General Concepts in Adult Congenital Heart Disease

Global Cardiac Surgery in Brazil: A Call to Action

Global Cardiac Surgery is an innovative initiative with a focus on improving health outcomes and achieving healthcare equity for individuals worldwide affected by cardiac surgical conditions or in need of cardiac surgical care. Considering the existing disparities in access to cardiac surgery and the substantial burden of cardiac conditions amenable to surgical procedures in Brazil, it is imperative to support and scale Global Cardiac Surgery initiatives and leave no Brazilian patient behind. Here, we advocate for national initiatives within this field and highlight opportunities and challenges to support their development.

Cardiac Computed Tomography in Congenital Heart Disease

Computed tomography (CT) has emerged as a leading imaging modality in the evaluation of congenital heart disease (CHD). With ever-faster acquisition speed, decreasing radiation exposure, impeccable anatomic detail, optional functional data, and numerous post-processing tools, CT offers broad utility in CHD diagnosis, preoperative planning, and postoperative assessment. In this article, the far-reaching role of CT in CHD is reviewed, focusing on technical imaging considerations and key clinical applications.

"From Vision to Reality: Virtual Reality's Impact on Baffle Planning in Congenital Heart Disease"

This study aims to evaluate the feasibility and utility of virtual reality (VR) for baffle planning in congenital heart disease (CHD), specifically by creating patient-specific 3D heart models and assessing a user-friendly VR interface. Patient-specific 3D heart models were created using high-resolution imaging data and a VR interface was developed for baffle planning. The process of model creation and the VR interface were assessed for their feasibility, usability, and clinical relevance. Collaborative and interactive planning within the VR space were also explored. The study findings demonstrate the feasibility and usefulness of VR in baffle planning for CHD. Patient-specific 3D heart models generated from imaging data provided valuable insights into complex spatial relationships. The developed VR interface allowed clinicians to interact with the models, simulate different baffle configurations, and assess their impact on blood flow. The VR space's collaborative and interactive planning enhanced the baffle planning process. This study highlights the potential of VR as a valuable tool in baffle planning for CHD. The findings demonstrate the feasibility of using patient-specific 3D heart models and a user-friendly VR interface to enhance surgical planning and patient outcomes. Further research and development in this field are warranted to harness the full benefits of VR technology in CHD surgical management.

Heartfelt Minds: Uncovering the Intricate yet Overlooked Connection Between Psychiatric Disorders and Cardiology

In recent years, there has been a notable and concerning rise in the prevalence of mental disorders, indicating a growing societal challenge that warrants attention and support for affected individuals. Psychiatric problems range on a wide spectrum from as little as work or school related stress to as big as severe depression related to the loss of a loved one, a sense of loneliness, etc. This current generation yields the highest amounts of mental disorder patients due to the newfound pressures, difficulties, and ways of life. According to the Center for Disease Control and Prevention, more than 1 in 5 US adults live with a mental illness and about 1 in 25 US adults live or lived with a serious mental illness such as schizophrenia, bipolar disorder, or major depression. A similar statistic shows us that about 695,000 people in the United States in 2021 died due to some form of heart related disease. That is 1 in every 5 deaths. More recently, it has been noticed that these psychiatric disorders and heart diseases could be correlated. In this manuscript, we review the current literature on the effect and correlation of psychiatric disorders on the cardiovascular system. We present a review on primarily the "5 major psychiatric disorders," according to the NIH: depression, autism, attention-deficit/hyperactivity disorder, bipolar disorder, and schizophrenia. We will also present a review on stress-induced cardiac diseases, especially more recently with the rise of the COVID-19 Pandemic.

The Transition of Children Living With Congenital Heart Disease to Adult Care

The article explores the significance of the timely transition of a child living with congenital heart disease (CHD) to adult care and the role played by multidisciplinary care. Due to recent healthcare advances, more children with CHD survive to adulthood without surgical intervention. This survival is mainly due to the lesion being compatible with life and its management being done medically. However, further management requires meeting the child's needs and helping him transition to become a healthy, independent adult with almost equal life expectancy as his counterparts. The article reviews the comprehensive framework of transition through multidisciplinary care. Highlighting the necessity of training physicians to acquire expertise in the management of CHD is a foundational aspect of this review article. Introduction to transition requires assessment of the child's needs through all phases of life and informative counseling of both parents and child. It highlights the approach to educating patients and families with the knowledge to safeguard compliance. Multidisciplinary collaboration from various fields such as cardiology, pediatric physiatrist, nursing, and psychology has been stressed. Patients also need to cultivate skills in self-management and independence and be educated to comprehend their condition, including the potential health issues. This collaborative and multidisciplinary process necessitates the cooperation of patients, families, and the adult congenital heart disease (ACHD) team. Emphasis has been given to individualized counseling for girls to address their sexual health. The article also highlights the possible obstacles and how to tackle them to improve healthcare adherence. Timely transition and follow-up can be measured using various tools or through indices measuring the quality of life and average life expectancy. The global patterns of transition to ACHD care have also been emphasized, as well as the need for research studies to develop reliable indicators for assessing transition success.

Congenital Heart Disease: A Growing Population with Challenges to Patients and Providers

Congenital heart disease (CHD) is the most frequent disorder encountered in the newborn period and the most frequent cause of infant mortality [...].

Pattern of cardiovascular diseases at a teaching hospital in Addis Ababa, Ethiopia: An echocardiographic study of 1500 patients

Cardiovascular diseases (CVD) represent a significant global health problem. They account for nearly one third of deaths worldwide. With improvements in diagnostic modalities, their prevalence in sub-Saharan Africa (SSA) is rising. Disease pattens vary in different regions and communities and the pattern in our setting is not known. Echocardiography is a noninvasive diagnostic tool that essential for structural and hemodynamic assessment of the heart. It stands at the far front for comprehensive evaluation of the heart because of its relative low cost and wide availability. The aim of this study was to assess pattern of CVDs among patients who had echocardiography done at a teaching Hospital in Addis Ababa, Ethiopia. A retrospective review of 1500 echocardiograms of patients referred to the echocardiography laboratory of St. Paul Hospital Millennium Medical College (SPHMMC) for cardiac evaluation from January 1, 2018 to June 30, 2019 was performed. All subjects had standard transthoracic echocardiography performed by cardiologists using General Electric Vivid E9 and E95 machines. Demographic parameters and echocardiographic findings were collected using a structured checklist from the echocardiography register. Descriptive statistics were used to assess the echocardiographic findings. The mean age of subjects was 48.2 (SD of 18.2) and ranged between 14 and 100 years of age. Both males and females were nearly equally distributed with males accounting for 48.3%. Most (77.9%) of the subjects had an abnormal echocardiographic report; only 332 (22.1%) had a normal study. Diastolic dysfunction (DD) (33.4%), valvular heart disease (18.4%), and left ventricular hypertrophy (LVH) (13.7%) were the most common findings in our hospital. Among patients with DD, Grade 1 dysfunction accounted for the majority (79.8%), of which 41% had associated LVH. Pulmonary hypertension (PH), cardiomyopathy and ischemic heart disease were also not uncommon. Abnormal echocardiographic findings are common in patients referred to our hospital for transthoracic echo. The commonest echocardiographic abnormalities were DD, Valvular heart disease (both rheumatic and calcific valves) and LVH.

Catheter-Based Techniques for Addressing Atrioventricular Valve Regurgitation in Adult Congenital Heart Disease Patients: A Descriptive Cohort

INTRODUCTION

Increasing survival of adult congenital heart disease (ACHD) patients comes at the price of a range of late complications-arrhythmias, heart failure, and valvular dysfunction. Transcatheter valve interventions have become a legitimate alternative to conventional surgical treatment in selected acquired heart disease patients. However, literature on technical aspects, hemodynamic effects, and clinical outcomes of percutaneous atrioventricular (AV) valve interventions in ACHD patients is scarce.

METHOD

This is a descriptive cohort from CAHAL (Center of Congenital Heart Disease Amsterdam-Leiden). ACHD patients with severe AV valve regurgitation who underwent a transcatheter intervention in the period 2020-2022 were included. Demographic, clinical, procedural, and follow-up data were collected from patient records.

RESULTS

Five ACHD patients with severe or torrential AV valve regurgitation are described. Two patients underwent a transcatheter edge-to-edge repair (TEER), one patient underwent a valve-in-valve procedure, one patient received a Cardioband system, and one patient received both a Cardioband system and TEER. No periprocedural complications occurred. Post-procedural AV valve regurgitation as well as NYHA functional class improved in all patients. The median post-procedural NYHA functional class improved from 3.0 (IQR [2.5-4.0]) to 2.0 (IQR [1.5-2.5]). One patient died 9 months after the procedure due to advanced heart failure with multiorgan dysfunction.

CONCLUSION

Transcatheter valve repair is feasible and safe in selected complex ACHD patients. A dedicated heart team is essential for determining an individualized treatment strategy as well as pre- and periprocedural imaging to address the underlying mechanism(s) of AV regurgitation and guide the transcatheter intervention. Long-term follow-up is essential to evaluate the clinical outcomes of transcatheter AV valve repair in ACHD patients.

Self- and informant-reported executive function in young adults operated for atrial or ventricular septal defects in childhood

BACKGROUND

Adults with simple congenital heart defects (CHD) have increased risk of neurodevelopmental challenges including executive dysfunction. It is unknown if the executive dysfunction is universal or if it is driven by dysfunction in specific clinical subscales and how it might affect psychosocial aspects of everyday life.

METHODS

The self-reported and informant-reported executive function of adults with an average age of 26 ± 5 (range 18-41) who underwent childhood surgery for atrial septal defects (n = 34) or ventricular septal defects (n = 32) and matched controls (n = 40) were evaluated using the Behavior Rating Inventory of Executive Functions - Adult version (BRIEF-A).

RESULTS

The CHD group reported having more executive dysfunction than controls in all BRIEF-A clinical subscales (p < 0.020) and more than their informants reported on their behalf (p < 0.006). The CHD group had received three times more special teaching (44% compared to 16%) and pedagogical psychological counselling (14% compared to none) and had a three times higher occurrence of psychiatric disorders than controls (33% compared to 11%). Lower educational levels and psychiatric disorders were associated with higher BRIEF-A scores (p < 0.03).

CONCLUSIONS

Adults operated for septal defects in childhood report more challenges with all aspects of the executive functions than controls and more than relatives are aware of.

Early and Mid-Term Outcomes of Coronary Artery Bypass Grafting in Adults With Congenital Heart Disease

Atherosclerotic coronary artery disease (CAD) is well-studied in acquired cardiac diseases; however, little data exist regarding outcomes of adult congenital heart disease (ACHD) with CAD. This study examined patients who underwent coronary artery bypass grafting (CABG) during repair of ACHD. This was a retrospective study of patients who underwent CABG for CAD concomitant with ACHD repair 1972-2021. Demographic information, ACHD diagnosis, surgical history, operative details, and outcomes were analyzed. Data are presented as median (interquartile range [IQR]). 157 patients were identified with a median age of 63 (IQR 17) years. Left anterior descending (LAD) was the predominant diseased artery (109 patients [69%]); of those 83 (76%) were treated with mammary artery. 90 (57.3%) patients had 1 bypass, 42 (26.7%) 2, 19 (12%) 3, and 6 (3.8%) had 4. There has been no early mortality since 1988. There was no long-term survival difference between the patients with LAD disease treated with mammary compared to vein (P = 0.68), but early mortality was higher in those treated with vein (10.3% vs 0%, P = 0.018). Late recurrent angina was found in 18 patients (12%) and recurrent CAD found in 17 patients (11%), with 16 patients (10%) requiring CAD reintervention. At most recent follow-up (7.2 [IQR 11.4] years), 101 (64.3%) patients were deceased at 10 (IQR 13.1) years after surgery. Surgical revascularization for CAD may be necessary during the treatment of ACHD, most commonly for LAD disease. Early mortality was low in recent decades. Continued surveillance for recurrent CAD is required.

Complex adult congenital heart disease on cross-sectional imaging: an introductory overview

Congenital heart disease is the most common group of congenital pathology. Over the past few decades, advances in surgical treatment have resulted in a rising population of adult patients with repaired complex congenital heart disease. Although the quality of life has greatly improved, a significant proportion of morbidities encountered in clinical practice is now seen in adults rather than in children. These patients often have significant haemodynamic pathophysiology necessitating repeat intervention. CT and MRI are excellent imaging modalities, which help elucidate potential complications that may need urgent management. Although imaging should be performed in specialised centres, occasionally patients may present acutely to emergency departments in hospitals with little experience in managing potentially complex patients. The purpose of this article is to provide an introductory overview to the radiologist who may not be familiar with complex congenital heart disease in adult patients. This educational review has three main sections: (1) a brief overview of the post-operative anatomy and surgical management of the most common complex conditions followed by (2) a discussion on CT/MRI protocols and (3) a review of the various complications and their CT/MRI findings.

Provision of medical health care for adults with congenital heart disease associated with aortic involvement

Background

All patients with congenital heart disease (CHD) are chronically ill from their cardiac disease. Despite the increasing evidence that aortic alterations are becoming relevant, the importance of aortopathy in CHD has long been underestimated. This study was conducted to determine the health status of patients and/or the provision of health services of adults with CHD (ACHD) with manifest aortopathy or at risk thereof.

Methods

In a questionnaire-based cross-sectional survey, the "real life"-care of ACHD was analysed, comparing patients with risk of developing aortopathy and/or manifest aortopathy.

Results

Of the 563 enrolled ACHD (49.6% female, mean age 35.8±12.1, 18-86 years) 56.8% (n=320) had a risk of developing aortopathy and/or manifest aortopathy. Of the 320 patients at risk, 187 (33.2% of the total number) had a proven aortopathy. Within this subgroup, the basic medical care for CHD-independent medical problems was given by primary medical care providers [family doctors/general practitioners (GP) in 89.4% (n=286), internists in 13.4% (n=43), physicians of another specialty in 2.5% (n=8)]. Almost all primary medical care providers knew about the CHD of their patients. Even for CHD-specific health problems, the basic medical care of risk patients was provided by a family doctor or GP in 56.6% (n=181) and by an internist in 18.4% (n=59). 30.0% (n=96) primarily consulted another specialist, including cardiologists. Only 32.8% of ACHD at risk had ever been referred to a CHD specialist by a GP for cardiac problems related to their CHD. In contrast, the need for advice was high for ACHD with aortopathy and related mainly to physical activity, employment and education, pregnancy, rehabilitation or health and life insurance. Only 35.5% of patients at risk indicated that their information on specific care structures for ACHD was sufficient, and a further 38.1% of patients were aware of patient organizations.

Conclusions

Even today, aortic involvement in ACHD is an often-overlooked condition, although considerable negative effects on morbidity and mortality exist. As aortopathy gains in importance with increasing age and complexity of CHD, almost all affected ACHD need lifelong medical advice and access to modern, scientifically based care concepts. According to the study-results, primary care providers and also patients are mostly insufficiently informed about the specialized ACHD facilities. The future goal is therefore to create a better awareness of CHD problems among both primary care physicians and the patients concerned.

The Fontan outcomes network: first steps towards building a lifespan registry for individuals with Fontan circulation in the United States

The Fontan Outcomes Network was created to improve outcomes for children and adults with single ventricle CHD living with Fontan circulation. The network mission is to optimise longevity and quality of life by improving physical health, neurodevelopmental outcomes, resilience, and emotional health for these individuals and their families. This manuscript describes the systematic design of this new learning health network, including the initial steps in development of a national, lifespan registry, and pilot testing of data collection forms at 10 congenital heart centres.

Diagnosis and treatment of adults with congenital heart disease

Approximately 50 million adults worldwide have known congenital heart disease (CHD). Among the most common types of CHD defects in adults are atrial septal defects and ventricular septal defects followed by complex congenital heart lesions such as tetralogy of Fallot. Adults with CHDs are more likely to have hypertension, cerebral vascular disease, diabetes and chronic kidney disease than age-matched controls without CHD. Moreover, by the age of 50, adults with CHD are at a greater than 10% risk of experiencing cardiac dysrhythmias and approximately 4% experience sudden death. Consequently, adults with CHD require healthcare that is two- to four-times greater than adults without CHD. This paper discusses the diagnosis and treatment of adults with atrial septal defects, ventricular septal defects and tetralogy of Fallot.

Sudden Cardiac Deaths in Adults with Congenital Heart Disease with Structural Abnormalities: A Retrospective Review of Cases in the Cook County Medical Examiner's Office

Sudden cardiac death is a significant cause of mortality in adults with congenital heart disease (CHD). The Cook County Medical Examiner's Office database was queried for cases of CHD as a cause of death in the period between July 2008 and April 2019. Twenty-two cases were identified, including 11 decedents with simple defects and 10 decedents with complex defects. All of the subjects were in apparent good health at the time of death. In the absence of other obvious causes of death, simple defects were considered cases of sudden cardiac death. Significant cardiac morphological changes were common in complex defects. While 16 cases had known, diagnosed/treated CHD, 5 cases had no diagnosis prior to autopsy. In these cases, the ability to recognize CHD (sometimes subtle) helped in determining the causes of death. Therefore, forensic pathologists must be able to properly recognize various forms of CHD and request consultations, when needed.

Efficient in vivo direct conversion of fibroblasts into cardiomyocytes using a nanoparticle-based gene carrier

The reprogramming of induced cardiomyocytes (iCMs) has shown potential in regenerative medicine. However, in vivo reprogramming of iCMs is significantly inefficient, and novel gene delivery systems are required to more efficiently and safely induce in vivo reprogramming of iCMs for therapeutic applications in heart injury. In this study, we show that cationic gold nanoparticles (AuNPs) loaded with Gata4, Mef2c, and Tbx5 function as nanocarriers for cardiac reprogramming. The AuNP/GMT/PEI nanocomplexes show high reprogramming efficiency in human and mouse somatic cells with low cytotoxicity and direct conversion into iCMs without integrating factors into the genome. Importantly, AuNP/GMT/PEI nanocomplexes led to efficient in vivo conversion into cardiomyocytes after myocardial infarction (MI), resulting in the effective recovery of cardiac function and scar area. Taken together, these results show that the AuNP/GMT/PEI nanocarrier can be used to develop effective therapeutics for heart regeneration in cardiac disease patients.