Heart Transplantation and Mechanical Circulatory Support in Adults with Congenital Heart Disease

Mortality and morbidity after combined heart and liver transplantation in the failing Fontan: An updated dual center retrospective study

INTRODUCTION

As the adult Fontan population with Fontan associated liver disease continues to increase, more patients are being referred for transplantation, including combined heart and liver transplantation.

METHODS

We report updated mortality and morbidity outcomes after combined heart and liver transplant in a retrospective cohort series of 40 patients (age 14 to 49 years) with Fontan circulation across two centers from 2006-2022.

RESULTS

The 30-day, 1-year, 5-year and 10-year survival rate was 90%, 80%, 73% and 73% respectively. Sixty percent of patients met a composite comorbidity of needing either post-transplant mechanical circulatory support, renal replacement therapy or tracheostomy. Cardiopulmonary bypass time > 283 min (4.7 h) and meeting the composite comorbidity were associated with mortality by Kaplan Meier analysis.

CONCLUSION

Further study to mitigate early mortality and the above comorbidities as well as the high risk of bleeding and vasoplegia in this patient population is warranted.

Updates in the management of congenital heart disease in adult patients

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.

Observations and Single-Center Outcomes in Orthotopic Heart Transplant for Patients With Adult Congenital Heart Disease: A Call for Equity and Parity

BACKGROUND

For persons with adult congenital heart disease (ACHD), optimum patient selection and eligibility for orthotopic heart transplant (OHT) is not well defined. There is difficulty quantifying risk in patients with ACHD, leading to variability in OHT listing time and status. They are often disadvantaged due to a lack of mechanical support options, a shortage of congenital surgeons, and encounters with risk adverse health care programs. We examined patient characteristics and outcomes of a contemporary cohort of patients with ACHD undergoing OHT at a single high-volume Adult Congenital Heart Association accredited transplant center.

METHODS

Retrospective analysis of 49 consecutive patients with ACHD who underwent OHT from November 2010 through March 2020 was performed. Survival analysis was performed using Kaplan-Meier analysis.

RESULTS

Survival at 1 month, 1 year, 3 years, and 10 years was 94%, 92%, 92%, and 83%, respectively.

CONCLUSIONS

This study highlights the diversity and complexity of the population with ACHD proceeding to OHT as well as the multispecialty care needed to overcome disadvantages and optimize survival. Continued national discussions and policy adjustments will be necessary to bring parity and equity to this unique population.

Durable Mechanical Circulatory Support in Adult Congenital Heart Disease: Reviewing Clinical Considerations and Experience

Adults with congenital heart disease (ACHD) patients are one of the fastest growing populations in cardiology, and heart failure (HF) is the most common cause of morbidity and mortality amongst them. The need for advanced HF therapies in ACHD patients stands to grow substantially. The anatomic considerations for placing durable mechanical circulatory support (MCS) devices in ACHD patients often require specialized approaches. Despite this, increasing evidence suggests that durable MCS can be implanted safely with favorable outcomes in ACHD patients. Expansion of MCS use in ACHD patients is imperative to improve their clinical outcomes. Knowledge of ACHD-specific anatomic and physiologic considerations is crucial to HF programs’ success as they work to provide care to this growing population.

Considerations in Critical Care and Anesthetic Management of Adult Patients Living with Fontan Circulation

The Fontan procedure is a staged palliation for various complex congenital cardiac lesions, including tricuspid atresia (TA), pulmonary atresia (PA), hypoplastic left heart syndrome (HLHS), and double inlet left ventricle (DILV), all of which involve a functional single-ventricle physiology. The complexity of the patients' original anatomy combined with the anatomical and physiological consequences of the Fontan circulation creates challenges. Teens and adults living with Fontan palliation will need perioperative support for non-cardiac surgery, peripartum management for labor and delivery, interventions related to their structural heart disease, electrophysiology procedures, pacemakers, cardioversions, cardiac surgery, transplant, and advanced mechanical support. This review focuses on the anesthetic and ICU management of these patients during their perioperative journey, with an emphasis on the continuity of pre-intervention planning, referral pathways, and post-intervention intensive care unit (ICU) management. Requests for recipes and doses of medications are frequent; however, as in normal anesthesia and ICU practice, the method of anesthesia and dosing are dependent on the presenting medical/surgical conditions and the underlying anatomy and physiological reserve. A patient with Fontan palliation in their early 20s attending school full-time with a cavopulmonary connection is likely to have more reserve than a patient in their late 40s with an atrio- pulmonary (AP) Fontan at home waiting for a heart transplant. Each case will require an anesthetic and critical care plan tailored to their situation. The critical care environment is a natural extension of the anesthetic management of a patient, with complex considerations for a patient with Fontan palliation.

Failures of the Fontan System in Univentricular Hearts and Mortality Risk in Heart Transplantation: A Systematic Review and Meta-Analysis

The Fontan procedure (FP) is the standard surgical treatment for Univentricular heart diseases. Over time, the Fontan system fails, leading to pathologies such as protein-losing enteropathy (PLE), plastic bronchitis (PB), and heart failure (HF). FP should be considered as a transitional step to the final treatment: heart transplantation (HT). This systematic review and meta-analysis aims to establish the risk of death following HT according to the presence of FP complications. There was a total of 691 transplanted patients in the 18 articles, immediate survival 88% (n = 448), survival from 1 to 5 years of 78% (n = 427) and survival from 5.1 to 10 years of 69% (n = 208), >10 years 61% (n = 109). The relative risk (RR) was 1.12 for PLE (95% confidence interval [CI] = 0.89-1.40, p = 0.34), 1.03 for HF (0.7-1.51, p = 0.88), 0.70 for Arrhythmias (0.39-1.24, p = 0.22), 0.46 for PB (0.08-2.72, p = 0.39), and 5.81 for CKD (1.70-19.88, p = 0.005). In patients with two or more failures, the RR was 1.94 (0.99-3.81, p = 0.05). After FP, the risk of death after HT is associated with CKD and with the presence of two or more failures.

Intensive Care Unit Management of the Adult with Congenital Heart Disease

PURPOSE

Adults with congenital heart disease (ACHD) are a rapidly growing population with ever-increasing complexity, and intensive care unit (ICU) management is often necessary. This review summarizes common cardiovascular and non-cardiovascular complications in ACHD and provides a framework for ICU care.

RECENT FINDINGS

Heart failure is the leading cause of hospitalization and mortality in ACHD. Varied anatomy and repairs, as well as differing physiological complications, limit generalized application of management algorithms. Recent studies suggest that earlier mechanical support in advanced cases is feasible and potentially helpful. Cardiac arrhythmias are poorly tolerated and often require immediate attention. Other complications requiring intensive care include infections such as endocarditis and COVID-19, pulmonary hypertension, renal failure, hepatic dysfunction, coagulopathy, and stroke. Successful ICU care in ACHD requires a multi-disciplinary approach with careful consideration of anatomy, physiology, and associated comorbidities. Few studies have formally examined ICU management in ACHD and further research is necessary.

Surgical outcomes in complex adult congenital heart disease: a brief review

Life expectancy of patients with congenital heart disease (CHD) continues to increase dramatically over the last few decades, primarily due to significant medical and surgical advancements in the field. Adult congenital heart disease (ACHD) patients are now living longer but continue to face morbidity and reduced long-term survival when compared to the general population. We briefly describe the growth of ACHD with a focus on surgical procedures and outcomes in the more complex lesions including Tetralogy of Fallot, Ebsteins Anomaly of the tricuspid valve, Coarctation of the Aorta, Transposition of the Great Arteries and single ventricle lesions. The advancing role of mechanical circulatory support and cardiac transplantation in ACHD patients is also highlighted. Cardiac surgery in these patients continues to improve with low surgical mortality rate and outstanding long-term outcomes and efficacy.

Ventricular assist device implantation in patients with a failing systemic right ventricle: a call to expand current practice

Ventricular assist device (VAD) implantation is an established treatment modality for patients with end-stage heart failure, and improves symptoms and survival. In the Netherlands, it is not yet routinely considered in patients with congenital heart disease and failing systemic right ventricle (SRV). Recently, a VAD was implanted in 2 SRV patients, one who underwent a Mustard procedure during infancy for transposition of the great arteries (male, 47 years old) and one with a congenitally corrected transposition of the great arteries (male, 54 years old). The first patient is doing well >1 year after implantation; the second patient will be discharged home soon. These examples and other reports demonstrate the feasibility of adopting VAD implantation into routine care for SRV failure. In conclusion, patients with SRV failure may be suitable candidates for VAD implantation: they are relatively young, usually have a preserved subpulmonary left ventricular function, and their specific anatomical and physiological characteristics often make them unsuitable for cardiac transplantation. Therefore it is important to recognise the possibility of VAD implantation early in the process of SRV failure, and to timely refer these patients to a heart failure clinic with experience in VAD implantation in this group of patients for optimisation, screening, and implantation.