Acquired coronary artery disease in adult patients with congenital heart disease: a true or a false problem?

Outcome of transcatheter atrial septal defect closure in a nationwide cohort

BACKGROUND

Transcatheter (TC) atrial septal defect (ASD) closure has been the mainstay of therapy for secundum-type ASDs for over 20 years.

AIMS

This nationwide cohort evaluated the long-term outcome of transcatheter-closed ASDs.

METHODS

The study enrolled every transcatheter ASD closure performed in Finland from 1999 to 2019. Five age, sex, and municipality-matched controls per ASD patient were gathered from the general population. The median follow-up period was 5.9 years (range 0-20.8). We used the hospital discharge register to gather all hospital visits and diagnoses. Closure complications and echocardiographic changes were collected from the electronic health records.

RESULTS

Transcatheter ASD closure was performed in 1000 patients (68.5% females) during the study period. The median (range) age at the time of the procedure was 37.9 (1.8-87.5) years. ASD patients had an increased risk for new-onset atrial fibrillation (RR 2.45, 95% CI: 1.84-3.25), migraine (RR 3.61, 95% CI: 2.54-5.14), ischemic heart disease (RR 1.73, 95% CI: 1.23-2.45), ventricular fibrillation/tachycardia (RR 3.54 (95% CI: 1.48-8.43) and AV conduction disorder (RR 3.60, 95% CI: 1.94-6.70) compared to the control cohort. Stroke risk was not increased (RR 1.36, 95% CI: 0.91-2.03). Adverse events occurred in 6.3% (n = 63) of the patients, including four erosions and ten device embolizations.

CONCLUSION

After TC closure of ASD, patients had a higher risk of new-onset atrial fibrillation and migraine than controls without ASD. As novel findings, we found an increased risk for ischemic heart disease, AV conduction disorders, and ventricular fibrillation/tachycardia.Key messagesEven though patients have an excellent overall prognosis after percutaneous ASD closure, the increased incidence of major comorbidities like atrial fibrillation and heart failure prompts more thorough lifelong follow-up.This study's novel findings revealed the increased risk for ischemic heart disease, AV conduction disorders, or ventricular tachycardia/fibrillation during the follow-up.Major complications after the closure are rare; erosion is seen in 0.4% of the patients and embolization in 1.0% of the patients.

Comparison of lipid profile values in pediatric patients with cyanotic and acyanotic congenital heart disease

Background Incidence of congenital heart disease (CHD) is about 0.8% of every child born. This heart defect is associated with dyslipidemia in children. Lipid profiles examination in patients with CHD can be used to determine risk factors for atherosclerosis. Objective To examine differences in lipid profiles in children with cyanotic and acyanotic CHD. Methods This was a cross-sectional study on 60 pediatric CHD patients at Haji Adam Malik Hospital, Medan, North Sumatera, from December 2020 to March 2021. Subjects were included by consecutive sampling. Data of patient’s age, gender, weight, height, complete blood count, blood glucose, and lipid profiles were recorded. Unpaired T-test analysis and Mann-Whitney test were then performed to analyze variables in cyanotic and acyanotic CHD patients. Results Of a total of 60 CHD children, 26 subjects had a diagnosis of cyanotic CHD and 34 subjects had a diagnosis of acyanotic CHD. The most common cause of cyanotic CHD was tetralogy of Fallot (76.9%), while the most common cause of acyanotic CHD were ventricular septal defect and patent ductus arteriosus (32.4% each). Analysis of lipid profiles on both groups revealed that low density lipoprotein (LDL) was significantly lower in the cyanotic group than in the acyanotic group (P<0.05). However, other lipid profile values, were not significantly different between groups. In addition, there was no significant difference in incidence of dyslipidemia between cyanotic and acyanotic CHD. Conclusion Low density lipoprotein is significantly lower in the cyanotic CHD group than in the acyanotic CHD group. But there are no significant differences in the other lipid profiles measurement and incidence of dyslipidemia between groups.

The challenges of an aging tetralogy of Fallot population

Introduction: Advancements in surgery and management have resulted in a growing population of aging adults with tetralogy of Fallot (TOF). As a result, there has been a parallel growth in late complications associated with the sequelae from the underlying cardiac anomalies as well as the surgical and other interventional treatments.Areas covered: Here, we review challenges related to an aging population of patients with TOF, particularly late complications, and highlight advances in management and key areas for future research. Pulmonary regurgitation, heart failure, arrhythmias, and aortic complications are some of these late complications. There is also a growing incidence of acquired cardiovascular disease, obesity, and diabetes associated with aging. Management of these late complications and acquired comorbidities continues to evolve as research provides insights into long-term outcomes from medical therapies and surgical interventions.Expert opinion: The management of an aging TOF population will continue to transform with advances in imaging technologies to identify subclinical disease and valve replacement technologies that will prevent and mitigate disease progression. In the coming years, we speculate that there will be more data to support the use of novel heart failure therapies in TOF and consensus guidelines on the management of refractory arrhythmias and aortic complications.

German Heart Centre Munich-45 years of surgery in adults with congenital heart defects: from primary corrections of septal defects and coarctation to complex reoperations

Background

Our historical overview in the form of a cohort study aimed to describe the changes in the cardiac operations in adults with congenital heart disease (ACHD), over 45 years in the German Heart Centre in Munich.

Methods

The study population comprised all consecutive patients aged 18 or more, who underwent surgery for congenital heart disease (CHD) at the German Heart Centre Munich, between 1974 and 2018. Operations were coded according to the Adult Congenital Heart Surgery (ACHS) score. Two-tailed chi-square test was used for testing on differences in the frequency of procedural groups between the decades.

Results

During the examined 45-year period, 2,882 operations were performed on ACHD. The number of operations per year increased with a correlation coefficient r=0.533, P<0.001. Overall operative mortality was 3.2%. There was no significant difference in mortality over the decades. The percentage of primary CHD diagnosis being the indication for the operation was 99% in the 1970s and decreased significantly to 56% in the 2010s, P<0.001. There was a significant decrease in the relative frequency of atrial septal defect closures from 45% in the 1970s and 1980s to 9% in 2010s (P<0.001). Coarctation repair made up 15% of all operations in the 1970s, then dropped significantly to 1% in the 2010s (P<0.001). The percentage of reoperations increased significantly from 7% in the 1970s to 50% in 2010s (P<0.001).

Conclusions

The spectrum of cardiac surgery in ACHD changed significantly over the last 45 years, from primary repair of septal defects and coarctation of the aorta in the 1970s to complex reoperations in the 2010s.

Metabolic syndrome and coronary artery disease in adults with congenital heart disease

In adults with congenital heart disease (ACHD), conditions acquired with aging, such as metabolic syndrome, hypertension, diabetes mellitus, and obesity, can negatively influence the original cardiovascular disease. Metabolic syndrome has a higher prevalence in ACHD than in the general population. In contrast, coronary artery disease shows a similar prevalence in adults with acyanotic CHD and the general population, while adults with cyanotic CHD, even after repair, have an even lower incidence of coronary artery disease than the general population/adults with acyanotic CHD. However, even in those with cyanotic CHD, coronary artery disease can develop when they have risk factors such as obesity, dyslipidemia, hypertension, diabetes mellitus, smoking habit, or limited exercise. The prevalence of risk factors for cardiovascular disease is similar between ACHD and the general population, but an increased risk of coronary atherosclerosis has been observed for congenital coronary artery anomalies, dextro-transposition of the great arteries after arterial switch operation, Ross procedure, and coarctation of the aorta. Aortopathy may be an additional risk factor for cardiovascular disease. As ACHD have other abnormalities that may make the heart more vulnerable to both the development of atherosclerosis and adverse cardiovascular sequelae, regular evaluation of their cardiovascular disease risk status is recommended. Metabolic syndrome is more common among ACHD than in the general population, and may therefore increase the future incidence of atherosclerotic coronary artery disease even in ACHD. Thus, ACHD should be screened for metabolic syndrome to eliminate risk factors for atherosclerotic coronary artery disease.

Causes of Death and Cardiovascular Comorbidities in Adults With Congenital Heart Disease

Background Little is known about the contemporary mortality experience among adults with congenital heart disease (CHD). The objectives of this study were to assess the age at death, presence of cardiovascular comorbidities, and most common causes of death among adults with CHD in a contemporary cohort within the United States. Methods and Results Patients with CHD who had a healthcare encounter between 2008 and 2013 at 1 of 5 comprehensive CHD centers in North Carolina were identified by International Classification of Diseases, Ninth Revision (ICD-9), code. Only patients who could be linked to a North Carolina death certificate between 2008 and 2016 and with age at death ≥20 years were included. Median age at death and underlying cause of death based on death certificate data were analyzed. The prevalence of acquired cardiovascular risk factors was determined from electronic medical record data. Among the 629 included patients, the median age at death was 64.2 years. Those with severe CHD (n=157, 25%), shunts (n=202, 32%), and valvular lesions (n=174, 28%) had a median age at death of 46.0, 65.0, and 73.3 years, respectively. Cardiovascular death was most common in adults with severe CHD (60%), with 40% of those deaths caused by CHD. Malignancy and ischemic heart disease were the most common causes of death in adults with nonsevere CHD. Hypertension and hyperlipidemia were common comorbidities among all CHD severity groups. Conclusions The most common underlying causes of death differed by lesion severity. Those with severe lesions most commonly died from underlying CHD, whereas those with nonsevere disease more commonly died from non-CHD causes.

Congenital heart disease in adults (when kids grow up) pediatric geriatric anesthesia

PURPOSE OF REVIEW

The current review focuses on the new development of adult congenital heart disease (ACHD) patients in the areas of imaging, percutaneous interventions, ventricular assist devices and transplantation.

RECENT FINDINGS

Since the last ACHD publication in the journal, several advances have been made in the evaluation and treatment of these patients. As CHD patients' longevity increases pregnancy, comorbities and acquired heart disease become a concern. Recent data show that the incidence of complications in low-risk CHD is not higher that the regular population. In addition, breakthrough research in percutaneous valve implantation has been published showing good outcomes but needing intensive care recovery in a significant number of patients. In the ACHD heart failure population, assist device and transplant fields mounting evidence shows that these therapies should not be the last resort since low-risk ACHD patient may have similar outcomes to those with acquired heart disease. Finally risk stratification is important in ACHD to define better ways to recover from surgery and anesthesia.

SUMMARY

The field of anesthesia for ACHD is growing with new indications for diagnostic, interventional and surgical procedures. Tailoring cardiac and noncardiac care to the different risk profile in ACHD patients will be defined in the next few years.

VIDEO ABSTRACT

Motta summary clip: http://links.lww.com/COAN/A65.

Coronary artery disease screening in adults with congenital heart disease prior to cardiac surgery

OBJECTIVE

As adults with congenital heart disease (CHD) grow older, preoperative screening for coronary artery disease (CAD) may be indicated prior to CHD surgery. Data regarding the indications for preoperative CAD screening in this population are limited. Current practice is to follow guidelines for patients with valvular heart disease; however, the risk for CAD in certain congenital heart diagnoses may be higher than the general population. This study aimed to assess the results of preoperative CAD screening in patients prior to CHD surgery.

DESIGN

Retrospective study.

SETTING

Single tertiary center.

PATIENTS

Patients ≥35 years that had CHD surgery from 1/1/2007 to 5/1/2017.

OUTCOME MEASURES

Data regarding CAD risk factors and preoperative CAD screening results were obtained. Prevalence and risk factors for CAD were analyzed, along with their relationship to perioperative outcomes.

RESULTS

A total of 73 patients underwent CAD screening with either cardiac catheterization (56%) or computed tomography angiography (34%) prior to CHD surgery. Overall 16 (22%) patients were found to have CAD. Only two patients had severe coronary stenosis and underwent coronary bypass grafting at time of CHD surgery. Patients with CAD were more likely to be older and have history of hypertension, dyslipidemia, and tobacco smoking. CHD diagnosis was not significantly associated with presence of CAD.

CONCLUSION

CAD is common in asymptomatic older patients referred for screening prior to CHD surgery; however, severe CAD requiring concomitant coronary intervention is uncommon. Preoperative CAD screening should be based on age and traditional CAD risk factors, rather than underlying CHD.

Italian survey on cardiac surgery for adults with congenital heart disease: which surgery, where and by whom?

OBJECTIVES

The population of ageing adults with congenital heart disease (ACHD) is increasing; surgery in these patients presents major difficulties in management. A great debate has developed about whether these patients should be cared for at an adult or paediatric hospital and by an acquired or congenital cardiac surgeon. We analysed data of the surgical treatment of ACHD from the Italian cardiac surgery centres in 2016, focusing on the type of surgery performed, where these patients were operated on and by whom.

METHODS

Ninety-two Italian cardiac surgery centres were contacted and 70 centres participated in this study. We collected data on the types of cardiac operations performed in congenital heart defect patients older than 18 years. In 2016, a total of 913 patients with ACHD were operated on: 440 by congenital cardiac surgeons (group I) in centres with paediatric and adult cardiac surgery units, and 473 by adult cardiac surgeons (group II) in centres with exclusively adult cardiac surgery units.

RESULTS

Pathologies of the right ventricular outflow tract were the most frequent diseases treated in group I and pathologies of the left ventricular outflow tract in group II. Group I included more complex and heterogeneous cases than group II. Surgery for ACHD represented 12% of the activity of congenital cardiac surgeons and only 1% of the activity of adult cardiac surgeons.

CONCLUSIONS

In Italy, ACHD patients are operated on both by congenital and adult cardiac surgeons. Congenital cardiac surgeons working in centres with both paediatric and adult cardiac surgery are more involved with ACHD patients and with more complex cases.

Current spectrum, challenges and new developments in the surgical care of adults with congenital heart disease

Today, more than two thirds of patients with congenital heart disease (CHD) are adults. Cardiac surgery plays an essential role in restoring and maintaining cardiac function, aside from evolving medical treatment and catheter-based interventions. The aim of the present publication was to describe the spectrum of operations performed on adults with CHD (ACHD) by reviewing current literature. Currently, surgery for ACHD is predominantly valve surgery, since valvular pathologies are often either a part of the basic heart defect or develop as sequelae of corrective or palliative surgery. Surgical techniques for valve repair, established in patients with acquired heart disease (non-ACHD), can often be transferred to ACHD. New valve substitutes may help to reduce the number of redo operations. Most of valve operations yield good results in terms of survival and quality of life, with the precondition that the ventricular function is preserved. Heart failure due to end-stage CHD is the most frequent cause of mortality in ACHD. However, surgical treatment by means of mechanical circulatory support (MCS) is still uncommon and the mortality exceeds the one following other operations in ACHD. Currently, different devices are used and new technical developments are in progress. However, there still is no ideal assist device available. Therefore, heart transplantation remains the only valid option for end-stage CHD. Despite higher early mortality following heart transplantation in ACHD compared to non-ACHD, the long-term survival compares favorably to non-ACHD. There is room for improvement by refining the indications, the time of listing, and the perioperative care of ACHD transplant patients. Sudden death is the second most frequent cause of mortality in ACHD. Ventricular tachycardia is the most frequent cause of sudden death followed by coronary artery anomaly. Due to the increasing awareness of physicians and the improved imaging techniques, coronary artery anomalies are coming more into the focus of cardiac surgeons. However, the reported experience is limited and it is currently difficult to provide a standardized and generally applicable recommendation for the indication and the adequate surgical technique. With the increasing age and complexity of ACHD, treatment of rhythm disturbances by surgical ablation, pacemaker or implantable cardioverter defibrillator (ICD) implantation and resynchronisation gains importance. A risk score specifically designed for surgery in ACHD is among the newest developments in predicting the outcome of surgical treatment of ACHD. This evidence-based score, derived from and validated with data from the Society of Thoracic Surgeons Congenital Heart Surgery Database, enables comparison of risk-adjusted performance of the whole spectrum of procedures performed in ACHD and helps in understanding the differences in surgical outcomes. The score is thus a powerful tool for quality control and quality improvement. In conclusion, new developments in surgery for ACHD are currently made with regard to valve surgery, which comprises more than half of all operations in ACHD and in treatment of end-stage CHD, which still yields high mortality and morbidity.

Prevalence of Coronary Artery Disease Risk Factors and Metabolic Syndrome in Children with Heart Disease

Children with acquired and congenital heart disease (CHD) are increasingly surviving to adulthood. Our aim was to determine the prevalence of coronary artery disease (CAD) risk factors in children at known risk for early CAD or with severe CHD. We recruited children (8-19 years) at risk for early CAD-Kawasaki disease (KD, N = 36) and coarctation (69) or severe CHD: > 1 cardiopulmonary bypass surgery (60), single ventricle (15), prosthetic valves (13). Anthropometric measurements, blood pressure, and fasting lipid data were compared with summaries from National Health and Nutrition Examination Survey (NHANES) publications (1999-2012). Relative risk (RR) ratios were calculated based on age classification and pooled to obtain overall RR. Of 174 subjects, 106 were male (61%) and 138 (79%) had CHD. Compared to NHANES data, hypertension and low HDL were higher in the study cohort [RR 11.7 (CI 6.34-21.6), p < 0.001; and 1.79 (CI 1.36-2.35). p < 0.001] and obesity and elevated total cholesterol were lower [RR 0.59 (CI 0.37-0.96), p = 0.03; and 0.42 (CI 0.19-0.95), p = 0.04]. Elevated non-HDL was similar between groups. Age category had similar RR for all CAD risk factors. Eight subjects had metabolic syndrome. Risk factors were similar between KD versus CHD subgroups. Both coarctation and non-coarctation subjects had increased RR for hypertension. Hypertension is the most common risk factor for children at risk of early CAD and severe CHD. Metabolic syndrome is rare. These patients should be screened and treated for hypertension and current recommendations for universal lipid screening are adequate for follow-up.