The prevalence of adult congenital heart disease, results from a systematic review and evidence based calculation

Caring for the Critically Ill Adult Congenital Heart Disease Patient

PURPOSE OF REVIEW

This review aims to discuss the unique challenges that adult congenital heart disease (ACHD) patients present in the intensive care unit.

RECENT FINDINGS

Recent studies suggest that ACHD patients make up an increasing number of ICU admissions, and that their care greatly improves in centers with specialized ACHD care. Common reasons for admission include arrhythmia, hemorrhage, heart failure, and pulmonary disease. It is critical that the modern intensivist understand not only the congenital anatomy and subsequent repairs an ACHD patient has undergone, but also how that anatomy can predispose the patient to critical illness. Additionally, intensivists should rely on a multidisciplinary team, which includes an ACHD specialist, in the care of these patients.

Incidence of diabetes mellitus and effect on mortality in adults with congenital heart disease

BACKGROUND

Worldwide, 1-2% of children are born with congenital heart disease (CHD) with 97% reaching adulthood.

OBJECTIVES

This study aims to demonstrate the risk of diabetes in patients with CHD, and the influence of incident diabetes on mortality in CHD patients and controls.

METHODS

By combining data from patient registries, the incidence of adult-onset diabetes registered at age 35 or older, and subsequent mortality risk were analysed in two successive birth cohorts (born in 1930-1959 and 1960-1983), by type of CHD lesion and sex, compared with population-based controls matched for sex and year of birth and followed until a maximum of 87 years of age.

RESULTS

Out of 24,699 patients with CHD and 270,961 controls, 8.4% and 5.6%, respectively, were registered with a diagnosis of diabetes at the age of 35 or older, hazard ratio (HR) 1.47 (95% CI 1.40-1.54). The risk of diabetes was higher in the second birth cohort (HR of 1.74, 95% CI 1.54-1.95) and increased with complexity of CHD. After onset of DM, the total mortality among patients with CHD was 475 compared to 411/ 10,000 person-years among controls (HR 1.16, 95% CI 1.07-1.25).

CONCLUSIONS

In this nationwide cohort of patients with CHD and controls, the incidence of diabetes was almost 50% higher in patients with CHD, with higher risk in the most recent birth cohort and in those with conotruncal defects, with the combination of CHD and diabetes associated with a significantly increased mortality compared to diabetic controls.

Obstetrical and neonatal outcomes in patients with surgically repaired heart disease

BACKGROUND

Congenital and acquired heart disease complicate 1% to 4% of pregnancies in the United States. Beyond the risks of the underlying maternal congenital heart disease, cardiac surgery and its sequelae, such as surgical scarring resulting in higher rates of arrhythmias and implanted valves altering anticoagulation status, have potential implications that could affect gestation and delivery.

OBJECTIVE

This study aimed to investigate whether history of maternal cardiac surgery is associated with adverse obstetrical or neonatal outcomes compared with patients without a history of cardiac disease or surgery, considered "healthy controls."

STUDY DESIGN

This is a secondary analysis of retrospective cohort studies performed at a tertiary care facility in the United States comparing obstetrical outcomes in patients with a history of open cardiac surgery who delivered from January 2007 to December 2018 with healthy controls, who delivered from April 2020 to July 2020. There were 74 pregnancies in 61 patients with a history of open cardiac surgery that were compared with pregnancies in healthy controls. Of the 74 pregnancies, 65 were successfully matched based on gestational age to controls at a 1:3 (case-to-control) ratio. The remainder of cases were matched at a 1:2 or 1:1 ratio; therefore, a total of 219 control pregnancies were included in the analysis. Our primary outcome was the incidence of hypertensive disorders of pregnancy, as well as cesarean delivery, in patients with a history of open cardiac surgery compared with healthy controls. Our secondary outcome was the incidence of low-birthweight neonates in patients with a history of open cardiac surgery compared with healthy controls.

RESULTS

Patients with a history of cardiac surgery were not more likely to have any hypertensive disorder diagnosed than healthy controls. Patients with a history of cardiac surgery were more likely to have an operative delivery (P<.0001) but equally likely to have a cesarean delivery (P=.528) compared with healthy controls. Birthweight was not statistically different of 2655±808 g in neonates born to patients with a history of cardiac surgery vs 2844±830 g born to healthy controls (P=.092).

CONCLUSION

Patients with a history of cardiac surgery may not be at higher risk of hypertensive disorder diagnosis during pregnancy. Similarly, most patients with a history of cardiac surgery are also likely not at higher risk of cesarean delivery or low-birthweight neonates.

Morbidity and Mortality in Adult Congenital Heart Surgery: Physiologic Component Augments Risk Prediction

BACKGROUND

We sought to evaluate whether the anatomic and physiologic stratification system (ACAP score), released as part of the American College of Cardiology/American Heart Association updated guidelines for management of adult congenital heart disease (ACHD) in 2018, better estimated mortality and morbidity after cardiac operations for ACHD.

METHODS

The ACAP score was determined for 318 patients (age ≥18 years) with ACHD undergoing heart surgery at our institution between December 2001 and August 2019. The primary end point was perioperative mortality. The secondary aim was to evaluate the performance of the ACAP, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Congenital Heart Surgery Mortality Categories, and ACHS mortality scores/categories at predicting a composite adverse outcome of perioperative mortality, prolonged ventilation, and renal failure requiring replacement therapy. Logistic regression models were built to estimate mortality and the composite outcome using anatomic and physiologic components independently and together. Receiver operating characteristic curves were created, and area under the curves were compared using the Delong test.

RESULTS

The median age was 37 years (interquartile range, 26.3-50.0 years). There were 9 perioperative mortalities (2.8%). With respect to perioperative mortality, the area under the curve using the anatomic component only was 0.74, which improved to 0.81 after including physiologic severity (P = .05). When physiologic severity was added to the model for the composite outcome, the discriminatory abilities of the ACHS mortality score and the STAT categories increased significantly to 0.83 (95% CI, 0.75-0.91; P = .02) and 0.82 (95% CI, 0.73-0.90; P = .04), comparable to the predictive power of ACAP.

CONCLUSIONS

Physiologic severity augments ability to predict mortality and morbidity after cardiac surgery for ACHD. There is need for more robust ACHD-specific risk models.

Racial Disparities in Breastfeeding Rates in Patients with Heart Disease

OBJECTIVE

To evaluate racial disparities in breastfeeding rates in patients with heart disease.

STUDY DESIGN

Retrospective cohort of pregnant patients with maternal cardiac disease managed by a Cardio-Obstetrics program. Patients self-identifying as Non-Hispanic Black (NHB) and Non-Hispanic White (NHW), who attended ≥ 1 prenatal visit at the Cardio-Obstetrics Program and delivered at the same hospital between March 2015 and June 2019 were included. The primary outcome was breastfeeding rate at discharge from the delivery-associated hospitalization. Secondary outcomes included breastfeeding intent on admission and breastfeeding rates at the postpartum visit among patients who initiated breastfeeding.

RESULTS

138 pregnant patients with cardiac disease were included: 58 (42%) NHB and 80 (58%) NHW patients. Parity, marital status and insurance were statistically different between groups. NHB patients were more likely to have government insurance compared to NHW patients (77.6% vs. 40%; p < 0.001). There was a significant difference in the intent to breastfeed upon admission for the delivery-associated hospitalization (74.2% NHB vs. NHW 91.3%; p = 0.01), but not at hospital discharge (84.5% NHB vs. 93.8% NHW; p = 0.08). However, breastfeeding rates were significantly lower among NHB patients at the postpartum visit among the entire cohort (38.2% in NHB vs. 61.1% in NHW women; p = 0.036) and among those who initiated breastfeeding (35.3% NHB vs. 61.1% NHW, p = 0.018).

CONCLUSIONS

Despite similar breastfeeding rates at hospital discharge, NHB patients with maternal cardiac disease were less likely to intend to breastfeed at admission and/or continue breastfeeding by the postpartum visits. Qualitative studies understanding these differences are crucial to improve breastfeeding rates, especially for NHB patients with maternal cardiac disease.

Valvular Heart Disease in Pregnancy

Valvular heart disease is a common cause of peripartum cardiovascular morbidity and mortality. The hemodynamic changes of pregnancy and their impact on preexisting valvular lesions are described in this paper. Tools for calculation of maternal and fetal risk during pregnancy are also discussed. The pathophysiology and management of valvular lesions, both obstructive and regurgitant, are then described, followed by discussion of mechanical and bioprosthetic valve complications during pregnancy.

Progression of Valvular Pulmonic Stenosis in Adulthood: Never Say Never

•Historic data indicate mild valvar PS in adults does not progress. •The prevalence of older adults with CHD is increasing. •Valvular calcification may lead to progression of PS in later life. •Echocardiography should be used for routine follow-up for PS.

Adult congenital heart diseases: systematic review/meta-analysis

Background

Congenital heart disease (CHD) is a gross structural abnormality of the heart that has functional significance. The impact of CHD on the patients' quality of life (QOL) is a topic of considerable interest and importance to both researchers and clinician. However, there is a lack of systematic reviews investigating and identifying the QOL of congenital heart disease patients.

Aim

To assess the QOL of adult patients with congenital heart disease by reviewing the previous studies conducted on this subject.

Methods

The PubMed and Google Scholar databases were explored for studies published between 2020 and 2022. The keywords used for the searching process included "QOL, Adults, CHD, Outcomes, Impact, Effects, Life of CHD Patients." The inclusion criteria were original English articles and full-text articles conducted on adult patients with congenital heart disease and reported quality of life.

Results

A total of 5455 articles were obtained, but only seven articles were eligible for the inclusion criteria. The included studies involved a total of 8549 participants; 104 were healthy, and 8445 were adult patients with congenital heart disease. The investigated items of the studies included quality of life, health-related QOL, including physical and psychological dimensions, sense of coherence, mental health, physical functioning, physiological wellbeing, psychological resilience, anxiety, depression, illness perception, and health status.

Conclusion

Patients with congenital heart disease experience low QOL across all dimensions. The risk factors for poor QOL included age, depression, anxiety, and female gender.

Outpatient care of adults with congenital heart disease in the UK: a qualitative appraisal of the clinician perspective

OBJECTIVE

This study aimed to explore clinicians' perspectives of ambulatory care in adult congenital heart disease (ACHD).

METHODS

Semistructured interviews were carried out remotely (Zoom) with a range of physicians providing ambulatory care to patients with ACHD across the UK. The chronic care model, thrive and candidacy frameworks were used to design prompt guides and subsequently develop themes. A framework approach was used to code and analyse transcripts, which were managed in NVivo.

RESULTS

21 clinicians (43% females, 38% specialists) from 10/12 ACHD networks in the UK participated. Shared themes included the purpose of the clinic appointment, problems in the 'hub-and-spoke' care system, role of the general practitioner and ACHD specialist nurse, communication with patients, burden of ambulatory care and patient self-management. Reflecting on these themes, participants identified resources, what care and how and by it is delivered alongside the role of the patient as key areas for future research.

CONCLUSIONS

The present structure of ACHD ambulatory care is neither patient-centred nor equitable. The concerned clinicians raise the question whether increasing resource alone without changing structure will lead to better outcomes for patients.

Anomalous origin of the left circumflex coronary artery: is surgery required? A case report

Background

Deviations from usual coronary artery anatomy are well documented. The left circumflex artery (LCx) arising from the pulmonary artery is an example of one such deviation which is rarely seen. We present the case of a 26-year-old male with this coronary artery distribution presenting with an episode of ventricular flutter with late gadolinium enhancement and pluri-morphological ventricular arrhythmias.

Case summary

A 26-year-old male with a history of cardiac surgery presented to his local hospital with an episode of symptomatic broad-complex tachycardia (BCT). It failed to revert to sinus rhythm following intravenous beta-blockers and amiodarone and required external cardioversion. Subsequently, the patient developed a aspiration pneumonia requiring ICU admission, after which he was transferred to our institute for ongoing cardiac management. Cardiac computed tomography CTA and coronary angiography revealed that the LCx was found to originate from the pulmonary artery. He underwent insertion of a subcutaneous pacemaker and was subsequently discharged. Despite the potential for steal syndrome of viable coronary territories. Multidisciplinary team discussion determined him to be fit for conservative management and not for surgical correction of his anomalous coronary artery anatomy.

Discussion

Aberrant coronary artery anatomy can lead to diverse outcomes for patients in terms of both morbidity and mortality. The need for surgery in these situations varies on a case-by-case basis and little research exists to guide decision-making for healthcare professionals. As such there is a need for further study both to guide treatment and to ensure high-quality outcomes for patients with this condition.

Advanced Imaging Technologies for Assessing Tetralogy of Fallot: Insights Into Flow Dynamics

Tetralogy of Fallot is the most common cyanotic congenital heart defect requiring surgical repair. Although surgical interventions have significantly reduced mortality, postrepair complications, such as pulmonary valve regurgitation and stenosis, may lead to adverse outcomes, including right ventricular dysfunction and increased risks of morbidity and mortality. This review explores the potential of advanced imaging technologies, including 4-dimensional-flow magnetic resonance imaging and high-frame-rate echocardiography, in providing valuable insights into blood flow dynamics and energy parameters. Quantitative measures, such as energy loss and vorticity, along with qualitative flow analysis, can provide additional insights into adverse haemodynamics at a potentially earlier and more reversible stage. Furthermore, personalized patient-specific information from these imaging modalities aids in guiding treatment decisions and monitoring postoperative interventions effectively. By characterizing flow patterns, these advanced imaging techniques hold great promise in improving the assessment and management of tetralogy of Fallot, providing tailored insights. However, further research and longitudinal studies are required to fully establish their clinical utility and potential impact on patient care.

Effects of perioperative exercise on cardiorespiratory endurance in children with congenital heart disease in plateau areas after surgical repair

We aimed to explore the effects of perioperative exercise on cardiorespiratory endurance in children with congenital heart disease (CHD) in plateau areas after surgical repair. Fifty children with CHD in the plateau admitted to our hospital were randomly divided into the exercise and control groups. The exercise group received a perioperative exercise intervention beginning within 24 h postoperatively, while the control group received routine nursing and treatment alone. To assess the 6 min walk distance (6MWD) at baseline and at end of intervention, children participated in a 6-min walk test before cardiac repair and at 1 week after general ward transfer. A subset of children in the study underwent the cardiopulmonary exercise test pre-operatively. The 6MWD of children with CHD at baseline was positively correlated with the peak oxygen uptake pre-operatively. No significant difference was reported in the preoperative baseline data of both groups. The 6MWD of the exercise group was significantly higher than that of the control group. Early exercise therapy after cardiac repair could significantly improve the cardiorespiratory endurance and exercise capacity of children with CHD in plateau areas.

Adult Congenital Heart Disease: Report from a Public Reference Hospital in Northeastern Brazil

INTRODUCTION

The increasing worldwide number of adults with congenital heart disease (CHD) demands greater attention from health professionals. The purpose of this report is to describe the clinical demographic profile, frequency, and invasive treatment status of adults with CHD in a public reference hospital in northeastern Brazil.

METHODS

This is a retrospective cross-sectional study including 704 patients attended between August 2016 and August 2020. Data were collected from virtual database.

RESULTS

Patients' age varied from 17 to 81 years (mean 32±14; median 27 years); 294 (41.8%) patients were male, and 410 (58,2%) were female; 230 (32,7%) had diagnosis from age 18 and up. Cardiac complexity categories were "simple defects" (134 [19%] patients), "moderate complexity" (503 [71.5%]), and "great complexity" (67 [9.5%]). Atrial septal defect (ASD) was diagnosed in 216 (30.7%) patients, ventricular septal defect (VSD) in 101 (14.3%), tetralogy of Fallot in 93 (13.2%), and other CHD in 294 (41.8%). New York Heart Association (NYHA) functional classes were I (401 [57%]), II (203 [28.8%]), III (76 [10.8%]), and IV (24 [3.4%]). Complications were arrhythmias (173 [24%]) and severe pulmonary hypertension (69 [9.8%]). Invasive treatments were corrective surgery (364 (51.6%]), reoperation (28 [4.0%]), palliation (11 [1.6%]), interventional catheterization (12 [1.7%]), surgery plus interventional catheterization (5 [0.7%]), and preoperation (91 [12.9%]). Treatment was not required in 102 (14,5%) patients, and 91 (12.9%) were inoperable.

CONCLUSION

The leading diagnosis was ASD. Frequency of unrepaired patients was high, mainly ASD, due to late diagnosis, which favored complications and denotes a matter of great concern.

Executive functioning of patients with congenital heart disease: 45 years after surgery

BACKGROUND

Nowadays, more than 90% of patients with congenital heart disease (CHD) reach adulthood. However, long-term impact on neurodevelopment and executive functioning in adults with CHD are not completely understood.

PURPOSE

To investigate the self- and informant-reported executive functioning in adults with CHD operated in childhood.

MATERIAL AND METHODS

Longitudinal study of a cohort of patients (n = 194, median age: 49.9 [46.1-53.8]) who were operated in childhood (< 15 years old) between 1968 and 1980 (median follow-up time: 45 [40-53] years) for one of the following diagnoses: atrial septal defect (ASD), ventricular septal defect (VSD), pulmonary stenosis (PS), tetralogy of Fallot (ToF) or transposition of the great arteries (TGA). Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A) questionnaire was used to assess self- and informant-reported executive functioning.

RESULTS

40-53 years after surgery, the CHD group did show significantly better executive functioning compared to the norm data. No significant difference was found between mild CHD (ASD, VSD and PS) and moderate/severe CHD (ToF and TGA). Higher education, NYHA class 1 and better exercise capacity were associated with better self-reported executive functioning, whereas females or patients taking psychiatric or cardiac medications reported worse executive functioning.

CONCLUSIONS

Our findings suggest favorable outcomes (comparable to normative data) regarding executive functioning in adults with CHD, both self- and informant-reported. However, further study is warranted to explore more in detail the different cognitive domains of executive functioning in these patients.

Outcomes of out-of-hospital cardiac arrest in adult congenital heart disease: a Danish nationwide study

AIMS

The risk, characteristics, and outcome of out-of-hospital cardiac arrest (OHCA) in patients with congenital heart disease (CHD) remain scarcely investigated.

METHODS AND RESULTS

An epidemiological registry-based study was conducted. Using time-dependent Cox regression models fitted with a nested case-control design, hazard ratios (HRs) with 95% confidence intervals of OHCA of presumed cardiac cause (2001-19) associated with simple, moderate, and severe CHD were calculated. Moreover, using multiple logistic regression, we investigated the association between pre-hospital OHCA characteristics and 30-day survival and compared 30-day survival in OHCA patients with and without CHD. Overall, 43 967 cases (105 with simple, 144 with moderate, and 53 with severe CHD) and 219 772 controls (median age 72 years, 68.2% male) were identified. Any type of CHD was found to be associated with higher rates of OHCA compared with the background population [simple CHD: HR 1.37 (1.08-1.70); moderate CHD: HR 1.64 (1.36-1.99); and severe CHD: HR 4.36 (3.01-6.30)]. Pre-hospital cardiopulmonary resuscitation and defibrillation were both associated with improved 30-day survival in patients with CHD, regardless of CHD severity. Among patients with OHCA, simple, moderate, and severe CHD had a similar likelihood of 30-day survival compared with no CHD [odds ratio 0.95 (0.53-1.69), 0.70 (0.43-1.14), and 0.68 (0.33-1.57), respectively].

CONCLUSION

A higher risk of OHCA was found throughout the spectrum of CHD. Patients with and without CHD showed the same 30-day survival, which relies on the pre-hospital chain of survival, namely cardiopulmonary resuscitation and defibrillation.

Changes in the Cath Lab in the Treatment of Adult Patients with Congenital Heart Disease: A 12-Year Experience in a Single Referral Center with the Establishment of a Dedicated Working Group

BACKGROUND

Adults with congenital heart disease (ACHD) are a growing population needing ongoing care. The aim of this study was to investigate if a dedicated ACHD team impacted the timing and indication of invasive cardiology procedures in these patients at our hospital.

METHODS

Our retrospective single-center study enrolled adult patients with moderate or complex congenital heart disease and with at least one cardiac catheterization between January 2010 and December 2021. According to the period, procedures were labeled as group A (2010 to 2015) or group B (2016 to 2021) and further divided into diagnostic (DCC) and interventional cardiac catheterizations (ICC).

RESULTS

594 patients were eligible for the study. Both DCC (p < 0.05) and ICC increased between groups A and B (p < 0.05). In group B: Fontan patients accounted for the majority of DCC (p < 0.001), while DCC decreased in arterial switch repair (p < 0.001). In Fontan patients, conduit stenting was prevalent (p < 0.001), while fenestration closures dropped (p < 0.01). In patients with tetralogy of Fallot and native outflow tract, percutaneous pulmonary valve implantations (PPVI) increased, with a concurrent reduction in pulmonary valve replacements (p < 0.001 vs. surgical series). In right ventricular conduits, ICC increased (p < 0.01), mainly due to PPVI. Among Mustard/Senning patients, baffle stenting increased from Group A to Group B (p < 0.001). In patients with pulmonary atresia and biventricular repair, ICC often increased for pulmonary artery stenting.

CONCLUSIONS

A dedicated working group could improve ACHD patients' indications for interventional procedures, leading to tailored treatment, better risk stratification and optimizing time until heart transplantation.

Improving long-term care and outcomes of congenital heart disease: fulfilling the promise of a healthy life

Advances in the prevention, diagnosis, and treatment for congenital heart disease (CHD), the most common birth defect in China, have drastically improved survival for individuals with the disease. However, China's current health system is not well prepared to manage the growing population of people with CHD and their complex medical needs, which range from early detection of the condition and intervention for physical, neurodevelopmental, and psychosocial impairment, to long-term management of major complications and chronic health problems. Health disparities caused by long-standing regional differences in access to care pose challenges when major complications such as pulmonary hypertension arise, and when individuals with complex CHD become pregnant and give birth. Currently, no data sources track neonates, children, adolescents, and adults with CHD in China and delineate their clinical characteristics and use of health resources. This scarcity of data should warrant attention from the Chinese Government and relevant specialists in the field. In the third paper of the Series on CHD in China, we summarise key literature and current data to identify knowledge gaps and call for concerted efforts by the government, hospitals, clinicians, industries, and charitable organisations to develop an actionable, lifelong framework of congenital cardiac care that is accessible and affordable for all individuals with CHD. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Clinical Characteristics and Outcomes in Adults With Moderate-to-Severe Complexity Congenital Heart Disease Undergoing Palliation or Surgical Repair

Background

Congenital heart disease (CHD) survival rate has improved dramatically due to advances in diagnostic and therapeutic techniques. However, concerning the unrepaired CHD population of moderate and severe complexity, the data regarding risk predictors and surgical outcomes are scarce. Our aim was to describe the surgical results and predictors of in-hospital outcomes in adult patients with moderate-to-severe complexity CHD that were not repaired in childhood.

Methods

We conducted a retrospective cohort study that included 49 adult patients with moderate-to-complex CHD who were treated in a single medical centre. Clinical and echocardiographic variables were obtained on admission, after surgical procedures and during follow-up.

Results

Most of the patients were female (66%). Left ventricular ejection fraction and right ventricular outflow tract fractional shortening were within the normal range. The median pulmonary artery systolic pressure was 37 (27-55) mm Hg. The median time was 118 (80-181) minutes for extracorporeal circulation and 76 (49-121) minutes for aortic cross-clamping. The most frequent complication was postoperative complete atrioventricular block (12.2%). In-hospital survival rate was 87.7%. The development of low cardiac output syndrome with predominant right ventricle failure in the postoperative period was the most important predictor of in-hospital death (P = 0.03).

Conclusions

Deciding to treat adults with CHD is challenging in moderate and severe unrepaired cases. Adequate clinical, functional, and imaging evaluation is essential to determine each patient's suitability for surgical management and to achieve the best clinical outcome for this population.

Changing epidemiology of congenital heart disease: effect on outcomes and quality of care in adults

The epidemiology of congenital heart disease (CHD) has changed in the past 50 years as a result of an increase in the prevalence and survival rate of CHD. In particular, mortality in patients with CHD has changed dramatically since the latter half of the twentieth century as a result of more timely diagnosis and the development of interventions for CHD that have prolonged life. As patients with CHD age, the disease burden shifts away from the heart and towards acquired cardiovascular and systemic complications. The societal costs of CHD are high, not just in terms of health-care utilization but also with regards to quality of life. Lifespan disease trajectories for populations with a high disease burden that is measured over prolonged time periods are becoming increasingly important to define long-term outcomes that can be improved. Quality improvement initiatives, including advanced physician training for adult CHD in the past 10 years, have begun to improve disease outcomes. As we seek to transform lifespan into healthspan, research efforts need to incorporate big data to allow high-value, patient-centred and artificial intelligence-enabled delivery of care. Such efforts will facilitate improved access to health care in remote areas and inform the horizontal integration of services needed to manage CHD for the prolonged duration of survival among adult patients.

Common genetic variants improve risk stratification after the atrial switch operation for transposition of the great arteries

BACKGROUND

Clinical factors are used to estimate late complication risk in adults after atrial switch operation (AtrSO) for transposition of the great arteries (TGA), but heterogeneity in clinical course remains. We studied whether common genetic variants are associated with outcome and add value to a clinical risk score in TGA-AtrSO patients.

METHODS AND RESULTS

This multicenter study followed 133 TGA-AtrSO patients (aged 28 [IQR 24-35] years) for 13 (IQR 9-16) years and examined the association of genome-wide single-nucleotide polymorphisms (SNPs) with a composite endpoint of symptomatic ventricular arrhythmia, heart failure hospitalization, ventricular assist device implantation, heart transplantation, or mortality. Thirty-two patients (24%) reached the endpoint. The genome-wide association study yielded one genome-wide significant (p < 1 × 10^-8) locus and 18 suggestive loci (p < 1 × 10^-5). A genetic risk score constructed on the basis of independent SNPs with p < 1 × 10^-5 was associated with outcome after correction for the clinical risk score (HR = 1.26/point increase [95%CI 1.17-1.35]). Risk stratification improved with a combined risk score (clinical score + genetic score) compared to the clinical score alone (p = 2 × 10^-16, C-statistic 0.95 vs 0.85). In 51 patients with a clinical intermediate (5-20%) 5-year risk of events, the combined score reclassified 32 patients to low (<5%) and 5 to high (>20%) risk. Stratified by the combined score, observed 5-year event-free survival was 100%, 79% and 31% for low, intermediate, and high-risk patients, respectively.

CONCLUSIONS

Common genetic variants may explain some variation in the clinical course in TGA-AtrSO and improve risk stratification over clinical factors alone, especially in patients at intermediate clinical risk. These findings support the hypothesis that including genetic variants in risk assessment may be beneficial.

Major elective non-cardiac operations in adults with congenital heart disease

OBJECTIVE

To assess the impact of congenital heart disease (CHD) on resource utilisation and clinical outcomes in patients undergoing major elective non-cardiac operations.

BACKGROUND

Due to advances in congenital cardiac management in recent years, more patients with CHD are living into adulthood and are requiring non-cardiac operations.

METHODS

The 2010-2018 Nationwide Readmissions Database was used to identify all adults undergoing major elective operations (pneumonectomy, hepatectomy, hip replacement, pancreatectomy, abdominal aortic aneurysm repair, colectomy, gastrectomy and oesophagectomy). Multivariable regression models were used to categorise key clinical outcomes.

RESULTS

Of an estimated 4 941 203 adults meeting inclusion criteria, 5234 (0.11%) had a previous diagnosis of CHD. Over the study period, the incidence of CHD increased from 0.06% to 0.17%, p<0.001. CHD patients were on average younger (63.3±14.8 vs 64.4±12.5 years, p=0.004), had a higher Elixhauser Comorbidity Index (3.3±2.2 vs 2.3±1.8, p<0.001) and received operations at high volume centres more frequently (66.6% vs 62.0%, p=0.003). Following risk adjustment, these patients had increased risk of in-hospital mortality (adjusted risk ratio (ARR): 1.76, 95% CI 1.25 to 2.47), experienced longer hospitalisation durations (+1.6 days, 95% CI 1.3 to 2.0) and cost more (+$8370, 95% CI $6686 to $10 055). Furthermore, they were more at risk for in-hospital complications (ARR: 1.24 95% CI 1.17 to 1.31) and endured higher adjusted risk of readmission at 30 days (ARR: 1.32 95% CI 1.13 to 1.54).

CONCLUSIONS

Adults with CHD are more frequently comprising the major elective operative cohort for non-cardiac cases. Due to the inferior clinical and financial outcomes suffered by this population, perioperative risk stratification may benefit from the inclusion of CHD as a factor that portends unfavourable outcomes.

Outcomes of pregnant women hospitalized with unrepaired congenital heart disease: Insights from a multidisciplinary center in Vietnam

Background

In developing countries, fewer women have access to multidisciplinary congenital heart disease and reproductive programs staffed by experts. We report pregnancy outcomes of a multidisciplinary healthcare strategy utilizing an in-hospital teamwork approach in Vietnam.

Methods

This retrospective cohort study included pregnant women with unrepaired congenital heart disease managed at a referral cardiovascular center.

Results

Undiagnosed congenital heart disease before pregnancy, a lack of pre-pregnancy cardiology counseling, and modified World Health Organization class III/IV were common. Under the multispecialty healthcare strategy, although the rate of maternal death was 8.2% in the modified World Health Organization class IV group, no deaths occurred in any other group. Fetal/neonatal complications occurred in 54% of pregnancies, and 49.4% of neonates survived. Poor pregnancy outcomes were associated with admission during the first/seconde trimester for fetus/neonates, third trimester for mother, modified World Health Organization class III/IV, cyanosis, and heart failure.

Conclusion

The outcomes of pregnant women with unrepaired congenital heart disease were poor but seemed to improve with a multidisciplinary in-hospital healthcare teamwork strategy.

The right ventricle in tetralogy of Fallot: adaptation to sequential loading

Right ventricular dysfunction is a major determinant of outcome in patients with complex congenital heart disease, as in tetralogy of Fallot. In these patients, right ventricular dysfunction emerges after initial pressure overload and hypoxemia, which is followed by chronic volume overload due to pulmonary regurgitation after corrective surgery. Myocardial adaptation and the transition to right ventricular failure remain poorly understood. Combining insights from clinical and experimental physiology and myocardial (tissue) data has identified a disease phenotype with important distinctions from other types of heart failure. This phenotype of the right ventricle in tetralogy of Fallot can be described as a syndrome of dysfunctional characteristics affecting both contraction and filling. These characteristics are the end result of several adaptation pathways of the cardiomyocytes, myocardial vasculature and extracellular matrix. As long as the long-term outcome of surgical correction of tetralogy of Fallot remains suboptimal, other treatment strategies need to be explored. Novel insights in failure of adaptation and the role of cardiomyocyte proliferation might provide targets for treatment of the (dysfunctional) right ventricle under stress.

Early Cerebrovascular Autoregulation in Neonates with Congenital Heart Disease

Neonates with congenital heart disease (CHD) display delayed brain development, predisposing them to impaired cerebrovascular autoregulation (CAR) and ischemic brain injury. For this paper, we analyzed the percentage of time with impaired CAR (%time impaired CAR) during the first 72 h after birth, the relation with clinical factors, and survival in 57 neonates with CHD. The primary outcome was a correlation coefficient of cerebral oxygenation (rcSO2) and mean arterial blood pressure (MABP, mmHg) for two hours on a daily basis. The %time impaired CAR ranged from 9.3% of the studied time on day one to 4.6% on day three. Variables associated with more %time impaired CAR were the use of inotropes (day 1, B = 19.5, 95%CI = 10.6–28.3; day 3, B = 11.5, 95%CI = 7.1–16), lower MABP (day 1, B = −0.6, 95%CI = −1.2–0.0), and dextro-transposition of the great arteries (dTGA) (16.2%) compared with other CHD types (2.0–5.0%; day 1, p = 0.022). Survival was not an associated variable. To summarize, impaired CAR was found in CHD neonates in up to 9.3% of the studied time. More evidence is necessary to evaluate an association with inotropes, dTGA, %time impaired CAR, and long-term outcome, further in larger cohorts.

Functional assessment of heart-specific enhancers by integrating ChIP-seq data

BACKGROUND

Identification and functional annotations of regulatory sequences play a pivotal role in heart development and function.

METHODS

To generate a map of human heart-specific enhancers, we performed an integrative analysis of 148 chromatin immunoprecipitation coupled to massively parallel sequencing (ChIP-seq) samples with enhancer-associated epigenetic marks from the heart, liver, brain, and kidney. Functional validation of heart-specific enhancer activity was then performed using cultured cells.

RESULTS

A 144.6-Mb candidate heart-specific enhancer compendium was generated by integrating the analysis of 148 epigenomic data sets from human and mouse hearts and control tissues. To validate in vivo enhancer activity, we tested 12 of these sequences around 45 CHD-related genes in cultured cells and found that 8 (67%) have reproducible heart-specific enhancer activity. A functional analysis demonstrated that the identified human heart-specific enhancer wf1 regulates the FBN1 gene which is involved in heart disease.

CONCLUSIONS

Our study provides an integrative analysis pipeline for ChIP-seq data and identified a comprehensive catalog of human heart-specific enhancers for clinical CHD-related studies.

IMPACT

Establishing an efficient way to analyze regulatory regions in CHD is very important. A highly qualified heart-specific enhancer compendium was generated by integrating 148 online ChIP-seq samples. Sixty-seven percent of predicted regulatory sequences have reproducible heart-specific enhancer activity in vivo. Human heart-specific enhancer wf1 regulates the CHD-related FBN1 gene.

Cardiac Concerns in the Pediatric Athlete

Cardiovascular disease remains the number one cause of death in Americans. It is no secret that exercise mitigates this risk. Exercise and regular physical activity are beneficial for physical health including aerobic conditioning, endurance, strength, mental health, and overall improved quality of life. Unfortunately, today many children and adolescents are sedentary, lacking the recommended daily amount of physical activity, leading to higher rates of obesity, cardiovascular disease, stroke, diabetes, anxiety, and depression. Given this rising concern, the World Health Organization launched a 12-year plan to improve physical activity in children and adolescents by reducing the inactivity rate by 15% in the world. How does this apply to children and adolescents with acquired or congenital heart disease?.

Exercise training in paediatric congenital heart disease: fit for purpose?

Exercise and physical activity (PA) have been shown to be effective, safe and feasible in both healthy children and children with congenital heart disease (CHD). However, implementing exercise training as an intervention is still not routine in children with CHD despite considerable evidence of health benefits and well-being. Understanding how children with CHD can safely participate in exercise can boost participation in PA and subsequently reduce inactivity-related diseases. Home-based exercise intervention, with the use of personal wearable activity trackers, and high-intensity interval training have been beneficial in adults' cardiac rehabilitation programmes. However, these remain underutilised in paediatric care. Therefore, the aims of this narrative review were to synthesise prescribed exercise interventions in children with CHD, identify possible limitation to exercise training prescription and provide an overview on how to best integrate exercise intervention effectively for this population into daily practice.

The Predictive Role of Plasma Biomarkers in the Evolution of Aortopathies Associated with Congenital Heart Malformations

Dilatation of the aorta is a constantly evolving condition that can lead to the ultimate life-threatening event, acute aortic dissection. Recent research has tried to identify quantifiable biomarkers, with both diagnostic and prognostic roles in different aortopathies. Most studies have focused on the bicuspid aortic valve, the most frequent congenital heart disease (CHD), and majorly evolved around matrix metalloproteinases (MMPs). Other candidate biomarkers, such as asymmetric dimethylarginine, soluble receptor for advanced glycation end-products or transforming growth factor beta have also gained a lot of attention recently. Most of the aortic anomalies and dilatation-related studies have reported expression variation of tissular biomarkers. The ultimate goal remains, though, the identification of biomarkers among the serum plasma, with the upregulation of circulating MMP-1, MMP-2, MMP-9, tissue inhibitor of metalloproteinase-1 (TIMP-1), asymmetric dimethylarginine (ADMA), soluble receptor for advanced glycation end-products (sRAGE) and transforming growth factor beta (TGF-β) being reported in association to several aortopathies and related complications in recent research. These molecules are apparently quantifiable from the early ages and have been linked to several CHDs and hereditary aortopathies. Pediatric data on the matter is still limited, and further studies are warranted to elucidate the role of plasmatic biomarkers in the long term follow-up of potentially evolving congenital aortopathies.

Ambulatory Care in Adult Congenital Heart Disease-Time for Change?

BACKGROUND

The adult congenital heart disease (ACHD) population is growing in size and complexity. This study evaluates whether present ambulatory care adequately detects problems and considers costs.

METHODS

A UK single-centre study of clinic attendances amongst 100 ACHD patients (40.4 years, median ACHD AP class 2B) between 2014 and 2019 and the COVID-19 restrictions period (March 2020-July 2021).

RESULTS

Between 2014 and 2019, there were 575 appointments. Nonattendance was 10%; 15 patients recurrently nonattended. Eighty percent of appointments resulted in no decision other than continued review. Electrocardiograms and echocardiograms were frequent, but new findings were rare (5.1%, 4.0%). Decision-making was more common with the higher ACHD AP class and symptoms. Emergency admissions (n = 40) exceeded elective (n = 25), with over half following unremarkable clinic appointments. Distance travelled to the ACHD clinic was 14.9 km (1.6-265), resulting in 433-564 workdays lost. During COVID 19, there were 127 appointments (56% in-person, 41% telephone and 5% video). Decisions were made at 37% in-person and 19% virtual consultations. Nonattendance was 3.9%; there were eight emergency admissions.

CONCLUSION

The main purpose of the ACHD clinic is surveillance. Presently, the clinic does not sufficiently predict or prevent emergency hospital admissions and is costly to patient and provider. COVID-19 has enforced different methods for delivering care that require further evaluation.

Common Genetic Variants Contribute to Risk of Transposition of the Great Arteries

RATIONALE

Dextro-transposition of the great arteries (D-TGA) is a severe congenital heart defect which affects approximately 1 in 4,000 live births. While there are several reports of D-TGA patients with rare variants in individual genes, the majority of D-TGA cases remain genetically elusive. Familial recurrence patterns and the observation that most cases with D-TGA are sporadic suggest a polygenic inheritance for the disorder, yet this remains unexplored.

OBJECTIVE

We sought to study the role of common single nucleotide polymorphisms (SNPs) in risk for D-TGA.

METHODS AND RESULTS

We conducted a genome-wide association study in an international set of 1,237 patients with D-TGA and identified a genome-wide significant susceptibility locus on chromosome 3p14.3, which was subsequently replicated in an independent case-control set (rs56219800, meta-analysis P=8.6x10-10, OR=0.69 per C allele). SNP-based heritability analysis showed that 25% of variance in susceptibility to D-TGA may be explained by common variants. A genome-wide polygenic risk score derived from the discovery set was significantly associated to D-TGA in the replication set (P=4x10-5). The genome-wide significant locus (3p14.3) co-localizes with a putative regulatory element that interacts with the promoter of WNT5A, which encodes the Wnt Family Member 5A protein known for its role in cardiac development in mice. We show that this element drives reporter gene activity in the developing heart of mice and zebrafish and is bound by the developmental transcription factor TBX20. We further demonstrate that TBX20 attenuates Wnt5a expression levels in the developing mouse heart.

CONCLUSIONS

This work provides support for a polygenic architecture in D-TGA and identifies a susceptibility locus on chromosome 3p14.3 near WNT5A. Genomic and functional data support a causal role of WNT5A at the locus.

Transition in cardiology 2: Maternal and fetal congenital heart disease

The number of women with congenital heart disease (CHD) reaching reproductive age has been increasing. Many women with CHDs are desirous of pregnancy, but they face issues regarding preconception, antepartum, and postpartum management. On the other hand, the fetal diagnosis of CHD has improved with advances in the technique and equipment for fetal echocardiography. Recently, experiences with fetal intervention have been reported in patients with severe CHD, such as critical aortic stenosis. Nevertheless, some types of CHD are challenge to diagnose prenatally, resulting in adverse outcomes. Medical care is part of the transitional care for women and fetuses with CHD during the perinatal period. Pre-conceptional and prenatal counseling play an important role in transitional care. Sex and reproductive education need to be performed as early as possible. We herein review the current status, important issues to be resolved, and the future of maternal and fetal CHD to relevant caregivers.

Individuals aged 1-64 years with documented congenital heart defects at healthcare encounters, five U.S. surveillance sites, 2011-2013

BACKGROUND

Many individuals born with congenital heart defects (CHD) survive to adulthood. However, population estimates of CHD beyond early childhood are limited in the U.S.

OBJECTIVES

To estimate the percentage of individuals aged 1-to-64 years at five U.S. sites with CHD documented at a healthcare encounter during a three-year period and describe their characteristics.

METHODS

Sites conducted population-based surveillance of CHD among 1 to 10-year-olds (three sites) and 11 to 64-year-olds (all five sites) by linking healthcare data. Eligible cases resided in the population catchment areas and had one or more healthcare encounters during the surveillance period (January 1, 2011-December 31, 2013) with a CHD-related ICD-9-CM code. Site-specific population census estimates from the same age groups and time period were used to assess percentage of individuals in the catchment area with a CHD-related ICD-9-CM code documented at a healthcare encounter (hereafter referred to as CHD cases). Severe and non-severe CHD were based on an established mutually exclusive anatomic hierarchy.

RESULTS

Among 42,646 CHD cases, 23.7% had severe CHD and 51.5% were male. Percentage of CHD cases among 1 to 10-year-olds, was 6.36/1,000 (range: 4.33-9.96/1,000) but varied by CHD severity [severe: 1.56/1,000 (range: 1.04-2.64/1,000); non-severe: 4.80/1,000 (range: 3.28-7.32/1,000)]. Percentage of cases across all sites in 11 to 64-year-olds was 1.47/1,000 (range: 1.02-2.18/1,000) and varied by CHD severity [severe: 0.34/1,000 (range: 0.26-0.49/1,000); non-severe: 1.13/1,000 (range: 0.76-1.69/1,000)]. Percentage of CHD cases decreased with age until 20 to 44 years and, for non-severe CHD only, increased slightly for ages 45 to 64 years.

CONCLUSION

CHD cases varied by site, CHD severity, and age. These findings will inform planning for the needs of this growing population.

Reproductive health conversations in adolescents with CHD

BACKGROUND

Reproductive issues as related to CHD must be discussed in the clinic and at home. Providers can ensure that correct information is imparted to the adolescent and encourage mothers to provide support and guidance to the adolescent. The level to which these conversations occur is unknown.

METHODS

A survey distributed to female adolescent/mother dyads assessed self-reported conversations with the healthcare provider and between each other about reproductive health topics. A clinician survey was completed to assess CHD diagnosis, risk of hormonal contraception, and pregnancy risk.

RESULTS

Among 91 dyads, 33.0% of adolescents and 42.9% of mothers reported discussing recurrence risk of CHD with the provider. In regard to the cardiac lesion affecting a baby, 30.7% of adolescents and 28.7% of mothers reported discussing this with a provider. Significantly less adolescents and mothers reported discussing the risks of hormonal contraception and pregnancy with a provider. In assessing conversations between adolescents and mothers, only 44.2% of adolescents and 52.3% of mothers reported discussing with each other the safety of using birth control and 46.5% of adolescents and 64.0% of mothers reported discussing the safety of pregnancy.

CONCLUSIONS

Adolescents with CHD and their mothers report low rates of reproductive health-related conversations with the healthcare provider, and mothers report low rates of having these conversations with their daughters. These topics should be discussed at each appointment with the cardiologist and must be encouraged to continue at home.

Incidence of Difficult Laryngoscopy in Adult Congenital Heart Disease Patients: A Retrospective Cohort Study

OBJECTIVE

To identify the incidence of difficult intubation in patients with adult congenital heart disease (ACHD) undergoing cardiac surgery or catheterization.

DESIGN

A retrospective cohort study.

SETTING

A single-center academic quaternary pediatric hospital.

PARTICIPANTS

All patients were >18 years of age with ACHD undergoing endotracheal intubation within the Heart Center at Texas Children's Hospital between January 2012 and December 2019.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

A retrospective chart review was performed, including patient demographics, preoperative airway assessment and intraoperative airway management characteristics. Airways were categorized as difficult using the Pediatric Difficult Intubation registry operational definitions. For patients classified as having a difficult airway, the preoperative airway examination findings were recorded in addition to factors associated with difficult airway in the adult. The study authors identified 1,029 patients with ACHD who underwent procedures with anesthesia at their institution and were analyzed for the presence of difficult airway. In total, 878 patients were intubated, with 4.3% (n = 38) identified to have difficult airway. The presence of concomitant syndromes was greater in patients with difficult intubations and those who were not intubated compared with those who were not difficult intubations (23.7% and 17.2 v 7.5; p < 0.001), respectively. Most patients did not have typical signs associated with difficult intubation.

CONCLUSIONS

The study authors identified an incidence of difficult laryngoscopy in their cohort of ACHD patients to be 4.3%. Their incidences of difficult laryngoscopy were fewer than that reported in adult patients with noncongenital heart disease. Most importantly, the risk factors associated with difficult laryngoscopy in the normal adult may be different from those presenting with ACHD, necessitating further investigation.

Physical activity modification in youth with congenital heart disease: a comprehensive narrative review

Congenital heart disease (CHD) affects nearly 1% of births. As survival rates have dramatically improved, the majority of individuals with CHD now live into adulthood. As these patients age, they become prone to a large range of complications, such as chronic heart failure and acquired cardiovascular disease. Promotion of a healthy and active lifestyle from childhood onwards has been suggested as a sustainable and effective strategy to enhance cardiovascular health, improve quality of life and reduce immediate and long-term risk in people with CHD. Well-established physical activity consensus statements for youth with CHD have now been published. In this article, we review how increasing physical activity in youth with CHD may offer immediate and long-term cardiovascular benefits, what is known about physical activity in children with CHD, describe the unique factors that contribute to achieving sufficient and insufficient physical activity levels and summarize the evidence of trials on physical activity promotion in youth with CHD. Furthermore, we discuss some of the challenges that need to be addressed by further research regarding the optimal strategy, timing and format of physical activity intervention programmes in children and adolescents with CHD. IMPACT: Congenital heart disease (CHD) affects nearly 1% of births, with the majority of individuals with CHD now living into adulthood due to improved survival. As CHD patients age, they become prone to a large range of cardiovascular complications. This article discusses how and why increasing physical activity in youth with CHD may offer immediate and long-term cardiovascular benefits, the barriers to achieving sufficient physical activity levels and the evidence from trials on physical activity promotion in youth with CHD. The optimal strategy, timing and format of physical activity intervention programmes in children and adolescents with CHD are discussed.

Vasoactive-ventilation-renal score: a reliable prognostic index for perioperative outcomes following congenital heart surgery in adults

INTRODUCTION

The number of adults requiring surgeries for CHD is increasing. We sought to evaluate the utility of the vasoactive-ventilation-renal (VVR) score as a predictor of prolonged length of stay in adults following CHD surgery.

METHODS

This is a retrospective review of 158 adult patients who underwent CHD surgery involving cardiopulmonary bypass. VVR score was calculated upon arrival to ICU and every 6 hours for the first 48 hours post-operatively. Our primary outcome was prolonged length of stay defined as hospital length of stay greater than 75th percentile for the cohort (≥8 days).

RESULTS

The study cohort had a median age of 25.6 years (18-60 years), and 83 (52.5%) were male. The groups with and without prolonged length of stay were comparable in age, gender, race, and surgical severity score. VVR score was significantly higher at all time points in the group with prolonged length of stay. The first post-operative day peak VVR score ≥13 had a sensitivity of 81% and specificity of 75% for predicting prolonged length of stay (p = 0.0001). On regression analysis, peak VVR score during the first day was independently associated with prolonged length of stay.

CONCLUSIONS

Peak VVR score during the first post-operative day was a strong predictor of prolonged length of stay in adults following CHD surgery.

Epidemiology of adult congenital heart disease among the general population in Kuwait

Background

Adult congenital heart disease (ACHD) is a highly underrepresented entity in medical literature, especially in the middle‐eastern region.

Hypothesis

This study is the first to assess the prevalence of adult congenital heart disease among the population of Kuwait.

Methods

After a retrospective register review of patients in Kuwait being followed up in the chest diseases hospital was conducted, patients who fit the inclusion criteria were enrolled in the study. Using the American College of Cardiology Task Force 1 of the 32nd Bethesda conference classification of the severity of ACHD, the patients were classified into those with simple, moderate, and complex congenital heart diseases. The age and gender of the patients, as well as the type repair performed, and the residual cardiac findings were recorded to assess the association between the complexity and residuals. Associations were assessed using STATA 15.

Results

A total of 611 patients were evaluated over a period of 18 months. The youngest participant was 20 years of age, and the oldest participant was 88 years old. Male participants with moderate congenital heart disease class were more common in our study population. Patients with complex congenital heart disease have more residual cardiac lesion than the moderate or simple groups. Almost (70%) of patients with complex cardiac anomalies have undergone either partial or complete repair. The most prevalent cardiac defect was atrial septal defect (21.5%). Tetralogy of Fallot was the most prevalent defect in the moderate group, representing (13%) of the group. The most prevalent anomaly in the complex group was double outlet right ventricle (DORV) representing (15.38%).

Conclusion

Adult Congenital heart disease is a growing entity of heart disease due to advanced repair techniques. This population requires registries to document cases and assign specialists for the management and care of this special group of patients.

Highlights

First database of adult congenital heart disease in Kuwait.

The most prevalent heart defect was ASD in Kuwait.

TOF was the most prevalent defect in the moderate group; and DORV was the most prevalent in the complex group.

Patients with moderate ACHD tended to have a more complete repair than those in the complex group.

Pregnancy and Delivery in Patients With Repaired Congenital Heart Disease - A Retrospective Japanese Multicenter Study

BACKGROUND

Although advances in cardiac surgery have led to an increased number of survivors with congenital heart disease (CHD), epidemiological data regarding the pregnancies and deliveries of patients with repaired CHD are scarce.Methods and Results:In this study, we retrospectively reviewed the clinical outcomes of pregnancies and deliveries of women with repaired CHD. Overall, 131 women with repaired CHD were enrolled and there were 269 gestations. All patients were classified as New York Heart Association (NYHA) Class I or II. The prevalence of cesarean sections was higher in patients with (CyCHD) than without (AcyCHD) a past history of cyanosis (51% vs. 19%, respectively; P<0.01). There were 228 offspring from 269 gestations and the most prevalent neonatal complication was premature birth (10%), which was more frequent in the CyCHD than AcyCHD group (15.7% vs. 5.6%, respectively; P<0.01). Five maternal cardiac complications during delivery were observed only in the CyCHD group (8%); these were classified as NYHA Class II and none was fatal.

CONCLUSIONS

Delivery was successful in most women with repaired CHD who were classified as NYHA Class I or II, although some with CyCHD and NYHA Class II required more attention. Cesarean sections were more common in the CyCHD than AcyCHD group, and CyCHD may be a potential risk for preterm deliveries.

European Society of Cardiology Working Group on Adult Congenital Heart Disease and Study Group for Adult Congenital Heart Care in Central and South Eastern European Countries consensus paper: current status, provision gaps and investment required

AIMS

To examine the current status of care and needs of adult congenital heart disease (ACHD) services in the Central and South Eastern European (CESEE) region.

METHODS AND RESULTS

We obtained data regarding the national ACHD status for 19 CESEE countries from their ACHD representative based on an extensive survey for 2017 and/or 2018. Thirteen countries reported at least one tertiary ACHD centre with a median year of centre establishment in 2007 (interquartile range 2002-2013). ACHD centres reported a median of 2114 patients under active follow-up with an annual cardiac catheter and surgical intervention volume of 49 and 40, respectively. The majority (90%) of catheter or surgical interventions were funded by government reimbursement schemes. However, all 19 countries had financial caps on a hospital level, leading to patient waiting lists and restrictions in the number of procedures that can be performed. The median number of ACHD specialists per country was 3. The majority of centres (75%) did not have ACHD specialist nurses. The six countries with no dedicated ACHD centres had lower Gross Domestic Product per capita compared to the remainder (P = 0.005).

CONCLUSION

The majority of countries in CESEE now have established ACHD services with adequate infrastructure and a patient workload comparable to the rest of Europe, but important gaps still exist. ACHD care is challenged or compromised by limited financial resources, insufficient staffing levels, and reimbursement caps on essential procedures compared to Western Europe. Active advocacy and increased resources are required to address the inequalities of care across the continent.

Tnni1b-ECR183-d2, an 87 bp cardiac enhancer of zebrafish

Background

Several heart malformations are associated with mutations in the regulatory regions of cardiac genes. Troponin I type 1b (tnni1b) is important for the formation of the atrioventricular canal in zebrafish hearts; however, the regulation of tnni1b is poorly understand. We aimed to identify a small but functional enhancer that is distal to tnni1b.

Methods

Evolutionary Conserved Region (ECR) Browser was used to analyze the 219 kb zebrafish and human genomes covering the tnni1b gene as well as the 100 kb regions upstream and downstream of tnni1b. Putative transcription factor binding sites (TFBSs) were analyzed using JASPAR and PROMO, and the enhancer activity was identified using zebrafish embryos and the luciferase reporter assay. A correlation analysis between the enhancer and transcription factors (TFs) was performed via TF overexpression and TFBS mutation experiments and the electrophoretic mobility shift assay (EMSA). To analyze the conservation between zebrafish and human enhancers, human DNA fragments were functionally verified. Images were captured and analyzed by fluorescence microscopy or confocal microscopy.

Results

Combined with comparative analysis and functional validation, we identified a 183 bp ECR (termed tnni1b-ECR183) that was located approximately 84 kb upstream of tnni1b that had the heart-specific enhancer activity in zebrafish. TFBS analysis and the enhancer activity detection assay data showed that the 87 bp core region (termed tnni1b-ECR183-d2) was capable of driving specific GFP expression near the atrioventricular junction and increased luciferase expression in HEK293 and HL1 cell lines. The GFP pattern in zebrafish embryos was similar to the expression profiles of tnni1b. A correlation analysis showed that the enhancer activity of tnni1b-ECR183-d2 was increased when NKX2.5 (p = 0.0006) or JUN (p < 0.0001) was overexpressed and was decreased when the TFBSs of NKX2.5 (p < 0.0001) or JUN (p = 0.0018) were mutated. In addition, DNA-protein interactions were not observed between these TFs and tnni1b-ECR183-d2 in the EMSA experiment. The conservation analysis showed that tnni1b-ECR183-h179 (aligned from tnni1b-ECR183) drove GFP expression in the heart and skeletal muscles and increased the luciferase expression after NKX2.5 (p < 0.0001), JUN (p < 0.0001) or ETS1 (p < 0.0001) was overexpressed. Interestingly, the truncated fragment tnni1b-ECR183-h84 mainly drove GFP expression in the skeletal muscles of zebrafish and the enhancer activity decreased when NKX2.5 (p = 0.0028), ETS1 (p = 0.0001) or GATA4 (p < 0.0001) was overexpressed.

Conclusions

An 87 bp cardiac-specific enhancer located 84 kb upstream of tnni1b in zebrafish was positively correlated with NKX2.5 or JUN. The zebrafish and human enhancers in this study target different tissues. The GFP expression mediated by tnni1b-ECR183-d2 is a valuable tool for marking the domain around the atrioventricular junction.