital Heart Disease, Mitera Childrens' Hospital, 15123 Athens, Greece
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
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Austin PC, Fang J, Lee DS. Using fractional polynomials and restricted cubic splines to model non-proportional hazards or time-varying covariate effects in the Cox regression model. Stat Med 2021; 41:612-624. [PMID: 34806210 PMCID: PMC9299077 DOI: 10.1002/sim.9259] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 10/15/2021] [Accepted: 10/29/2021] [Indexed: 12/19/2022]
Abstract
The Cox proportional hazards model is used extensively in clinical and epidemiological research. A key assumption of this model is that of proportional hazards. A variable satisfies the proportional hazards assumption if the effect of that variable on the hazard function is constant over time. When the proportional hazards assumption is violated for a given variable, a common approach is to modify the model so that the regression coefficient associated with the given variable is assumed to be a linear function of time (or of log‐time), rather than being constant or fixed. However, this is an unnecessarily restrictive assumption. We describe two different methods to allow a regression coefficient, and thus the hazard ratio, in a Cox model to vary as a flexible function of time. These methods use either fractional polynomials or restricted cubic splines to model the log‐hazard ratio as a function of time. We illustrate the utility of these methods using data on 12 705 patients who presented to a hospital emergency department with a primary diagnosis of heart failure. We used a Cox model to assess the association between elevated cardiac troponin at presentation and the hazard of death after adjustment for an extensive set of covariates. SAS code for implementing the restricted cubic spline approach is provided, while an existing Stata function allows for the use of fractional polynomials.
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Affiliation(s)
- Peter C Austin
- ICES, Toronto, Ontario, Canada.,Institute of Health Management, Policy and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Douglas S Lee
- ICES, Toronto, Ontario, Canada.,Institute of Health Management, Policy and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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12
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Tsang W, Silversides CK, Rashid M, Roche SL, Alonso-Gonzalez R, Austin PC, Lee DS. Outcomes and healthcare resource utilization in adult congenital heart disease patients with heart failure. ESC Heart Fail 2021; 8:4139-4151. [PMID: 34402222 PMCID: PMC8497229 DOI: 10.1002/ehf2.13529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/11/2021] [Accepted: 07/05/2021] [Indexed: 12/14/2022] Open
Abstract
AIMS While heart failure (HF) is a leading cause of death in adults with congenital heart disease (ACHD), few studies report contemporary outcomes after the first HF hospitalization. We examined outcomes of ACHD patients newly admitted for HF compared with ACHD patients without HF and the general HF population without ACHD. METHODS AND RESULTS Using population databases from a single-payer health system from 1994 to 2018, ACHD patients newly admitted for HF were matched 1:1 to ACHD patients without HF (n = 4030 matched pairs). Similarly, ACHD patients newly admitted for HF were matched 1:1 to HF patients without ACHD (n = 4336 matched pairs). Patients with ACHD and HF (median age 68 years, 45% women) experienced higher mortality in short-term [30 day adjusted hazard ratio (HR) 4.68, 95% confidence interval (CI) 4.06, 5.43, P < 0.001], near-term (1 year HR 3.87, 95% CI 3.77, 4.92, P < 0.001), and long-term (24 year HR 1.59, 95% CI 1.13, 2.36, P = 0.008) follow-up. Patients with ACHD and HF had fewer baseline cardiovascular comorbidities than non-ACHD HF but demonstrated higher 30 day (HR 1.56, 95% CI 1.41, 1.73, P < 0.001), 1 year (HR 1.30, 95% CI 1.20, 1.40, P < 0.001), and 24 year (HR 2.40, 95% CI 1.73, 3.38, P < 0.001) mortality. Those with ACHD and HF also exhibited higher cardiovascular readmission rates at 30 days with HRs 9.15 (95% CI; 8.00, 10.48, P < 0.001) vs. ACHD without HF, and 1.71 (95% CI; 1.54, 1.85, P < 0.001) vs. HF without ACHD, and the higher readmission risk extended to 10 year follow-up. CONCLUSIONS Adults with congenital heart disease patients with new HF have high risks of death and cardiovascular hospitalization, and preventative strategies to improve outcomes are urgently needed.
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Affiliation(s)
- Wendy Tsang
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada.,Toronto Adult Congenital Heart Disease Program, Toronto, Ontario, Canada
| | - Mohammed Rashid
- ICES (formerly the Institute for Clinical Evaluative Sciences), 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - S Lucy Roche
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada.,Toronto Adult Congenital Heart Disease Program, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada.,Toronto Adult Congenital Heart Disease Program, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES (formerly the Institute for Clinical Evaluative Sciences), 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Douglas S Lee
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.,Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
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