Systemic Complications of Cyanosis in Adults with Congenital Heart Disease

Management of Fallot's Uncorrected Tetralogy in Adulthood: A Narrative Review

The majority of cyanotic congenital cardiac defects are caused by the tetralogy of Fallot. Some symptoms include a biventricular connection of the aortic root, right ventricular hypertrophy, blockage of the right ventricular outflow tract, and a ventricular septal defect. Our understanding of tetralogy of Fallot (TOF) has significantly advanced since it was first described in 1888, and early diagnosis has led to improved surgical management and increased life expectancy. Adults with unrepaired and repaired TOF present with a range of late complications, including heart failure, the need for re-interventions, and late arrhythmias. Right ventricular (RV) failure, often caused by chronic pulmonary regurgitation, is a significant cause of heart failure in patients with TOF. Current treatment options are limited, and mainstay surgical procedures such as pulmonary-valve replacement (PVR), trans-annular repair (TAR), or infundibular widening repair have not shown a significant reduction in preventing right ventricular (RV) failure or death. Here, we explain the mechanisms of RV failure in ToF, chronic pulmonary regurgitation, heart failure, and secondary polycythemia. HF management in untreated adults is discussed. The progression of the disease, as well as complications, are also discussed. The treatment plan and the need to investigate the best management approach for this unsolved problem are included. This review aims to fill the knowledge gaps and supply valuable information regarding mechanisms of RV failure, chronic pulmonary regurgitation, and secondary polycythemia. To summarize, a new combat strategy must be found to battle RVF, and a more profound vision of these mechanisms is required. If it is not corrected, it will be one of the future research lines that will contribute to designing more efficacious treatment techniques for adults with TOF.

Tetralogy of Fallot complicated by multiple cerebral abscesses in a child: a case report

INTRODUCTION

Brain abscesses are rare but potentially fatal condition and can be associated with cyanotic congenital heart disease of which 5-18.7% of these patients that develop cerebral abscess commonly have tetralogy of Fallot (TOF).

CASE PRESENTATION

We report a case of 3-year-old Muganda male that presented with convulsions, cyanosis and difficulty in breathing. The patient had a combination intervention of medical treatment and surgical drainage of the abscess. Post-operative Computerized tomography scan images and pre-operative brain Computerized tomography scans were compared. The multiple rings enhancing lesions were reduced in number and sizes. The largest measured ring was 44 × 22.5×16mm compared to the previous; 42 × 41×36mm. The mass effect had reduced from 16 mm to 7.5 mm. The periventricular hypodensities persisted. Findings showed radiological improvement with residual abscesses, subacute subdural hematoma and pneumocranium. The patient was treated with intravenous ceftriaxone 1 g OD for six weeks and he showed marked improvement and was discharged home after 3 months.

CONCLUSION

A comprehensive strategy involving medications, surgical drainage, and early neurosurgical consultation is vital in treating brain abscesses in uncorrected TOF. Early identification of the pathogen, appropriate antibiotic therapy, and vigilant follow-up through clinical assessments and imaging are crucial, potentially spanning a 4-8-week treatment.

Analysis of the 2020 European Society of Cardiology (ESC) Guidelines for the Management of Adults With Congenital Heart Disease (ACHD)

Adult congenital heart disease (ACHD) continues to rapidly increase worldwide. With an estimated 1.5 million adults with ACHD in the USA alone, there is a growing need for better education in the management of these complex patients and multiple knowledge gaps exist. This manuscript comprehensively reviewed the recent (2020) updated European Society of Cardiology Guidelines for the management of ACHD created by the Task Force for the management of adult congenital heart disease of the European Society of Cardiology, with perioperative implications for the adult cardiac anesthesiologist and intensivist who may be called upon to manage these complex patients.

Evaluation of renal injury in children with uncorrected CHDs with significant shunt using urinary neutrophil gelatinase-associated lipocalin

BACKGROUND

CHDs can be complicated by renal injury which worsens morbidity and mortality. Urinary neutrophil gelatinase-associated lipocalin, a sensitive and specific biomarker of renal tubular injury, has not been studied in children with uncorrected CHDs. This study evaluated renal injury in children with uncorrected CHDs using this biomarker.

METHODS

The patients were children with uncorrected CHDs with significant shunt confirmed on echocardiogram with normal renal ultrasound scan, in the paediatric cardiology clinic of a tertiary hospital. The controls were age-matched healthy children recruited from general practice clinics. Information on bio-data and socio-demographics were collected and urine was obtained for measurement of urinary neutrophil gelatinase-associated lipocalin levels.

RESULTS

A total of 65 children with uncorrected CHDs aged 2 to 204 months were recruited. Thirty-one (47.7%) were males while 36 (55.4%) had acyanotic CHDs. The median urinary neutrophil gelatinase-associated lipocalin level of patients of 26.10 ng/ml was significantly higher than controls of 16.90 ng/ml (U = 1624.50, p = 0.023). The median urinary neutrophil gelatinase-associated lipocalin level of patients with cyanotic and acyanotic CHDs were 30.2 ng/ml and 22.60 ng/ml respectively; (Mann-Whitney U = 368.50, p = 0.116). The prevalence of renal injury using 95th percentile cut-off value of urinary neutrophil gelatinase-associated lipocalin was 16.9%. Median age of patients with renalinjury was 16 (4-44) months.

CONCLUSIONS

Children with uncorrected CHDs have renal injury detected as early as infancy. The use of urinary neutrophil gelatinase-associated lipocalin in early detection of renal injury in these children may enhance early intervention and resultant prevention of morbidity and reduction in mortality.

Preeclampsia: a gestational cardiorenal syndrome

It is generally accepted today that there are two different types of preeclampsia: an early-onset or placental type and a late-onset or maternal type. In the latent phase, the first one presents with a low output/high resistance circulation eventually leading in the late second or early third trimester to an intense and acutely aggravating systemic disorder with an important impact on maternal and neonatal mortality and morbidity; the other type presents initially as a high volume/low resistance circulation, gradually evolving to a state of circulatory decompensation usually in the later stages of pregnancy, with a less severe impact on maternal and neonatal outcome. For both processes, numerous dysfunctions of the heart, kidneys, arteries, veins and interconnecting systems are reported, most of them presenting earlier and more severely in early- than in late-onset preeclampsia; however, some very specific dysfunctions exist for either type. Experimental, clinical and epidemiological observations before, during and after pregnancy are consistent with gestation-induced worsening of subclinical pre-existing chronic cardiovascular dysfunction in early-onset preeclampsia, and thus sharing the pathophysiology of cardiorenal syndrome type II, and with acute volume overload decompensation of the maternal circulation in late-onset preeclampsia, thus sharing the pathophysiology of cardiorenal syndrome type 1. Cardiorenal syndrome type V is consistent with the process of preeclampsia superimposed upon clinical cardiovascular and/or renal disease, alone or as part of a systemic disorder. This review focuses on the specific differences in haemodynamic dysfunctions between the two types of preeclampsia, with special emphasis on the interorgan interactions between heart and kidneys, introducing the theoretical concept that the pathophysiological processes of preeclampsia can be regarded as the gestational manifestations of cardiorenal syndromes.

How to evaluate patients with congenital heart disease-related pulmonary arterial hypertension

INTRODUCTION

Patients with congenital heart disease (CHD), who develop pulmonary arterial hypertension (PAH), live longer, and have better quality of life compared to the past due to PAH-specific therapy and improved tertiary care. Areas covered: Clinical examination, objective assessment of functional capacity, natriuretic peptide levels, cardiac imaging, and hemodynamics all play a pivotal role in the evaluation, general care, and management of PAH-specific therapy. This review discusses the epidemiology and pathophysiology of PAH-CHD and provides hints for the optimal evaluation of these patients. Expert commentary: Further research should be performed in the field of PAH-CHD, as there are many of areas lacking evidence that should be addressed in the future. Networking, especially among the tertiary expert centers, could play a key role in this direction.

Risk factors for hyperuricemia in congenital heart disease patients and its relation to cardiovascular death

INTRODUCTION

Hyperuricemia has been associated with cardiovascular risk factors but it remains controversial if uric acid is an independent predictor of cardiac mortality.

METHODS

A total of 503 CHD patients (457 nonhypoxemic and 46 hypoxemic) and 772 control patients fulfilled inclusion criteria. Demographic, clinical, and analytical data [serum uric acid and 24h urine uric acid levels, N-terminal pro-B-type natriuretic peptide (NT-pro-BNP), and C-reactive-protein (CRP) concentrations] were studied. Survivals curves to determine cardiac death and arterial thrombosis in CHD patients were also examined.

RESULTS

Noncyanotic and cyanotic CHD patients had significant higher serum uric acid concentration (5.2 ± 1.5 vs 4.9 ± 1.3mg/dL, P = .007 and 6.7 ± 2.1 vs 4.9 ± 1.3mg/dL, P < .001, respectively) and gout (1% vs 0%, P = .003 and 4% vs 0%, P < .01, respectively) than the control population. Among CHD patients, hyperuricemic patients were significant older and with overweight, used more diuretics, were more cyanotic and had higher serum creatinine, NT-pro-BNP and CRP concentrations than nonhyperuricemic. In the multivariable analysis, the body mass index (BMI) (OR 1.09; 95% CI 1.01-1.18), cyanosis (OR 6.2; 95 CI 1.5-24.6), serum creatinine concentration (OR 49; 95% CI 44-538), and being under diuretic treatment (OR 4.5; 95% CI 1.4-14.5) proved to be risk factors for hyperuricemia in CHD patients. The Kaplan-Meier events free survival curves, during a 5.2 ± 2.7 years follow-up of up time, showed that hyperuricemic CHD patients had significant higher cardiovascular death (P = .002). However, after applying the Cox regression analysis uric acid levels lost its statistical significance. No significant differences were seen in relation to thrombotic events between CHD patients with and without hyperuricemia.

CONCLUSIONS

CHD patients, noncyanotic and cyanotic, have higher serum uric acid levels and gout than patients in the general population. BMI, renal insufficiency, cyanosis, and the use of diuretics were risk factor for hyperuricemia among CHD patients.

Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association

Life expectancy and quality of life for those born with congenital heart disease (CHD) have greatly improved over the past 3 decades. While representing a great advance for these patients, who have been able to move from childhood to successful adult lives in increasing numbers, this development has resulted in an epidemiological shift and a generation of patients who are at risk of developing chronic multisystem disease in adulthood. Noncardiac complications significantly contribute to the morbidity and mortality of adults with CHD. Reduced survival has been documented in patients with CHD with renal dysfunction, restrictive lung disease, anemia, and cirrhosis. Furthermore, as this population ages, atherosclerotic cardiovascular disease and its risk factors are becoming increasingly prevalent. Disorders of psychosocial and cognitive development are key factors affecting the quality of life of these individuals. It is incumbent on physicians who care for patients with CHD to be mindful of the effects that disease of organs other than the heart may have on the well-being of adults with CHD. Further research is needed to understand how these noncardiac complications may affect the long-term outcome in these patients and what modifiable factors can be targeted for preventive intervention.

Medium-term follow-up of renal function in hypoxaemic congenital heart disease patients

Introduction Hypoxaemic congenital heart disease (CHD) patients are at higher risk of complications. The aim of this study was to compare and follow-up blood and 24-hour urine analytical data in hypoxaemic and non-hypoxaemic CHD patients.

METHODS

The inclusion criteria for this study were as follows: patients older than 14 years of age with a structural CHD with or without associated hypoxaemia.

RESULTS

In total, 27 hypoxaemic and 48 non-hypoxaemic CHD patients were included in order to compare blood and 24-hour urine analytical data. Among hypoxaemic patients, 13 (48.1%) were male, two (7.4%) had diabetes mellitus, one of whom was a smoker, one (3.7%) had systemic arterial hypertension, and 11 (40.7%) showed pulmonary arterial hypertension. The mean follow-up time was 3.1±1.9 years. Hypoxaemic CHD patients showed higher proteinuria concentrations (g/24 hours) (0.09 (0.07; 0.46) versus 0.08 (0.07; 0.1), p=0.054) and 24-hour albumin excretion rate (µg/min) (16.5 (11.2; 143.5) versus 4.4 (0.0; 7.6), p<0.001) compared with non-hypoxaemic CHD patients; however, no significant differences were found in the proteinuria levels and in the 24-hour albumin excretion rate in CHD patients with associated hypoxaemia, both at baseline and at follow-up. When divided into groups, hypoxaemic patients with palliative shunts showed significantly higher proteinuria concentrations compared with hypoxaemic patients not operated on or with Fontan procedures (p=0.01). No significant differences were seen in 24-hour proteinuria and 24-hour albumin excretion rate during the follow-up of patients with palliative shunts.

CONCLUSIONS

Hypoxaemic CHD patients have significant higher 24-hour proteinuria concentration and 24-hour albumin excretion rate compared with non-hypoxaemic CHD patients. Among hypoxaemic CHD patients, those with palliative shunts showed the highest 24-hour proteinuria concentrations.

Acquired Von Willebrand Factor Abnormalities in Adults with Congenital Heart Disease: Dependence Upon Cardiopulmonary Pathophysiological Subtype

Hemostasis is often abnormal in adults with con genital heart disease, and von Willebrand factor abnormalities have been reported in this patient population. We sought to determine the prevalence, type, and severity of the von Wil lebrand factor abnormality, and its relationship to three patho physiological variables; cyanosis, pulmonary vascular disease, and turbulent blood flow. This prospective study comprised 76 unoperated congenital heart disease patients aged 20 to 68 years (mean = 34 years). There were 44 cyanotic and 32 acyanotic patients. Twenty-seven cyanotic and 6 acyanotic pa tients had pulmonary vascular disease, 31 cyanotic and 16 acyanotic patients had turbulent blood flow, and 11 patients were acyanotic without pulmonary vascular disease or turbu lent flow. The largest plasma von Willebrand factor multimers were relatively decreased or absent in 77% of cyanotic versus 41 % of acyanotic patients ( p < .001); in 76% of patients with, versus 51 % without, pulmonary vascular disease ( p < .029); and in 72% of patients with, versus 45% without, turbulent flow ( p <.016). Von Willebrand factor multimers were normal in all 11 acyanotic patients without pulmonary vascular disease or turbulent blood flow. Von Willebrand factor multimer ab normalities normalized after reparative surgery in five patients. Depletion of the largest plasma von Willebrand factor multim ers is common in adults with congenital heart disease. Cyano sis, pulmonary vascular disease, and turbulent flow are deter minants of the abnormality that is acquired and reversible.

Impaired Right, Left, or Biventricular Function and Resting Oxygen Saturation Are Associated With Mortality in Eisenmenger Syndrome: A Clinical and Cardiovascular Magnetic Resonance Study

BACKGROUND

Patients with Eisenmenger syndrome (ES) have better survival, despite similar pulmonary vascular pathology, compared with other patients with pulmonary arterial hypertension. Cardiovascular magnetic resonance (CMR) is useful for risk stratification in idiopathic pulmonary arterial hypertension, whereas it has not been evaluated in ES. We studied CMR together with other noninvasive measurements in ES to evaluate its potential role as a noninvasive risk stratification test.

METHODS AND RESULTS

Between 2003 and 2005, 48 patients with ES, all with a post-tricuspid shunt, were enrolled in a prospective, longitudinal, single-center study. All patients underwent a standardized baseline assessment with CMR, blood test, echocardiography, and 6-minute walk test and were followed up for mortality until the end of December 2013. Twelve patients (25%) died during follow-up, mostly from heart failure (50%). Impaired ventricular function (right or left ventricular ejection fraction) was associated with increased risk of mortality (lowest quartile: right ventricular ejection fraction, <40%; hazard ratio, 4.4 [95% confidence interval, 1.4-13.5]; P=0.01 and left ventricular ejection fraction, <50%; hazard ratio, 6.6 [95% confidence interval, 2.1-20.8]; P=0.001). Biventricular impairment (lowest quartile left ventricular ejection fraction, <50% and right ventricular ejection fraction, <40%) conveyed an even higher risk of mortality (hazard ratio, 8.0 [95% confidence interval, 2.5-25.1]; P=0.0004). No other CMR or noninvasive measurement besides resting oxygen saturation (hazard ratio, 0.90 [0.83-0.97]/%; P=0.007) was associated with mortality.

CONCLUSIONS

Impaired right, left, or biventricular systolic function derived from baseline CMR and resting oxygen saturation are associated with mortality in adult patients with ES. CMR is a useful noninvasive tool, which may be incorporated in the risk stratification assessment of ES during lifelong follow-up.

Proteinuria and clinical outcome in CHD patients

INTRODUCTION

CHD patients, especially those with associated hypoxaemia, usually have some level of renal function impairment, even though they are relatively young. The aim of the study was to evaluate those clinical and analytical factors that may contribute to microalbuminuria and determine the association of 24-hour proteinuria with thrombotic events and mortality.

METHODS

A total of 251 CHD patients were studied and demographic characteristics, blood test, and 24-hour urinalysis were analysed.

RESULTS

Of the patients, 221 were non-hypoxaemic, and 30 were hypoxaemic (oxygen saturation of 84.3±5.9%). Of the non-hypoxaemic patients, 30 (13.6%), and of the hypoxaemic patients 9 (30%), showed proteinuria (>0.15 g/24 hours) (p=0.028). Hypoxaemic CHD patients also showed higher haematocrit (%) (50.7 (34.6; 72.1) versus 42.8 (34.6; 48.9), p<0.001), serum creatinine (mg/dl) (1.07±0.2 versus 0.96±1.9, p=0.004), microalbuminuria (mg/dl/24 hours) (1.2 (0.0; 261.5) versus 0.5 (0.0; 4.37), p<0.001), proteinuria (gr/24 hours) (1.0 (0.4; 3.1) versus 0.08 (0.04; 0.52), p=0.043), and N-terminal pro-B-type natriuretic peptide (pg/ml) (417.8 (35.7; 8534.0) versus 44.9 (0.0; 670.5), p<0.001) concentrations than non-hypoxaemic CHD patients. During a median follow-up of 26.0 (16.9; 57.7) months, five patients died - one patient had 24-hour proteinuria and four patients did not (p=0.581) - and three patients had some type of thrombosis - two patients had 24-hour proteinuria and one patient did not (p=0.014). Kaplan-Meier survival analysis showed no significant difference between CHD patients with and without 24-hour proteinuria (p=0.631).

CONCLUSION

CHD patients with proteinuria have significantly more thrombosis and more hypoxaemia than those patients without proteinuria.

Pulmonary hypertension related to congenital heart disease: a call for action

Pulmonary arterial hypertension related to congenital heart disease (PAH-CHD) is a common type of pulmonary arterial hypertension (PAH). Despite this, little emphasis has been given to this group of patients until recently, when compared with idiopathic PAH. This is largely because of the complexity and the wide range of underlying cardiac anatomy and physiology, with a multitude of adaptive mechanisms not fully understood. Pulmonary arterial hypertension related to congenital heart disease is, therefore, best diagnosed and managed in centres specializing in both CHD and PAH, to avoid common pitfalls and old practices and to provide state-of-the-art care. We discuss the optimal management of PAH-CHD patients in a series of actions to be taken in order to optimize short- and long-term outcome, based on current knowledge of the condition and the advent of targeted advanced therapies.

Congenital heart disease and pulmonary hypertension

Many patients with congenital heart disease and systemic-to-pulmonary shunts develop pulmonary arterial hypertension (PAH), particularly if the cardiac defect is left unrepaired. A persistent increase in pulmonary blood flow may lead to obstructive arteriopathy and increased pulmonary vascular resistance, a condition that can lead to reversal of shunt and cyanosis (Eisenmenger syndrome). Cardiac catheterization is crucial to confirm diagnosis and facilitate treatment. Bosentan is the only medication to date to be compared with placebo in a randomized controlled trial specifically targeting congenital heart disease-associated PAH. Lung transplantation with repair of the cardiac defect or combined heart-lung transplantation is reserved for recalcitrant cases.

Truncus arteriosus: A major cause of proteinuria in children

Background:

There are many studies about the association of nephropathy with congenital heart diseases (CHD), and the risk factors such as cyanosis and pulmonary hypertension have been evaluated. In our study, we have considered the relation of CHD associated nephropathy with other newer factors and the type of the structural heart defect.

Materials and Methods:

A prospective cross sectional study was carried out. 48 children were selected on the basis of specific inclusion criteria, and reviewed over a period of 9 months. Nine different simple and complex structural heart defects were evaluated and compared after obtaining the imaging, blood and urine test results.

Results:

Significant proteinuria occurred in 8 patients included in the study. More severe forms of pulmonary hypertension were observed in patients suffering from truncus arteriosus (TA); while the least values were detected in cases of pulmonary stenosis (PS) and tetralogy of fallot (TOF). The highest values of protein excretion were seen in patients of TA; and, the lowest values were observed in patients of PS and aortic stenosis (AS). Renal insufficiency was uncommon in infants and children with CHD.

Conclusion:

TA is an important cause of proteinuria among the infants and children suffering from CHD, probably because of the associated severe pulmonary hypertension (PH) and cyanosis. Also, proteinuria occurred at an earlier age in patients of TA as compared to other conditions, and was also found to be more severe if the TA was associated with moderate to severe tricuspid regurgitation.

Three-dimensional cortical bone microstructure in a rat model of hypoxia-induced growth retardation

Little is known about hypoxia-induced modification of the canal network in the cortical bone despite its involvement in intracortical vascularity and bone blood supply. In this study, we examined the effect of chronic hypoxia on the canal network in postnatal bone. Tibiae were harvested from 4- and 8-week-old rats (hyp-4 and -8, n = 8 each), whose growth was retarded owing to postnatal exposure to hypoxia (12-14% O₂), and from 3- and 4-week-old normoxic rats (cnt-4 and -5, n = 8 each), which were similar in tibial length and cortical cross-sectional area to hyp-4 and -8, respectively. The diaphyseal canals were detected by monochromatic synchrotron radiation CT with a 3.1-μm voxel resolution. The anatomical properties of the canal network were compared between age- or size-matched hypoxic and normoxic groups. The canals were larger in diameter, were more densely distributed and connected, and opened into the marrow cavity with a higher density in hyp-4 than in cnt-4. The canal density and connectivity were also higher in hyp-4 than in cnt-3. The canal diameter, density, and connectivity were smaller in hyp-8 than in cnt-4; however, the densities of endocortical and periosteal canal openings did not differ between hyp-8 and cnt-4. We concluded that chronic hypoxia enhanced the formation of cortical canal networks at the postnatal developmental stage, probably facilitating intra- and transcortical vascularization and bone perfusion accordingly.

Minimally Invasive Options for Failing Homografts in the Pulmonary Position

Homograft implantation in the pulmonary position is usually part of initial repair in congenital heart defects with dysplasia or atresia of the pulmonary valve and at the time of the Ross operation. As part of reoperations, homografts are mainly required after nonvalved right ventricular outflow tract procedures. Due to an annual increase of homograft dysfunction, replacement is inevitable. Recently, percutaneous catheter-based valve implantations gain increasing acceptance. Even transventricular pulmonary valve implantation has been reported. Prior to decision making for any surgical or interventional therapy, the right ventricular outflow tract morphology together with additional pathologies need to be assessed. With the development of new prostheses and delivery modes, the demand for conventional surgery will further decrease.

Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: complex congenital cardiac lesions

With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. They have distinctive forms of heart failure and their cardiac disease can be associated with pulmonary hypertension, thromboemboli, complex arrhythmias and sudden death. Medical aspects that need to be considered relate to the long-term and multisystemic effects of single ventricle physiology, cyanosis, systemic right ventricles, complex intracardiac baffles and failing subpulmonary right ventricles. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with CHD, there have been significant advances in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. Part III of the guidelines includes recommendations for the care of patients with complete transposition of the great arteries, congenitally corrected transposition of the great arteries, Fontan operations and single ventricles, Eisenmenger's syndrome, and cyanotic heart disease. Topics addressed include genetics, clinical outcomes, recommended diagnostic workup, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy risk and follow-up requirements. The complete document consists of four manuscripts, which are published online in the present issue of The Canadian Journal of Cardiology. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.

Surgical repair of tetralogy of Fallot in adults today

BACKGROUND

Today, corrective surgery of native tetralogy of Fallot beyond childhood is a rare exception. In the years following the fall of the Berlin wall, 22 adults with uncorrected tetralogy presented to our center, mostly from former Eastern Block countries.

HYPOTHESIS

Our aim was to examine whether adults with tetralogy of Fallot benefit from late surgical repair. Nineteen patients underwent corrective surgery; hospital mortality was 16%. Follow-up examination 3.5 (0.3-9.7) years postoperatively consisted of chart review and a written questionnaire. Incidence of ventricular arrhythmias was 32% before surgery and increased to 50% 3.5 years after surgery. Clinical status and New York Heart Association classification were clearly improved. This was not reflected in an improvement of the patients' socioeconomic status, as none of the 9 patients in our group of 19, who were jobless before the surgery, experienced a change in employment status. Marital status did not change in any patient and, in particular, the number of single male patients remains high. Except for one nearly asymptomatic younger woman who had delivered four children, only one of the seven married women had delivered a child before and one of the younger women after cardiac repair, which we consider to be a positive effect of this surgery. Surgical correction of adult patients with tetralogy of Fallot carries a higher risk compared with correction in childhood. It improves quality of life but does not change socioeconomic habits.

Long-term results after the Rastelli repair for transposition of the great arteries

BACKGROUND

This study sought to assess risk factors for late mortality after the Rastelli operation for patients with transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction.

METHODS

Records of 39 patients who underwent the Rastelli operation between 1977 and 2004 were reviewed. Median age at the time of operation was 5.1 years (2.2 years within the last 5 years).

RESULTS

There were no early deaths. During a median follow-up of 8.9 years (range, 0 to 25 years), 2 patients died of sudden death, 1 of pneumonia, 1 during reoperation, and 2 received heart transplantation. Freedom from death or transplantation was 93.8% +/- 4.3% and 57.5% +/- 15.1% at 10 and 20 years, respectively. Freedom from conduit replacement was 48.8% +/- 10.3% and 32.5% +/- 10.3% at 10 and 20 years, respectively. Subvalvular and valvular left ventricular outflow tract obstruction (p = 0.012), stenosis of the peripheral pulmonary arteries (p < 0.001), enlargement of the ventricular septal defect (p = 0.030), and longer ischemic time (p = 0.015) were predictive for death or transplantation. Patients younger than 4 years at the time of the Rastelli operation showed a trend toward a better freedom from death or transplantation (p = 0.068), but needed significantly more conduit replacements (p = 0.038) compared with patients 4 years or older.

CONCLUSIONS

The Rastelli operation is a low-risk procedure with regard to early mortality. The status of the pulmonary arteries and ventricular septal defect enlargement are predictive for long-term survival. Patients 4 years of age or older at the time of the Rastelli operation require fewer reoperations for conduit exchange. Nevertheless, early Rastelli repair is recommended because patients 4 years or older are at risk for a higher long-term mortality.

Pulmonary Vascular Disease in Adults With Congenital Heart Disease

Pulmonary arterial hypertension of variable degree is commonly associated with adult congenital heart disease. Depending on size and location of the underlying cardiac defect as well as on repair status, pulmonary arterial hypertension may present with or without reversed shunting and associated cyanosis (ie, Eisenmenger syndrome). We review available data on etiology, clinical presentation, prognosis, and management strategies of pulmonary arterial hypertension in adult patients with congenital heart disease. In addition, we discuss the numerous complications associated with Eisenmenger syndrome, representing a multisystem disorder. Finally, we present general management strategies and emerging disease-targeting therapies.

Univentricular Heart

As early as 1699, Chemineau described a heart composed of 2 auricles but only 1 ventricle. 1 The univentricular heart has since fascinated the medical community. Unique in its complexity and scope, the univentricular heart has sparked intense debates about embryology and nomenclature, challenged our understanding of cardiovascular physiology and hemodynamics, and inspired some of the most creative surgical and interventional approaches in human history. The present report provides an overview of the nomenclature and classification of the univentricular heart, epidemiology and pathological subtypes, genetic factors, physiology, clinical features, diagnostic assessment, therapy, and postoperative sequelae. Although the present report touches on issues applicable to neonates and children with univentricular hearts, the focus is on information of interest and relevance to the adult cardiologist.

Correction of Tetralogy of Fallot and of Pulmonary Atresia with Ventricular Septal Defect in Adults

BACKGROUND

Early correction is regarded as the treatment of choice for patients with tetralogy of Fallot or pulmonary atresia with ventricular septal defect. Nevertheless, some of these patients reach adulthood without early correction. This study sought to assess risk factors for operative mortality and determine the benefit of total correction in adolescent and adult patients.

METHODS

A retrospective analysis of 52 patients (>16 years at the time of corrective surgery) for tetralogy of Fallot (n = 42) or pulmonary atresia with ventricular septal defect (n = 10) between 1974 and 2003 was performed.

RESULTS

Age at correction was 28.9 +/- 9.9 (16 to 57 years). There were 8 early deaths (15.4%). Preoperative hemoglobin concentration (p = 0.002) and reconstruction of the right ventricular outflow tract with a patch (p = 0.002) were correlated with a significantly higher early mortality. Mean follow-up time was 12.3 +/- 10.4 years. Late deaths (n = 6; 11.5%) were cardiac-related in 2 of 6 cases. At follow-up, 28 patients (87.5%) were assigned to the New York Heart Association functional class I. Twenty-four patients led a normal life with full-time work, 6 patients were able to do part-time work, and only 2 patients experienced noticeable limitation on activities.

CONCLUSIONS

Repair of tetralogy of Fallot and of pulmonary atresia with ventricular septal defect in this patient group is associated with a high early mortality. Preoperative chronic cyanosis, expressed by elevated hemoglobin concentration, is predictive for early mortality. Because cyanosis has been shown to lead to multiorgan dysfunction, we conclude that preoperative multiorgan dysfunction may be the intrinsic risk factor for perioperative mortality. Surgical correction in this patient group should still be recommended because the functional status considerably improves.

Myocardial perfusion reserve in adults with cyanotic congenital heart disease

In patients with cyanotic congenital heart disease (CCHD), a right-to-left shunt results in systemic hypoxemia. Systemic hypoxemia incites a compensatory erythrocytosis, which increases whole blood viscosity. We considered that these changes might adversely influence myocardial perfusion in CCHD patients. Basal and hyperemic (intravenous dipyridamole) perfusion measurements were obtained with [13N]ammonia positron emission tomographic imaging in left (LV) and right (RV) ventricular and septal myocardium in 14 adults with CCHD [age: 34.1 yr (SD 6.5)]; hematocrit: 62.2% (SD 4.8)] and 10 healthy controls [age: 34.1 yr (SD 6.5)]. In patients, basal perfusion measurements were higher in LV [0.77 (SD 0.24) vs. 0.55 ml·min−1·g−1 (SD 0.09), P < 0.02], septum [0.71 (SD 0.16) vs. 0.49 ml·min−1·g−1 (SD 0.09), P < 0.001], and RV [0.77 (SD 0.30) vs. 0.38 ml·min−1·g−1 (SD 0.09), P < 0.001]. However, basal measurements normalized for the rate-pressure product were similar to those of controls. Calculated oxygen delivery relative to rate-pressure product was higher in the patients [2.2 (SD 0.8) vs. 1.6 (SD 0.4) × 10−5 ml O2·min−1·g tissue−1·(beats·mmHg)−1 in the LV, P < 0.05, and 2.0 (SD 0.7) vs. 1.4 (SD 0.3) × 10−5 ml O2·min−1·g tissue−1·(beats·mmHg)−1 in the septum, P < 0.01]. Hyperemic perfusion measurements in CCHD patients did not differ from controls [LV, 1.67 (SD 0.60) vs. 1.95 ml·min−1·g−1 (SD 0.46); septum, 1.44 (SD 0.56) vs. 1.98 ml·min−1·g−1 (SD 0.69); RV, 1.56 (SD 0.56) vs. 1.65 ml·min−1·g−1 (SD 0.64), P = not significant], and coronary vascular resistances were comparable [LV, 55 (SD 25) vs. 48 mmHg·ml−1·g·min (SD 16); septum, 67 (SD 35) vs. 50 mmHg·ml−1·g·min (SD 21); RV, 59 (SD 26) vs. 61 mmHg·ml−1·g·min (SD 27), P = not significant]. These findings suggest that adult CCHD patients have remodeling of the coronary circulation to compensate for the rheologic changes attending chronic hypoxemia.

Glomerular and tubular dysfunction in children with congenital cyanotic heart disease: effect of palliative surgery

BACKGROUND

Nephropathy has long been recognized as a potential complication of congenital cyanotic heart disease (CCHD). The present study was undertaken to investigate some aspects of glomerular function by measuring urinary total protein, microalbumin, and tubular function by assessing urinary alpha-1-microglobulin. The structural integrity of the renal proximal tubules was also studied by measuring urinary activities of the brush-border enzyme leucine-aminopeptidase and the lysosomal enzyme -acetyl-beta-d-glucosaminidase. The levels of hematocrit (Hct) and oxygen saturation were also investigated as predisposing factors for renal impairment in CCHD.

METHODS

These investigations were done by recruiting 86 children who were grouped as follows: the control group (G1 ) consisted of 14 children (aged 4-12 years); the other 72 children with CCHD were divided according to age (ie, duration of cyanosis) into 4 equal groups, each containing 18 patients: G2 (age <1 year), G3 (age > or = 1 year and <5 years), G4 (age > or = 5 years and <10 years), and G5 (age > or = 10 years). In addition, 10 of the 72 patients underwent a palliative surgery and were included as G6 (regardless of age: 2 from G3, 4 from G4, and 4 from G5 ) to study the effect of the palliative surgery on the above-mentioned parameters.

RESULTS

Results of the present work showed that with increasing duration of cyanosis (ie, on going from G2 to G5 ) among the studied children with CCHD, there was a significant elevation in the urinary excretion of the investigated functional and structural parameters of the glomeruli and proximal tubules compared with the control children. The data also showed a significant increase in Hct, whereas oxygen saturation was significantly decreased. Results of G6 after the palliative surgery demonstrated a significant decrease in the urinary excretion of the investigated parameters of the kidney, with a significant decrease in Hct and increase in oxygen saturation levels, compared with the results of the patients of this group before the palliative surgery.

CONCLUSIONS

These results suggest impairment of both glomerular and tubular functions as well as structure of the proximal tubules among children with CCHD and that the palliative surgery has significantly improved this impairment.

Renal function after cardiopulmonary bypass surgery in cyanotic congenital heart disease

We studied perioperative renal damage in 22 patients with long-standing cyanotic congenital heart disease.

BACKGROUND

[corrected] Postoperative acute renal failure is a major complication of cardiac surgery associated with poor prognosis. Our study was designed to identify risk factors for renal failure in patients with cyanotic congenital heart disease.

PATIENTS

22 cyanotic patients with a oxygen saturation of 82% (38-92%), age 14 years (5-42 years) and six controls with atrial septal defect, age 37 years (28-66 years) were investigated with repeated urinary analyses.

RESULTS

Before operation, six of 22 of the cyanotic patients had albuminuria. Postoperatively three patients developed acute renal failure including glomerular and tubular damage. Urinary albumin analysis >1000 mg g(-1) creatinine after 24 h and N-acteyl-beta-D-glucosaminidase analysis >100 U g(-1) creatinine after 48 h predicted dialysis requirement. In noncyanotic controls only one preoperative and none of the postoperative analyses were pathological.

CONCLUSIONS

Patients with cyanotic congenital heart disease are at risk for acute renal failure, which can be prognosed by urine analysis already 24 h after surgery. Cyanotic glomerulopathy should be known before surgery. To lower the risk, cardiopulmonary bypass time should be kept as short as possible and adequate hydration should be maintained in combination with extended diuretic therapy.