The cost of congenital heart disease in children and adults. A model for multicenter assessment of price and practice variation

OBJECTIVE

To assess the cost of congenital heart disease (CHD) and to assess whether practice pattern or price was more responsible for variation. RESEARCH DESIGN AND SETTING: Data were collected from Charleston, NC; Columbus, Ohio; Detroit, Mich; Houston, Tex; Los Angeles, Calif; and New York, NY. The CHD was first classified as to physiologic characteristics and severity. For each type of CHD, the number of clinic visits, hospitalizations, and years of medication use were estimated.

RESULTS

On the basis of actual charges, the "prices" were calculated as follows, in 1992 dollars: for patients from birth to 21 years: benign disease (19% of patients), $3940; acyanotic disease (45%), $49,730; cyanotic disease (36%), $102,084; and average for all CHD categories, $59,877; for patients 22 to 40 years of age (of whom 24% had resolved defects or were dead): benign disease (19%), $3470; acyanotic disease (52%), $12,981; cyanotic disease (29%), $39,187; and average for all CHD, $18,773. The cost for the group from birth to 21 years varied from $47,500 to $73,600, accounting for 55% by practice (number of echocardiograms and cardiac catheterizations) and 45% by price, although mortality was similar.

CONCLUSIONS

The treatment of CHD is comparatively inexpensive, especially in adult survivors. The variation in both practice and price bears further study, with comparison to determine the most cost-effective strategies for treating these patients.

Wide complex bigeminy: unusual presentation of an atriofascicular fiber

Ventricular bigeminy in children is regarded as a benign arrhythmia in the absence of coexisting heart disease. We present the case of a patient with an atriofascicular fiber that electrocardiographically presented as wide complex bigeminy and wide complex tachycardia. At electrophysiologic study, the mechanism for the wide complex extrasystoles was reentry within the atriofascicular fiber or at its atrial insertion. Retrograde conduction within the fiber was also demonstrated under the influence of verapamil and ventricular extrastimulus testing. We conclude that conduction through an atriofascicular fiber should be included in the differential diagnosis of wide complex bigeminy having left bundle branch block morphology.

Adult patients with congenital heart disease

Adult patients with congenital heart disease present complex problems that require individualized management. Unfortunately, few physicians who care for adults with congenital heart disease have received adequate specific training to deal with their problems. Pediatric cardiologists who are familiar with congenital heart disease often refer patients to adult cardiologists after adolescence. And adult cardiologists have not traditionally had much training or experience in dealing with congenital heart disease. The cardiac needs of these patients are often best managed through the collaborative efforts of adult and pediatric cardiologists, cardiac surgeons, specialized nurse clinicians, and social workers. Of course, it is crucial to their optimal care that there be involvement of a primary care physician who can help with their many medical, surgical, and psychosocial problems.

Successful closure of a previously unsuspected atrial septal defect by an implantable Clamshell device and subsequent transvenous pacemaker implantation

Implantation of transvenous leads for a permanent cardiac pacing system usually requires the absence of intracardiac shunts. We report the case of an asymptomatic atrial septal defect in an 11-year-old boy who required permanent pacing. We implanted an atrial septal defect closure (Clamshell) device prior to implantation of transvenous leads. This new device makes transvenous implantation possible and may reduce the risk of stroke in patients with these anomalies.

Prolonged QT interval in hypertrophic and dilated cardiomyopathy in children

When the QT interval is prolonged in a patient with structural heart disease, there is a question of whether the QT interval prolongation is the result of coexistent long QT interval syndrome or ventricular hypertrophy. The purpose of this study was to assess whether QT interval prolongation can be attributed to ventricular hypertrophy/dilation alone. Electrocardiograms (ECGs) of 25 children in each of six echocardiographically proven groups (right ventricular hypertrophy, left ventricular hypertrophy, biventricular hypertrophy, hypertrophic cardiomyopathy, dilated cardiomyopathy, and normals) were analyzed. All patients had QRS interval durations < 100 msec, and patients with ventriculotomies were excluded. No patients in the normal group had a QTc interval > or = 0.45 sec. Eight (32%) of 25 patients with dilated cardiomyopathy had a QTc interval > or = 0.45 sec (p = 0.007 vs normal), 6 (24%) of 25 patients with hypertrophic cardiomyopathy had a QTc interval > or = 0.45 sec (p = 0.03 vs normal), and 2 of 25 patients each with right ventricular hypertrophy, left ventricular hypertrophy, and biventricular hypertrophy had a QTc interval > or = 0.45 sec (p = NS vs normal). There was no relation of the QTc interval to age, QRS duration, T-wave axis, or heart rate in any group. In the dilated cardiomyopathy group, there was no relationship of QTc interval to age, shortening fraction, or left ventricular end diastolic dimension. In conclusion, (1) a significant number of patients (24% to 32%) with dilated or hypertrophic cardiomyopathy may have a long QTc interval on the surface ECG, and (2) ventricular hypertrophy/dilation may be additional rare causes of acquired prolongation of the QT interval.

Psychosocial concerns of adults with congenital heart disease. Employability and insurability

Addressing the psychosocial concerns of the growing population of adults with congenital heart disease presents a unique challenge to health care providers. These patients frequently need information about their disease with emphasis on how it may affect their sexuality, childbearing, and risk of having children with congenital heart disease. These patients also face problems in securing employment that will provide health insurance coverage for their cardiac conditions.

Training in the care of adult patients with congenital heart disease

The growing population of patients with congenital heart lesions surviving to adulthood necessitates a fresh look at the clinical training required to care for these patients. Physicians in pediatric and medical cardiology, general pediatrics, general medicine, family practice, obstetrics and gynecology and other specialities will all have a role in the care of these patients. Most likely, training will need to be incorporated into existing pathways with a clear delineation of a body of knowledge necessary to assimilate to complete the training program. The authors favor a certificate of added qualification for the treatment and management of adults with congenital heart disease to encourage excellence in preparation of physicians to care for this complex patient population.

Incidence and management of dysrhythmias after Fontan procedure

The modified Fontan procedure for univentricular heart disease results in the full spectrum of significant cardiac arrhythmias: tachycardias and bradycardias. The tachycardias are primarily supraventricular in origin: 1. atrial flutter, 2. primary atrial tachycardia, 3. atrial fibrillation, and 4. accelerated junctional rhythm or junctional tachycardia; however, ventricular tachyarrhythmias occur also, but less frequently. Bradycardia usually is a result of 1. sinoatrial node dysfunction resulting in junctional rhythm or 2. less commonly, atrioventricular conduction abnormalities, such as second degree and third degree atrioventricular block. Finally, the combination of atrial tachyarrhythmias and sinoatrial node dysfunction can occur in a small but significant number of patients after Fontan surgery. A complete array of medical and pacemaker therapeutic options is necessary for the physician to treat these difficult arrhythmias successfully.

How to measure the QT interval--what is normal?

The QT interval extends from the beginning of the QRS complex to the end of the T wave. Since the report of Jervell and Lange-Nielsen in 1957, it has been difficult to determine whether to measure a QT or a QU interval. U waves are more prominent in the left chest leads and less prominent in lead II, with the end of the T wave in lead II corresponding to the end of significant repolarization in any other lead. Therefore, by convention, lead II has been chosen to measure the QT interval. Numerous attempts at correction have been made, but Bazett's correction (QT/square root of RR) remains the current standard. In stable sinus rhythm, a QT interval corrected for heart rate (QTc) of > 0.44 sec is considered abnormal. In this study, in the presence of sinus arrhythmia, the QT interval following the shortest RR interval was > 0.46 sec in 98.4% of patients with the congenital long QT syndrome, but in only 3.8% of control subjects (p < 0.0001). Likewise, in the presence of sinus arrhythmia, the uncorrected QT interval varied by > 0.03 seconds in a 10-sec rhythm strip of lead II in 33% of long QT syndrome patients but in 0% of controls (p < 0.01). The QT interval varied depending on autonomic tone and state of wakefulness, being approximately 19 msec longer in sleeping patients with a heart rate of 60 beats/min than in awake patients with the same heart rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Developmental differences in canine cardiac surgical scars

Sudden death and arrhythmias are significant problems in patients with various types of repaired congenital heart disease and have been associated with increasing time after and older age at surgery. Arrhythmias have been mapped clinically to areas of surgical scars in some patients, leading to the hypothesis that scar morphology changes with age. This study compared the morphology and histology of right ventriculotomy scars or right atriotomy scars in newborn (2 to 3 weeks), young (5 to 8 weeks), and older (> or = 6 months) dogs at postmortem examination 5 months postoperatively. Atriotomy lengths increased significantly compared with the initial incision in the newborn (6.0 mm +/- 0.1 to 15.2 mm +/- 5.8; p < 0.05) and young (6.8 mm +/- 0.9 to 19.6 mm +/- 4.8; p < 0.01) groups but were similar in the older group (35.5 mm +/- 11.7 to 27.0 mm +/- 2.5). Ventriculotomy scars grew 110 +/- 69% in the newborn group and 126 +/- 71% in the young group but shrank 31 +/- 6% of the original length in the older group (young vs older; p < 0.05). This increase in the atriotomy and ventriculotomy scars in the young group and the decrease in the older group resulted in scars of similar length; only those scars in the newborn group remained significantly shorter than scars in the older group (p < 0.05). Atriotomy and ventriculotomy scars in the older group had more bone or cartilage (p < 0.05) but less dystrophic calcification (p < 0.05) than those scars in the younger groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid ventricular pacing in dogs with right ventricular outflow tract obstruction: insights into a mechanism of sudden death in postoperative tetralogy of Fallot

OBJECTIVES

We explored the hypothesis that residual outflow tract obstruction and ventricular hypertrophy associated with rapid ventricular rhythm contribute to sudden death, in part because they result in humoral or hemodynamic changes that predispose to ventricular fibrillation, such as increased catecholamine release or decreased coronary flow, or both.

BACKGROUND

Ventricular arrhythmia after surgical repair of tetralogy of Fallot has been associated with sudden death, particularly in patients with residual right ventricular hypertension. However, the mechanisms by which sudden death occurs remain unclear.

METHODS

Seven awake, unanesthetized mature beagles with chronically elevated right ventricular pressure (high pressure group: right ventricular/left ventricular systolic pressure ratio > 0.5) were compared with six beagles with low right ventricular pressure at rest and at the end of 5 min of ventricular pacing at 240 beats/min (low pressure group).

RESULTS

In the high pressure group, cardiac output decreased during ventricular pacing (compared with sinus rhythm) from 304 +/- 21 to 218 +/- 21 ml/min per kg (p < 0.01) and plasma norepinephrine increased substantially from 673 +/- 64 to 1,047 +/- 92 pg/ml (p < 0.01). Comparable changes were not observed in the low pressure group. Plasma epinephrine levels were similar in both groups at rest and did not change with pacing. Postpacing norepinephrine levels from both groups correlated positively with both right ventricular systolic and diastolic pressure at rest and correlated negatively with the change in cardiac output from rest to pacing. Regional right ventricular myocardial blood flow increased with pacing in the low pressure group, whereas in the high pressure group it was increased at rest and did not increase further with pacing.

CONCLUSION

During ventricular pacing, dogs with right ventricular outflow tract obstruction and high right ventricular pressure had a decrease in cardiac output and an increase in plasma norepinephrine, coupled with a loss of right ventricular myocardial blood flow reserve. Similar changes may occur in postoperative patients with similar hemodynamics and tachyarrhythmia and could contribute to the occurrence of ventricular fibrillation and sudden death.

The long QT syndrome in children. An international study of 287 patients

BACKGROUND

The Pediatric Electrophysiology Society studied children with the long QT syndrome (LQTS) to describe the features of LQTS in patients less than 21 years old, define potential "low-risk" and "high-risk" subpopulations, and determine optimal treatment.

METHODS AND RESULTS

Patients less than 21 years old were included if either QTc was more than 0.44; they had unexplained syncope, seizures, or cardiac arrest preceded by emotion or exercise; or family history of LQTS. We found 287 patients from 26 centers in seven countries. Mean +/- SD age at presentation was 6.8 +/- 5.6; 9% presented with cardiac arrest, 26% with syncope, and 10% with seizures. Of those with symptoms, 67% had symptoms related to exercise. Family history was positive for long QT interval in 39% and for sudden death in 31%. Hearing loss was present in 4.5%. A normal QTc was present in 6%, and QTc of more than 0.60 was in 13%. Atrioventricular block occurred in 5%, but 13 of 15 patients had second-degree atrioventricular block (2:1), and only two of 287 had complete atrioventricular block. Ventricular arrhythmias were found on 16% of initial routine ECGs: 4% uniform premature ventricular contractions, 5% multiform premature ventricular contractions, 1% monomorphic ventricular tachycardia, and 6% torsade de pointes. Overall, treatment was effective for symptoms in 76% and for ventricular arrhythmias in 60%. There was no difference between propranolol and other beta-blockers in effective treatment. Left stellectomy was performed in nine patients, and defibrillators were implanted in four; no sudden death occurred in these 13 patients. In follow-up (duration, 5.0 +/- 4 years; age, 10.9 +/- 6.3 years), 5% had cardiac arrest, 4% had syncope, and 1% had seizures. The two multivariate predictors of symptoms at follow-up were symptoms at presentation and propranolol failure. Sudden death occurred in 8%; multivariate predictors of sudden death were length of QTc at presentation of more than 0.60 and medication noncompliance.

CONCLUSIONS

The appearance of 2:1 atrioventricular block, multiform premature ventricular contractions, and torsade de pointes are relatively more common in children with LQTS than other children and should raise the index of suspicion for LQTS. Because 9% of patients presented with cardiac arrest and no preceding symptoms, perhaps prophylactic treatment in asymptomatic children is indicated. Asymptomatic patients with normal QTc and positive family history may be a low-risk group. Patients with QTc of more than 0.60 are at particularly high risk for sudden death, and if treatment is not effective, consideration should be given to cardiac sympathetic denervation, pacemaker implantation, and perhaps implantation of a defibrillator.