Long-term results of pediatric cardiac surgery in Finland: education, employment, marital status, and parenthood

Rationale and Design of CHD PULSE: Congenital Heart Disease Project to Understand Lifelong Survivor Experience

BACKGROUND

With improved survival of adults with congenital heart disease (CHD) comes a need to understand the lifelong outcomes of this population. The aim of this paper is to describe the rationale and design of Congenital Heart Disease Project to Understand Lifelong Survivor Experience (CHD PULSE), a study to determine long-term medical, neurocognitive, and psychosocial outcomes among adults with a history of intervention for CHD and to identify factors associated with those outcomes.

METHODS

CHD PULSE is a cross-sectional survey conducted from September 2021 to April 2023 among adults aged 18 and older with a history of at least one intervention for CHD at one of 11 participating U.S. centers in the Pediatric Cardiac Care Consortium. Participants with CHD were asked to complete a 99-question survey on a variety of topics including: demographics, surgeries, health insurance, health care, heart doctors, general health, height and weight, education and work history, reproductive health (for women only), and COVID-19. To construct a control group for the study, siblings of survey respondents were invited to complete a similar survey. Descriptive statistics for demographics, disease severity, center, and method of survey completion were computed for participants and controls. Comparisons were made between participants and non-participants to assess for response bias and between CHD participants and sibling controls to assess for baseline differences.

RESULTS

Among the 14,322 eligible participants, there were 3133 respondents (21.9%) from 48 U.S. states with surveys returned for inclusion in the study. Sibling contact information was provided by 691 respondents, with surveys returned by 326 siblings (47.2%). The median age of participants was 32.8 years at time of survey completion, with an interquartile range of 27.2 years to 39.7 years and an overall range of 20.1 to 82.9 years. Participants were predominantly female (55.1%) and of non-Hispanic White race/ethnicity (87.1%). There were no differences between participants and non-participants regarding severity of CHD. Compared to non-participants, participants were more likely to be female, of older age, and be of non-Hispanic White race/ethnicity. Enrolled siblings were more likely to be female and slightly younger than participants.

CONCLUSIONS

With surveys from 3133 participants from across the U.S., CHD PULSE is poised to provide keen insights into the lifelong journey of those living with CHD, extending beyond mere survival. These insights will offer opportunities for informing strategies to enhance and improve future outcomes for this population of patients.

Educational outcomes among children with congenital heart disease compared to peers: a Scotland-wide record-linkage study of 715,850 schoolchildren

BACKGROUND

Nine in every thousand children born in the United Kingdom have congenital heart disease, and 250,000 adults are living with the condition. This study aims to investigate the associations between congenital heart disease and educational outcomes among school-aged children in Scotland.

METHODS

Routine health and education databases were linked to produce a cohort of all singleton children born in Scotland and attending a local authority run primary, secondary, or special school in Scotland at some point between 2009 and 2013. Children with congenital heart disease within this cohort were compared with children unaffected by congenital conditions. Outcomes investigated were special educational need (SEN), absenteeism, exclusion, academic attainment, and unemployment. All analyses were adjusted for sociodemographic and maternity confounders. Absenteeism was investigated as a mediating factor in the associations with attainment and unemployment.

RESULTS

Of the 715,850 children, 6,295 (0.9%) had congenital heart disease and 4,412 (6.1%) had isolated congenital heart disease. Congenital heart disease and isolated congenital heart disease were both significantly associated with subsequent special educational need (OR 3.45, 95% CI 3.26-3.65, p < 0.001 and OR 1.98, 95% CI 1.84-2.13, p < 0.001 respectively), absenteeism (IRR 1.13, 95% CI 1.10-1.16, p < 0.001 and IRR 1.10, 95% CI 1.06-1.13, p < 0.001 respectively), and low academic attainment (OR 1.69, 95% CI 1.39-2.07, p < 0.001 and OR 1.35, 95% CI 1.07-1.69, p = 0.011 respectively). Neither congenital heart disease nor isolated congenital heart disease were associated with school exclusion. Only congenital heart disease (OR 1.21, 95% CI 1.03-1.42, p = 0.022) but not isolated congenital heart disease was associated with unemployment. When days absent were included in the analyses investigating attainment and unemployment, the conclusions were not altered.

CONCLUSION

Children with congenital heart disease have greater special educational need, lower school attendance, attain lower examination grades and have greater unemployment compared to peers. In addition to healthcare support, affected children need educational support to avoid additional impact on their long-term wellbeing.

Educational attainment in patients with congenital heart disease: a comprehensive systematic review and meta-analysis

BACKGROUND

Our aim was to comprehensively review published evidence on the association between having a congenital heart disease (CHD) compared with not, on educational attainment (i.e. not obtaining a university degree, completing secondary education, or completing any vocational training vs. obtaining/completing) in adults.

METHOD

Studies were eligible if they reported the rate, odds, or proportion of level of educational attainment in adults by whether or not they had a CHD.

RESULT

Out of 1537 articles screened, we identified 11 (N = 104,585 participants, 10,487 with CHD), 10 (N = 167,470 participants, 11,820 with CHD), and 8 (N = 150,813 participants, 9817 with CHD) studies reporting information on university education, secondary education, and vocational training, respectively in both CHD and non-CHD participants. Compared to their non-CHD peers, CHD patients were more likely not to obtain a university degree (OR = 1.38, 95% CI [1.16, 1.65]), complete secondary education (OR = 1.33, 95% CI [1.09, 1.61]) or vocational training (OR = 1.11, 95% CI [0.98, 1.26]). For all three outcomes there was evidence of between study heterogeneity, with geographical area contributing to this heterogeneity.

CONCLUSION

This systematic review identified all available published data on educational attainment in CHD patients. Despite broad inclusion criteria we identified relatively few studies that included a comparison group from the same population, and amongst those that did, few adjusted for key confounders. Pooled analyses suggest evidence of lower levels of educational attainment in patients with CHD when compared to non-CHD peers. The extent to which this may be explained by confounding factors, such as parental education, or mediated by treatments is not possible to discern from the current research literature.

Life chances after surgery of congenital heart disease: A case-control-study of inter- and intragenerational social mobility over 15 years

Background

Patients of congenital heart disease surgery have good prospects for reaching old age. Against the backdrop of increasing life expectancies, the question of how well such patients are mastering daily routines and their working life emerges. In our study, the educational and occupational performance of patients over 15 years was examined.

Methods

Intergenerational social mobility (changes in social positions from the parental generation to the generation of children) was examined in terms of education, and intragenerational social mobility (changes in positions within the same generation, i.e., in individuals over their life courses) was examined in terms of occupational positions. Comparisons were made between patients and a control group drawn from the German Socio-Economic Panel (SOEP). Controls were drawn from respondents who participated in the 2004 and 2018 SOEP surveys.

Results

The data were from 244 out of 360 patients (68%) with complete social data from the first survey (2003–2004) and who were included in the follow-up (2017–2019), and 238 controls were drawn from the SOEP. At the time of the second survey, subjects’ ages ranged from 28 to 59 years of age (M = 40.1 years). Intergenerational educational mobility did not differ between cases and controls. For intragenerational social mobility, downward changes were more frequent among controls. This latter finding may be explained by patients retiring earlier than the general population. Retirement rates increased over time, particularly among patients with severe congenital malformations. Unemployment rates were also higher among patients.

Conclusions

Taken together, although a considerable proportion of patients with congenital heart disease retired prematurely or never entered the labour force, their educational and occupational careers proceeded more favourably than expected.

Lifetime Burden of Adult Congenital Heart Disease in the USA Using a Microsimulation Model

Congenital heart defects (CHD) represent a growing burden of illness among adults. We estimated the lifetime health, education, labor, and social outcomes of adults with CHD in the USA using the Future Adult Model, a dynamic microsimulation model that has been used to study the lifetime impacts of a variety of chronic diseases. We simulated a cohort of adult heads of households > 25 years old derived from the Panel Survey of Income Dynamics who reported a childhood heart problem as a proxy for CHD and calculated life expectancy, disability-free and quality-adjusted life years, lifetime earnings, education attainment, employment, development of chronic disease, medical spending, and disability insurance claiming status. Total burden of disease was estimated by comparing to a healthy cohort with no childhood heart problem. Eighty-seven individuals reporting a childhood heart problem were identified from the PSID and were used to generate the synthetic cohort simulated in the model. Life expectancy, disability-free, quality-adjusted, and discounted quality-adjusted life years were an average 4.6, 6.7, 5.3, and 1.4 years lower than in healthy adults. Lung disease, cancer, and severe mental distress were more common compared to healthy individuals. The CHD cohort earned $237,800 less in lifetime earnings and incurred higher average total medical spend by $66,600 compared to healthy individuals. Compared to healthy adults, the total burden of CHD is over $500K per adult. Despite being among the healthiest adults with CHD, there are significant decrements in life expectancy, employment, and lifetime earnings, with concomitant increases in medical spend.

Long-term Social Outcomes After Congenital Heart Surgery

BACKGROUND

Patients are surviving decades after congenital heart surgery (CHS), raising the importance of postoperative quality of life as an outcome measure. We determined the long-term social outcomes after CHS performed during childhood.

METHODS

Between 1953 and 2009, 10 635 patients underwent surgery for congenital heart defects at <15 years of age in Finland. We obtained 4 control subjects per patient, matched by age, sex, birth time, and hospital district, from Statistics Finland, which also provided data on the highest education level, employment status, marital status, and progeny for both patients and control subjects. We included patients who were alive and ≥18 years of age at the end of the follow-up on December 31, 2017.

RESULTS

A total of 7308 patients met inclusion criteria. Patients had on average similar high school or vocational education rates as the general population but lower undergraduate or higher education rates (female patients: risk ratio [RR] 0.8 [95% confidence interval (CI) 0.8-0.9]; male patients: RR 0.8 [95% CI 0.7-0.9]). Patients were less likely to be married or have progeny compared with the general population. The rate of employment was significantly lower (female patients: RR 0.8 [95% CI 0.8-0.9]; male patients: RR 0.8 [95% CI 0.8-0.9]) and the rate of retirement (female patients: RR 2.1 [95% CI 2.0-2.3]; male patients RR 3.1 [95% CI 2.9-3.5]) significantly higher among patients.

CONCLUSIONS

Patients who undergo CHS at childhood age are, on average, more disadvantaged from both an educational and professional standpoint compared with the general population, regardless of the severity of the defect.

Employment status and contributing factors among adults with congenital heart disease in Japan

BACKGROUND

Working is an important concern in transitional care for adults with congenital heart disease (ACHD) because work connects people with society. Employment status is correlated with gender, but studies on patient employment by gender have rarely been conducted. This study therefore aimed to examine the employment status of ACHD by gender and to explore the factors influencing this status.

METHODS

In this study, 193 Japanese ACHD (mean age: men-33.62 years, women-32.69 years; 89 men, no students included) completed a questionnaire including questions about employment status, an evaluation of hindrances to employment, the Linear Analog Scale to assess quality of life (QOL), and the Satisfaction with Life Scale (SWLS).

RESULTS

In the study sample, 13 of 89 (14.6%) men and 13 of 104 (12.5%) women did not have a job. These rates were higher than the national standard rates in Japan (men: 5.0%, women: 2.9%). Of these patients, only one man and one woman listed their illness as a reason for their unemployment. The factors thought to explain unemployment were age for men and disease severity for women (P < 0.05 for both). Unemployed patients had significantly lower QOL and SWLS scores.

CONCLUSIONS

Most ACHD can join the workforce but a higher percentage of ACHD do not work and find it challenging to have a career compared with the general population. Moreover, because unemployed patients have low QOL and SWLS scores, obtaining work is crucial to enable these people to have mentally and emotionally stable and fulfilling lives.

Education as important predictor for successful employment in adults with congenital heart disease worldwide

Background

Conflicting results have been reported regarding employment status and work ability in adults with congenital heart disease (CHD). Since this is an important determinant for quality of life, we assessed this in a large international adult CHD cohort.

Methods

Data from 4028 adults with CHD (53% women) from 15 different countries were collected by a uniform survey in the cross‐sectional APPROACH International Study. Predictors for employment and work limitations were studied using general linear mixed models.

Results

Median age was 32 years (IQR 25‐42) and 94% of patients had at least a high school degree. Overall employment rate was 69%, but varied substantially among countries. Higher education (OR 1.99‐3.69) and having a partner (OR 1.72) were associated with more employment; female sex (OR 0.66, worse NYHA functional class (OR 0.67‐0.13), and a history of congestive heart failure (OR 0.74) were associated with less employment. Limitations at work were reported in 34% and were associated with female sex (OR 1.36), increasing age (OR 1.03 per year), more severe CHD (OR 1.31‐2.10), and a history of congestive heart failure (OR 1.57) or mental disorders (OR 2.26). Only a university degree was associated with fewer limitations at work (OR 0.62).

Conclusions

There are genuine differences in the impact of CHD on employment status in different countries. Although the majority of adult CHD patients are employed, limitations at work are common. Education appears to be the main predictor for successful employment and should therefore be encouraged in patients with CHD.

Educational achievement of children with congenital heart disease: Promising results from a survey by the German National Register of Congenital Heart Defects

BACKGROUND

Survival rates of children with congenital heart disease (CHD) have increased significantly in the decade. There is now increased interest in the long-term outcome and quality of life of these children.

AIMS

To assess the educational achievement of patients with CHD in Germany.

STUDY DESIGN

Cross-sectional study using an online survey. The recruitment of study participants was carried out via the database of the German National Register for Congenital Heart Defects (NRCHD).

SUBJECTS

Patients born between 1992 and 2011 were enrolled in the study. For 2609 study participants (female = 1870 (71.7%); 1072 (41.1%) patients; 1537 (58.9%) parents), who participated in the survey, detailed information regarding the underlying CHD diagnosis and clinical data was available.

OUTCOME MEASURES

Age at enrollment, secondary school form, school year repetition, school degree.

RESULTS

The large majority of study participants were enrolled at a conventional elementary school (83.4%) and started school at the age of 6 years or below (73.3%). In total 45.7% of graduated study participants graduated with the qualification necessary to study at any university. In terms of analysis of the different CHD severity subgroups 57.3% of patients with a mild CHD, 47.5% with a moderate CHD and only 35.1% suffering from a severe CHD attained a high school diploma.

CONCLUSIONS

In our study, the majority of participating CHD patients had a standard school career. These initial results are of great importance to affected families and treating physicians as they show that, in general, a normal school career is possible for all CHD patients.

Brain Monitoring and Protection During Pediatric Cardiac Surgery

With advances in medical care, survival after cardiac surgery for congenital heart disease has dramatically improved, and attention is increasingly focused on longterm functional morbidities, especially neurodevelopmental outcomes, with their profound consequences to patients and society. There are multiple reasons for concern about brain injury. Some cardiac defects are associated with brain anomalies and altered cerebral blood flow regulation. Brain imaging studies have demonstrated that injury to gray and white matter is quite frequent before heart surgery in neonates. Cardiopulmonary bypass and deep hypothermic circulatory arrest are associated with shortand longer-term adverse neurologic outcome. Additional brain injury can occur during the patient's recovery from surgery. Strategies to optimize neurologic outcome continue to evolve. With new technological developments, perioperative neurologic monitoring of small children has become easier, and data suggest these modalities usefully identify adverse neurologic events and might predict outcome. Monitoring methods to be discussed include processed electroencephalography, near infrared spectroscopy, and transcranial Doppler ultrasound. Alternative perfusion techniques to deep hypothermic circulatory arrest have been developed, such as regional antegrade cerebral perfusion during cardiopulmonary bypass. Other neuroprotective strategies employed during open-heart surgery include temperature regulation, acid-base management, degree of hemodilution, blood glucose control and anti-inflammatory therapies. Evidence of the impact of these measures on neurologic outcome is examined, and deficiencies in our current understanding of neurologic function in children with congenital heart disease are identified.

What Does it Mean to Live with a Congenital Heart Disease? A Qualitative Study on the Lived Experiences of Adult Patients

Background: Adults with congenital heart disease constitute a relatively new and continuously growing patient population. In addition to medical problems, patients perceive specific psychosocial concerns that influence their lived experiences and quality of life.

Aim: This study aimed to explore the lived experiences of adult congenital heart disease patients.

Methods: Unstructured, in-depth interviews were performed with 12 patients, aged between 25 and 40 years and suffering from moderate or severe heart defect (tetralogy of Fallot, transposition of the great arteries). Interviews were tape recorded and transcribed verbatim. Data were analyzed using Grounded Theory procedures.

Results: Feeling different was the central theme of the patients’ lived experience, as they are faced with physical limitations and visible signs due to the heart defect. The experienced discordance between their world and healthy individuals’ world implies that patients struggle constantly with themselves and with their environment to be accepted as normal. The feeling of being different was influenced by attitudes of the environment, health care, and patient's personality. Moreover, it determined the perceived impact of the disease on the patient's daily life.

Conclusion: This study shows that normalisation is the most important process when dealing with patients suffering from a congenital heart disease.

Academic achievement and satisfaction in adolescents with CHD

OBJECTIVES

To evaluate academic achievement and satisfaction in adolescents with CHD. Study design Questionnaires were sent to all adolescents, aged between 17 and 20 years with CHD, currently treated at our hospital (n=326) in order to assess the patients' education and satisfaction with their academic career. Results were compared with the official community statistics.

RESULTS

A total of 207 patients completed the questionnaires (participation rate 63.5%), 113 boys and 94 girls; 50% had completed mandatory school at the highest, 37.3% at the middle, and 12.7% at the lowest educational level. The distribution in the general population was comparable: 57.6, 32.5, and 9.9%, respectively (p=0.8). Adolescents with severe CHD were less likely to attain a higher educational level than those with moderate or mild CHD (p=0.03 for school grades 7-9). None of the other examined medical or socio-demographic factors, such as socio-economic status, foreign language, severity of CHD, cyanosis, and open heart surgery, were found to be associated with lower educational attainment. After the mandatory 9 years of schooling, 21.4% (n=44) of the patients with CHD compared with 16.7% in the general population attended higher school levels heading towards university education (p=0.7). From the 165 patients who provided information on career satisfaction, 79% regarded their job or school situation as being their desired one without a difference for those with severe CHD.

CONCLUSION

School education in Swiss adolescents with CHD is very similar to the normal population. In addition, the majority of adolescents are satisfied with their educational career. This fact may be due to the good educational support provided during schooling.

Long-term psychosocial outcome of adults with tetralogy of Fallot and transposition of the great arteries: a historical comparison

OBJECTIVE

To make a historical comparison on the long-term psychosocial outcome of cardiothoracic surgery during childhood.

METHODS

Adult patients operated for tetralogy of Fallot or transposition of the great arteries between 1980 and 1990 (recent sample) were compared with patients who underwent surgery and were investigated 10 years earlier (historical sample). In addition, atrial switch and arterial switch patients within the recent sample were compared. Psychosocial functioning was measured using standardised, validated psychological questionnaires.

RESULTS

Although the recent sample of patients overall shows a favourable quality of life, impairments were found in income, living conditions, relationships, offspring, and occupational level. Compared with the historical sample, the recent sample showed no significant improvements on psychosocial functioning, except for a better educational level. The amount of educational problems, such as learning difficulties, was still high compared with normative data. Recently operated patients with transposition of the great arteries (arterial switch) scored significantly better on the Short Form-36 vitality scale (p = 0.02) compared with historical patients with transposition of the great arteries (atrial switch).

CONCLUSIONS

Despite improvements in medical treatment over the past few decades, hardly any change was found in the psychosocial outcome of the recent patient sample compared with the historical patient sample. In particular, the percentage of patients needing special education and showing learning problems remained high, whereas income was low compared with normative data.

Depression in adults with congenital heart disease-public health challenge in a rapidly expanding new patient population

There is a growing population of adults with congenital heart disease (CHD) due to improved survival beyond childhood. It has been suggested that adults with CHD may be at increased risk for mental health problems, particularly depression. The reported incidence of depression in CHD varies from 9% to 30%. This review examines the evidence for a higher depression rate in CHD vs general population. Possible explanations are offered from a variety of disease models, ranging from brain injury to the psychoanalytical approach. Risk factors for an abnormal emotional adjustment and depression include early exposure to stress from illness and medical interventions in infancy, separation from the parents during hospitalizations and brain organic syndromes. Later in life, patients often have to cope with physical limitations. Recent improvements in care may be protective. Current patients may benefit from an earlier age at first surgical intervention, fewer reoperations and inclusion to the mainstream schooling, among other factors. At this point, there is little systematic knowledge about evidence-based therapeutic interventions for depression in adults with CHD. Health care providers of patients with CHD should be aware of mental health challenges and may take a more proactive approach to identifying patients at risk for depression.

Gender differences in health conditions and socio-economic status of adults with congenital heart disease in a developing country

BACKGROUND

Providing appropriate care for adults with congenital heart disease requires the evaluation of their current situation. There is limited research in Iran about these patients, particularly in relation to gender differences in the demographic/socio-economic and lifestyle factors, as well as disease parameters.

MATERIALS AND METHODS

The sample consisted of 347 congenital heart disease patients in the age group of 18–64 years, including 181 women, assessed by an analytical cross-sectional study. The patients were recruited from the two major heart hospitals in Tehran. Data were collected using questionnaires.

RESULTS

The mean age of the patients was 33.24 years. Women were more often married and more often had offspring than men (p < 0.001). Educational level and annual income were similar between women and men. Unemployment was higher among women (p < 0.001), but financial strain was higher among men (p < 0.001). Smoking, alcohol, and water-pipe use was higher among men than among women (p < 0.001). Cardiac factors, for example number of cardiac defects, were similar among women and men, except that there were more hospitalisations owing to cardiac problems, for example arrhythmia, among men. Disease was diagnosed mostly at the hospital (57.4%). Most medical care was provided by cardiologists (65.1%). Only 50.1% of patients had knowledge about their type of cardiac defect.

CONCLUSION

Gender differences exist in the socio-economic and lifestyle characteristics of adults with congenital heart disease, in some cases related to the disease severity. Our findings also point to the need for interventions to increase patients’ knowledge about, and use of, healthier lifestyle behaviours, irrespective of gender. Furthermore, providing appropriate jobs, vocational training, and career counselling may help patients to be more productive.

Social burden and lifestyle in adults with congenital heart disease

We aimed to evaluate how the presence and severity of congenital heart disease (CHD) influence social life and lifestyle in adult patients. A random sample (n = 1,496) from the CONgenital CORvitia (n = 11,047), the Dutch national registry of adult patients with CHD, completed a questionnaire on educational attainment, employment and marital statuses, and lifestyle (response 76%). The Utrecht Health Project provided a large reference group (n = 6,810) of unaffected subjects. Logistic regression models were used for subgroup analyses and to adjust for age, gender, and socioeconomic status where appropriate. Of all patients 51.5% were men (median age 39 years, interquartile range 29 to 51) with mild (46%), moderate (44%), and severe (10%) CHD. Young (<40-year-old) patients with CHD were more likely to have achieved a lower education (adjusted odds ratios [ORs] 1.6 for men and 1.9 for women, p <0.05 for the 2 comparisons), significantly more often unemployed (adjusted ORs 5.9 and 2.0 for men and women, respectively), and less likely to be in a relationship compared to the reference group (adjusted ORs 8.5 for men and 4.5 for women). These poorer outcomes were seen in all severity groups. Overall, the CHD population smoked less (adjusted OR 0.5, p <0.05), had more sports participation (adjusted OR 1.2, p <0.05), and had less obesity (adjusted OR 0.7, p <0.05) than the reference group. In conclusion, there was a substantial social disadvantage in adult patients with CHD, which was seen in all severity groups and primarily in young men. In contrast, adults with CHD had healthier lifestyles compared to the reference group.

Pediatric Cardiopulmonary Bypass

This current review describes how components of the cardiopulmonary bypass (CPB) circuit are selected and examines the benefits of pulsatile perfusion for use during CPB. Pulsatile flow generates significantly greater surplus hemodynamic energy (SHE) than nonpulsatile flow; higher SHE values have been associated with better microcirculation perfusion, lower rates of systemic inflammatory response, and better vital organ protection. Pulsatile perfusion may have a positive effect on clinical outcomes, play a role in preserving homeostasis, and help to decrease morbidity associated with CPB.

Educational achievement among long-term survivors of congenital heart defects: a Danish population-based follow-up study

BACKGROUND

Congenital heart defect patients may experience neurodevelopmental impairment. We investigated their educational attainments from basic schooling to higher education.

PATIENTS AND METHODS

Using administrative databases, we identified all Danish patients with a cardiac defect diagnosis born from 1 January, 1977 to 1 January, 1991 and alive at age 13 years. As a comparison cohort, we randomly sampled 10 persons per patient. We obtained information on educational attainment from Denmark's Database for Labour Market Research. The study population was followed until achievement of educational levels, death, emigration, or 1 January, 2006. We estimated the hazard ratio of attaining given educational levels, conditional on completing preceding levels, using discrete-time Cox regression and adjusting for socio-economic factors. Analyses were repeated for a sub-cohort of patients and controls born at term and without extracardiac defects or chromosomal anomalies.

RESULTS

We identified 2986 patients. Their probability of completing compulsory basic schooling was approximately 10% lower than that of control individuals (adjusted hazard ratio = 0.79, ranged from 0.75 to 0.82 0.79; 95% confidence interval: 0.75-0.82). Their subsequent probability of completing secondary school was lower than that of the controls, both for all patients (adjusted hazard ratio = 0.74; 95% confidence interval: 0.69-0.80) and for the sub-cohort (adjusted hazard ratio = 0.80; 95% confidence interval: 0.73-0.86). The probability of attaining a higher degree, conditional on completion of youth education, was affected both for all patients (adjusted hazard ratio = 0.88; 95% confidence interval: 0.76-1.01) and for the sub-cohort (adjusted hazard ratio = 0.92; 95% confidence interval: 0.79-1.07).

CONCLUSION

The probability of educational attainment was reduced among long-term congenital heart defect survivors.

[Quality-of-life measures in pediatric cardiology]

The need of outcome measures from the patients' aspect emerges reasonably in the field of rapidly developing pediatric cardiac surgery and pediatric cardiology. The professional standards and the possibilities of applicability of quality of life measures are often unknown for medical doctors. This is particularly true in pediatrics due to the numerous difficulties of pediatric measures and--in consequence--to the lower number of correct investigations.

AIM

To summarize the basic professional expectations and results of previous quality of life studies performed in pediatric cardiology from a clinical point of view.

METHOD

Survey of the literature of quality of life measures performed on mixed or specified adult and child population with congenital heart disease with a presentation of the main results and the basic characteristics of methodology.

CONCLUSION

According to previous results, quality of life measures have a role in pediatric cardiology. Adequate measures can improve the level of care.

Factors associated with adverse neurodevelopmental outcomes in infants with congenital heart disease

OBJECTIVE

To review reported neurodevelopmental outcome data for patients with congenital heart disease, identify risk factors for adverse neurodevelopmental sequelae and summarize potential neuromonitoring strategies that have been described.

METHODS

A Medline search was performed utilizing combinations of the keywords congenital heart, cardiac, neurologic, neurodevelopment, neuromonitoring, quality of life, and outcome. All prospective and longitudinal follow-up studies of patients with congenital heart disease were included. Additionally, studies that examined neuroimaging, neuromonitoring, and clinical factors in relation to outcome were examined. Case reports and editorials were excluded. Additional references were retrieved from selected articles if the abstract described an evaluation of neurodevelopmental outcomes and/or predictors of outcome in patients with congenital heart disease.

RESULTS

Overall, patients with CHD have increased rates of neurodevelopmental impairments, although intelligence appears to be in the normal range. Preoperative risk stratification, intraoperative techniques, postoperative care, and neuromonitoring strategies may all contribute to ultimate long-term neurodevelopmental outcomes in patients with CHD postsurgical repair.

CONCLUSIONS

As advances in the medical and surgical management improves survival in patients with CHD, increasing knowledge about neurodevelopmental outcomes and the factors that affect them will provide for strategies to optimize long-term outcome in this high-risk population.

Perioperative neuroprotective strategies

Long-term neurodevelopmental impairment is common in newborns and infants undergoing corrective or palliative congenital heart surgery. The etiologies of neurodevelopmental morbidity in these children are multifactorial and include prenatal, preoperative, intraoperative, and postoperative factors. Perioperative neurologic monitoring is thought to be integral to prevention or rescue from adverse neurologic events. Recent advances in perfusion techniques for congenital heart surgery now ensure adequate cerebral O(2) delivery during all phases of cardiopulmonary bypass. Periventricular leukomalacia and other serious neurologic injury can be minimized by an optimized perfusion strategy of continuous high-flow, high hematocrit cardiopulmonary bypass, minimal use of deep hypothermic circulatory arrest, antegrade cerebral perfusion during aortic arch reconstruction, pH-stat blood gas strategy, and cerebral monitoring with NIRS and trans-cranial Doppler. Because there is evidence that brain injury can also occur in the prenatal, preoperative, and postoperative periods, improved strategies to prevent injury in these arenas are much needed. Extensive further clinical investigation is warranted to identify neuroprotective management strategies for the operating room and intensive care unit to preserve neurologic function and optimize long-term neurodevelopmental outcomes in children with congenital heart disease.

Life chances after surgery of congenital heart disease: the influence of cardiac surgery on intergenerational social mobility. A comparison between patients and general population data

BACKGROUND

To examine whether operated congenital heart disease (CHD) is setting preconditions for an active life by comparing intergenerational social mobility in patients with a population sample.

DESIGN AND METHODS

The patient sample consisted of 314 females (42.1%) and males who underwent surgery for CHD (mean age at surgery 7.3 years, SD 7.8). According to the type of surgery, patients were classified as curative, reparative, or palliative. Consequently, the three groups reflect increasing severities of the initial heart defect. The mean age at examination was 26.9 years (7.6). Controls consisted of individuals who participated in the 2002 survey of the German Socio-Economic Panel. All individuals with complete sociodemographic information were included, and the final sample consisted of 4864 women (46.1%) and men (mean age 32.5 years, SD 7.2).

RESULTS

Once having entered the labour market, intergenerational social mobility between patients and controls did not differ. For upward mobility respondents' social background was the key determinant; the respective standardized regression effect was beta=0.66. After dividing the study population, the social background turned out to having a slightly stronger effect in patients (beta=0.73) than in controls (beta=0.65). For downward mobility effects of the social background were smaller than for upward mobility (beta=0.19 in patients and beta=0.21 in controls). In economically active patients CHD severity did not determine social mobility.

DISCUSSION

We conclude that a large proportion of patients could not or did not enter the labour market. Those who did experienced social mobility rates that are comparable with the general population.

Outcome after surgical repair of congenital cardiac malformations at school age

OBJECTIVES

To explore the long-term physical, educational, behavioural, and emotional outcome of patients undergoing surgical correction of congenital cardiac disease at school age, and to investigate the relation, if any, between the outcome and comorbidity, age and sex, and level of complexity of the cardiac surgery.

METHODS

Information was obtained concerning 101 patients who underwent open-heart surgery for correction of congenital cardiac malformations between 1992 and 2000 whilst aged from 6 to 16 years. The patients, and their parents, completed the questionnaire "Outcome of congenital heart disease and surgery", the RAND 36-Item Health Survey, and the Child Behaviour Checklist/Youth Self-Report/Young Adult Self-Report.

RESULTS

Of the patients, 26% had comorbidity. Of those without comorbidity, 39% had frequent physical complaints, and 28% experienced limitations due to the cardiac disease. Nevertheless, the patients reported a good subjective state of health, and did not report any behavioural or emotional problems. Patients did show academic difficulties. They had received special education more frequently than their healthy peers, and many had needed to repeat a grade, or had received remedial teaching. Consequently, the educational level of patients was lower than that of their healthy peers. Patients with comorbidity, female patients, and patients who underwent complex surgery, seemed to be most at risk for physical, behavioural, and emotional problems.

CONCLUSION

It is necessary to distinguish between physical state and its appraisal, and clinicians should be aware of this. Further research is needed to find out the cause and nature of the academic difficulties. Groups of patients at risk should be followed closely to enable early interventions.

Changes in Hospitalization Patterns Among Patients With Congenital Heart Disease During the Transition From Adolescence to Adulthood

OBJECTIVES

This study was designed to evaluate hospitalization patterns of congenital heart disease (CHD) patients surrounding the transition from adolescence to adulthood.

BACKGROUND

Few population data exist on hospitalizations among adolescent and adult CHD patients.

METHODS

Patients ages 12 to 44 years with CHD were selected from the 2000 to 2003 California hospital discharge database. Patient demographics, hospitalization patterns, emergency department (ED) admissions, CHD complexity, and insurance patterns were described. Data were analyzed in 3-year age increments and compared between patients over and under age 21. Predictors of admission via the ED were determined using multivariate regression analysis.

RESULTS

There were 9,017 hospitalizations at 368 hospitals. For patients ages 12 to 20 years, 12 hospitals accounted for 70% of hospitalizations; for patients ages 21 to 44 years, 25 hospitals accounted for only 44.8% of cases. Regarding insurance, 53% of admissions were private, 44% public, and <4% were self-pay. Sixty-five percent of patients had complex CHD and 19% had a cardiac procedure during hospitalization. The proportion of patients admitted via the ED nearly doubled surrounding the transition to adulthood. The positive predictors of admission via the ED included public insurance, self-pay, and age >17 years, whereas having a procedure and being female decreased the likelihood.

CONCLUSIONS

Congenital heart disease hospitalizations occur at a wide variety of hospitals and disperse as patients enter adulthood. Those without private insurance and >17 years old are at higher risk of being admitted via the ED. These findings require further investigation to examine access to care and possible disparities, as they are important for future healthcare planning.

Psychological symptoms in patients after surgery for congenital cardiac disease

AIMS

We studied a population of patients with surgically corrected congenital cardiac disease to determine whether limitations in activity, impaired cardiac performance, and perception of body image have effects on psychological symptoms.

METHODS

We undertook medical examinations, and carried out standardized interviews, in 361 patients aged between 14 and 45 years with surgically corrected congenital cardiac disease. From this data, findings from 343 patients were suitable for analysis. Subjectively reported limitations in activity were classified according to the system proposed by the New York Heart Association, while cardiopulmonary capacity was used as the indicator of cardiac performance. The Brief Symptom Inventory was used for assessing psychological symptoms, such as somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The Body Image Questionnaire was used to depict attitudes towards body image, which is assessed on the two subscales of rejection of the body and vitality. Multivariate regression analyses were conducted separately for females and males, taking into account age and socio-economic position.

RESULTS

Impairments of everyday activities had only a few substantial associations with psychological symptoms. No significant effects of cardiac functional capacity as a standardized physiological measure emerged. Psychological symptoms were strongly influenced by perceptions of body image, particularly if they rejected it, this holding particularly for males. There were no gender differences in terms of psychological symptoms.

CONCLUSIONS

Limitations of activity, and impaired cardiac performance, have only minor effects on psychological symptoms in patients with surgically corrected congenital cardiac disease. The perception of body image was the strongest predictor, especially if patients rejected their body as a result of disfigurement or perceived deficiency.

Central nervous system outcomes in children with complex congenital heart disease

PURPOSE OF REVIEW

To provide a brief overview of our current understanding of the types of neurodevelopmental sequelae in congenital heart disease survivors and to review the most recent studies from the past year, which have focused on 4 interrelated issues: (1) outcome studies, (2) the mechanism and etiology of central nervous system injury in children with CHD, (3) perioperative monitoring for brain injury, and (4) strategies for neuroprotection during cardiac surgery.

RECENT FINDINGS

As the number of survivors of surgery for complex congenital heart disease continues to rise, it is recognized that there is an increased incidence of adverse neurological outcomes in the survivors. In particular, a pattern similar to that seen in premature infants is emerging, including learning disabilities, behavioral abnormalities, inattention and hyperactivity. Imaging studies have revealed a high prevalence of structural brain abnormalities and periventricular leukomalacia, fetal and postnatal cerebral blood flow is abnormal, postnatal oxygen delivery is decreased, and intraoperative support techniques and postoperative low cardiac output are associated with cerebral hypoperfusion.

SUMMARY

The causes of these late developmental abnormalities are most likely sequential, cumulative and multifactorial.

Late results and quality of life after pediatric cardiac surgery in Finland: a population-based study of 6,461 patients with follow-up extending up to 45 years

This population-based study characterizes the history and progress of pediatric cardiac surgery in Finland. For the first time in the literature, all defects and procedures are included in an outcome study, reflecting the true effectiveness of operative treatment. All the patients operated on since the beginning of pediatric cardiac surgery in Finland in 1953 and through the end of 1989 were included in this population-based, long-term outcome study. The survival was defined from the Finnish Population Registry Center. The survival rates were compared with those of an age- and sex-matched general population. During the study period, 6,461 patients underwent surgery; 96% of them were traced. A questionnaire was used to study the quality of life. The 45-year survival of patients was 15% less than that of the general population. The survival and the number of necessary operations varied widely with the defect. The patients coped well with their defects when compared with the general population. The education level was similar, and the employment level was higher than expected. Patients were living in a steady relationship as often as the general population, but parenthood was less frequent than expected. The incidence of congenital heart disease among the children of the patients was 2.4%. The overall survival of children operated on for heart defects is fairly good. The patients, especially those with simpler defects, do not have increased risk of death years after successful operation. The majority of patients are feeling well, and their life situation is similar to the general population.

Educational and behavioral issues in transitioning from pediatric cardiology to adult-centered health care

It is assumed that when they begin growing up, a child with congenital heart disease will take personal responsibility for his or her care. For this purpose, patients need sufficient knowledge on the heart defect, treatment,and measures to prevent complications. However, empirical studies indicated that the levels of knowledge and understanding of both parents and children with congenital heart disease are poor. Therefore, sound patient education is imperative, particularly when patients are transitioned from pediatric cardiology to adult congenital cardiology. In this respect, the focus of communication shifts from the parent to the young patient; moreover, education should be tailored according to the developmental level of the patient. Issues that should typically be covered by educational programs for adolescents with congenital heart disease are information on the heart defect, treatment, endocarditis, sexuality and reproduction, sports, employability and insurability, and cardiovascular risk factor. International guidelines indicate that advanced practice nurses are key in developing and implementing patient education programs during the transition from pediatric cardiology to adult-centered health care.

Congenital heart disease never goes away, even when it has been 'treated': the adult with congenital heart disease

PURPOSE OF REVIEW

As the specialties of pediatrics and pediatric cardiology continue to forge ahead with better diagnoses, medical care, and surgical results, an expanding population of patients with congenital heart disease (CHD) outgrows the pediatric age group, yet does not quite graduate to routine adult cardiology or general medicine. The adult with congenital heart disease (ACHD) faces medical, surgical, and psychosocial issues that are unique to this population and must be addressed as such. This review attempts to discuss and highlight some of the important advances and controversies brought up in the past year, in the care and management of these patients.

RECENT FINDINGS

The past five to 10 years have seen dynamic interest in understanding sequelae of corrected, uncorrected, or palliated congenital heart disease. The search for the ideal surgery, optimal prosthesis, and a smooth transition to adult care continues and is reflected in the vast amount of academic work and publications in this field. Of particular interest, conduit reoperations and single ventricle pathway modifications are still an art and a science in evolution.

SUMMARY

While all are agreed that there is a pressing need to focus on the delivery of care to the adult with congenital heart disease, this essentially requires a clearer understanding of late sequelae of CHD. The sheer heterogeneity of anatomy, age, surgery, and institutional management protocols can make it difficult to develop clear guidelines. This review attempts to give an up-to-date perspective on some of the new findings related to the more common lesions and problems faced in this group.