Long-term outlook in treated congenital heart disease

Overview of adult congenital heart transplants

Transplantation for adult patients with congenital heart disease (ACHD) is a growing clinical endeavor in the transplant community. Understanding the results and defining potential high-risk patient subsets will allow optimization of patient outcomes. This review summarizes the scope of ACHD transplantation, the mechanisms of late ventricular dysfunction, the ACHD population at risk of developing heart failure, the indications and potential contraindications for transplant, surgical considerations, and post-transplant outcomes. The findings reveal that 3.3% of adult heart transplants occur in ACHD patients. The potential mechanisms for the development of late ventricular dysfunction include a morphologic systemic right ventricle, altered coronary perfusion, and ventricular noncompaction. The indications for transplant in ACHD patients include systemic ventricular failure refractory medical therapy, Fontan patients failing from chronic passive pulmonary circulation, and progressive cyanosis leading to functional decline. Transplantation in ACHD patients can be quite complex and may require extensive reconstruction of the branch pulmonary arteries, systemic veins, or the aorta. Vasoplegia, bleeding, and graft right ventricular dysfunction can complicate the immediate post-transplant period. The post-transplant operative mortality ranges between 14% and 39%. The majority of early mortality occurs in ACHD patients with univentricular congenital heart disease. However, there has been improvement in operative survival in more contemporary studies. In conclusion, the experience with cardiac transplantation for ACHD patients with end-stage heart failure is growing, and high-risk patient subsets have been defined. Significant strides have been made in developing evidence-based guidelines of indications for transplant, and the intraoperative management of complex reconstruction has evolved. With proper patient selection, more aggressive use of mechanical circulatory support, and earlier referral of patients with failing Fontan physiology, outcomes should continue to improve.

Congenital heart disease in pregnancy in a low-income country

OBJECTIVE

To assess maternal and perinatal outcomes among pregnant women with congenital heart disease (CHD) in a low-resource country.

METHODS

A prospective, observational study was conducted at a teaching hospital in Kolkata, India, between January 1, 2008, and December 31, 2010. All pregnant women with CHD were followed up from first prenatal visit to discharge. Both maternal and perinatal outcomes were analyzed.

RESULTS

Of 174 pregnant women with heart disease, 27 (16%) had CHD. Mean age was 23.5±3.6 years. Four (15%) patients were diagnosed with CHD during the index pregnancy. Nine (33%) women had undergone surgical correction before conception. Cesarean delivery was performed in 12 (44%) women. Fifteen (56%) neonates weighed less than 2500 g, and 4 (15%) were born preterm. Mean birth weight was slightly higher in women with corrected heart lesions than in those with uncorrected ones (2593±480 g vs 2294±620 g; P=0.22). Three (11%) neonates died, but no stillbirths occurred. One (4%) woman died after delivery owing to atonic postpartum hemorrhage.

CONCLUSION

Delayed diagnosis, lack of treatment, and unplanned pregnancy are major challenges for women with CHD, which need to be addressed to improve maternal and neonatal outcomes in low-resource countries.

Long-term symptoms of depression and anxiety in mothers of infants with congenital heart defects

OBJECTIVE

To examine the relationship between the severity of infants' congenital heart defects (CHD) and their mothers' symptoms of depression and anxiety from pregnancy to 18 months postpartum.

METHODS

Mothers of infants with mild, moderate, or severe CHD (n=162) and mothers (n=44,400) within the Norwegian Mother and Child Cohort Study were assessed with an eight-item short version (SCL-8) of the Hopkins Symptom Checklist-25 at the 30th week of gestation and at 6 and 18 months postpartum.

RESULTS

Only the postpartum mental health trajectory of mothers of infants with severe CHD deviated from the mental health trajectory of the cohort at 6 and 18 months postpartum, showing significantly elevated levels of depression and anxiety symptoms.

CONCLUSIONS

The results elucidate the relationship between infants' CHD severity and maternal symptoms of depression and anxiety, possibly identifying a specifically vulnerable patient dyad in need of postoperative interventions.

Congenital heart disease in pregnancy

INTRODUCTION

Pregnancy, birth, and the puerperium are associated with significant physiological changes and adaptations in the cardiovascular system, which pose a significant risk to pregnant women with congenital heart disease (CHD). Thanks to advances in pediatric cardiac surgery and cardiology the majority of children with CHD survive to adulthood, and an increasing number eventually become pregnant. In fact, cardiac disease - mostly congenital - is now a leading cause of maternal death in western industrialized countries.

METHODS

Selective literature review.

RESULTS AND DISCUSSION

Optimal care of women with CHD before, during, and after pregnancy requires a multidisciplinary team including obstetricians, cardiologists, and anaesthetists. Successful pregnancy at a minimum risk is feasible for most women with CHD when appropriate counseling and optimal care are provided.