Lifetime risk of comorbidity in patients with simple congenital heart disease: a Danish nationwide study

AIMS

In a continuously ageing population of patients with congenital heart disease (CHD), understanding the long-term risk of morbidity is crucial. The aim of this study was to compare the lifetime risks of developing comorbidities in patients with simple CHD and matched controls.

METHODS AND RESULTS

Using the Danish nationwide registers spanning from 1977 to 2018, simple CHD cases were defined as isolated atrial septal defect (ASD), ventricular septal defect (VSD), pulmonary stenosis, or patent ductus arteriosus in patients surviving until at least 5 years of age. There were 10 controls identified per case. Reported were absolute lifetime risks and lifetime risk differences (between patients with simple CHD and controls) of incident comorbidities stratified by groups and specific cardiovascular comorbidities. Of the included 17 157 individuals with simple CHD, the largest subgroups were ASD (37.7%) and VSD (33.9%), and 52% were females. The median follow-up time for patients with CHD was 21.2 years (interquartile range: 9.4-39.0) and for controls, 19.8 years (9.0-37.0). The lifetime risks for the investigated comorbidities were higher and appeared overall at younger ages for simple CHD compared with controls, except for neoplasms and chronic kidney disease. The lifetime risk difference among the comorbidity groups was highest for neurological disease (male: 15.2%, female: 11.3%), pulmonary disease (male: 9.1%, female: 11.7%), and among the specific comorbidities for stroke (male: 18.9%, female: 11.4%). The overall risk of stroke in patients with simple CHD was mainly driven by ASD (male: 28.9%, female: 17.5%), while the risks of myocardial infarction and heart failure were driven by VSD. The associated lifetime risks of stroke, myocardial infarction, and heart failure in both sexes were smaller in invasively treated patients compared with untreated patients with simple CHD.

CONCLUSION

Patients with simple CHD had increased lifetime risks of all comorbidities compared with matched controls, except for neoplasms and chronic kidney disease. These findings highlight the need for increased attention towards early management of comorbidity risk factors.

Adult congenital heart disease: magnitude of the problem

PURPOSE OF REVIEW

To define the magnitude of problems faced by patients with adult congenital heart disease (ACHD) and to identify unmet needs for this population.

RECENT FINDINGS

The ACHD population is estimated to include more than 1 million people in the United States and continues to grow at a steady rate. Owing to the decline in early mortality in this group, modern medicine is now faced by the long-term complications associated with congenital heart disease such as chronic heart failure, increased endocarditis risk, elevated burden of arrhythmias, pulmonary hypertension, valvular dysfunction, and pregnancy.

SUMMARY

Increasing access to ACHD care, evolution of imaging techniques and transcatheter technology and continued efforts at quality improvement will be key to successfully facing the challenges that are a product of the astounding success of pediatric cardiac surgery.

Infective Endocarditis Associated with Atrial Septal Defect in an Intravenous Drug Abuser: A Case Report

Atrial septal defect (ASD) is a common congenital abnormality, which accounts for 20-40% of all the adult patients with congenital heart diseases. Due to the slow velocity of shunt flow, ASD has a negligible risk for infective endocarditis (IE). However, intravenous drug abuse (IVDA) is a potential cause for IE. IE remains a diagnostic and therapeutic challenge. Our case report demonstrates the atypical presentation of IE in an ASD patient. The diagnosis was made on the basis of modified Duke criteria, and blood cultures were found out to be positive for methicillin-resistant Staphylococcus aureus (MRSA). The treatment for IE was completed in six weeks with full recovery, and the patient underwent a surgery for ASD closure. This case highlights that IE should not be overlooked in ASD patients and that a high index of suspicion, in addition to proper antibiotic therapy, is lifesaving. Also, follow-up, along with rehabilitation measures, should be taken for patients with a history of drug abuse in order to prevent the risk of reinfection.

An Atypical Temporal Sequence for Right Heart Endocarditis: Case Report

In 2010, an 82-year-old patient received a diagnosis of stage IV chronic obstructive pulmonary disease, ischemic dilated cardiomyopathy, severe secondary pulmonary hypertension, atrial fibrillation with slow ventricular response, and severe tricuspid regurgitation. In December 2011, he was hospitalized for exacerbation of chronic obstructive pulmonary disease. The patient received antibiotics via injections (for 2 weeks through a peripheral venous catheter). In February 2012, he returned to the hospital with congestive heart failure and vascular purpura skin lesions. The echocardiography examination revealed a rupture of cordage afferent to the septal tricuspid valve. Because blood cultures were sterile after 10 days and no vegetation was revealed, the Duke criteria were not fulfilled. In March 2012, the patient returned with congestive heart failure, fatigue, and anorexia. Echocardiography evaluation then revealed attached septal tricuspid valve vegetation. The Duke criteria were now satisfied. The patient received antibiotics at doses recommended for infective endocarditis, with a favorable outcome.

Infective endocarditis in congenital heart disease

Congenital heart disease (CHD) has become the leading risk factor for pediatric infective endocarditis (IE) in developed countries after the decline of rheumatic heart disease. Advances in catheter- and surgery-based cardiac interventions have rendered almost all types of CHD amenable to complete correction or at least palliation. Patient survival has increased, and a new patient population, referred to as adult CHD (ACHD) patients, has emerged. Implanted prosthetic material paves the way for cardiovascular device-related infections, but studies on the management of CHD-associated IE in the era of cardiovascular devices are scarce. The types of heart malformation (unrepaired, repaired, palliated) substantially differ in their lifetime risks for IE. Streptococci and staphylococci are the predominant pathogens. Right-sided IE is more frequently seen in patients with CHD. Relevant comorbidity caused by cardiac and extracardiac episode-related complications is high. Transesophageal echocardiography is recommended for more precise visualization of vegetations, especially in complex type of CHD in ACHD patients. Antimicrobial therapy and surgical management of IE remain challenging, but outcome of CHD-associated IE from the neonate to the adult is better than in other forms of IE.

CONCLUSION

Primary prevention of IE is vital and includes good dental health and skin hygiene; antibiotic prophylaxis is indicated only in high-risk patients undergoing oral mucosal procedures.