Quality of life and perceived health status in surviving adults with univentricular heart

[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.

Univentricular Heart

As early as 1699, Chemineau described a heart composed of 2 auricles but only 1 ventricle. 1 The univentricular heart has since fascinated the medical community. Unique in its complexity and scope, the univentricular heart has sparked intense debates about embryology and nomenclature, challenged our understanding of cardiovascular physiology and hemodynamics, and inspired some of the most creative surgical and interventional approaches in human history. The present report provides an overview of the nomenclature and classification of the univentricular heart, epidemiology and pathological subtypes, genetic factors, physiology, clinical features, diagnostic assessment, therapy, and postoperative sequelae. Although the present report touches on issues applicable to neonates and children with univentricular hearts, the focus is on information of interest and relevance to the adult cardiologist.

Indications for Heart Transplantation in Pediatric Heart Disease

Background— Since the initial utilization of heart transplantation as therapy for end-stage pediatric heart disease, improvements have occurred in outcomes with heart transplantation and surgical therapies for congenital heart disease along with the application of medical therapies to pediatric heart failure that have improved outcomes in adults. These events justify a reevaluation of the indications for heart transplantation in congenital heart disease and other causes of pediatric heart failure.

Methods and Results— A working group was commissioned to review accumulated experience with pediatric heart transplantation and its use in patients with unrepaired and/or previously repaired or palliated congenital heart disease (children and adults), in patients with pediatric cardiomyopathies, and in pediatric patients with prior heart transplantation. Evidence-based guidelines for the indications for heart transplantation or retransplantation for these conditions were developed.

Conclusions— This evaluation has led to the development and refinement of indications for heart transplantation for patients with congenital heart disease and pediatric cardiomyopathies in addition to indications for pediatric heart retransplantation.

Health-related quality of life: A closer look at related research in patients who have undergone the Fontan operation over the last decade

The advancements in surgical technique and perioperative care have significantly improved the survival of children with single ventricle (SV) congenital heart disease (CHD) over the past decade. The population who have undergone the Fontan operation are growing into adulthood and facing many unique challenges. Past research has focused on functional and neurodevelopmental outcomes with inferences made to health-related quality of life (HRQOL). With the population who have undergone the Fontan operation surviving into adulthood, little research has been directed toward the self-report of HRQOL in adolescents and young adults after surgical palliation. Questions still remain on how these patients will transition into adulthood and whether they will live normal productive lives. This article reviews the literature related to HRQOL in the SV subgroup of CHD. In addition, an overview of newly developed disease-specific HRQOL instruments is presented as well as limitations and future research in HRQOL of the SV Fontan population.

The Role of the Psychologist in Adult Congenital Heart Disease

In addition to monitoring and treating the cardiac disease, patients benefit from health professionals recognizing and managing the potential psychosocial consequences of growing up with congenital heart disease. Working groups from Europe and North America have emphasized the benefit of inclusion of specialized mental health care for adult congenital heart disease (ACHD) patients. This article reviews the evidence that ACHD patients have special and unique psychosocial needs and outlines ways in which psychologists can be integrated into multidisciplinary ACHD care teams. There are three professional domains in which clinical health psychologists can contribute to an ACHD team: provision of clinical services, multidisciplinary research, and professional education. Considerations for incorporating psychology into ACHD teams are presented.

Relationship of Patient and Medical Characteristics to Health Status in Children and Adolescents After the Fontan Procedure

BACKGROUND

After the Fontan procedure, patients are at risk for suboptimal health status related to their complex healthcare experience, physiological limitations, medical complications, and guarded long-term prognosis.

METHODS AND RESULTS

In the Pediatric Heart Network cross-sectional study of Fontan survivors 6 to 18 years of age, parents completed the Child Health Questionnaire, and scores were related in multivariable analysis to patient and medical characteristics obtained from medical record review. For 537 patients (mean age at study, 11.9 years; 60% male) with a median age at Fontan of 2.8 years (range, 0.7 to 14.6 years), parent-reported patient morbidities included deficits in vision in 33%, speech in 27%, and hearing in 7%, as well as problems with attention in 46%, learning in 43%, development in 24%, behavior in 23%, anxiety in 17%, and depression in 8%. Child Health Questionnaire summary scores were significantly lower than the US population sample for Physical Functioning (mean Z score, -0.47+/-1.19; P<0.001) and Psychosocial Functioning (-0.28+/-1.08; P<0.001). Parent-reported medical conditions and long-term and current medical problems explained the greatest amount of variation in the Physical Functioning scores. Parent-reported patient conditions, including behavior, learning, anxiety, and attention problems and depression, explained the greatest amount of variation in the Psychosocial Functioning scores. Lower family income had a negative impact on both Physical and Psychosocial Functioning.

CONCLUSIONS

There are deficits in health status in children and adolescents after the Fontan procedure. Strategies to address this problem might emphasize coordinated and effective prevention, detection, and management of noncardiac and psychosocial conditions, as well as specific targeting of patients from low-income households.

Long-term and developmental outcomes of children with complex congenital heart disease

As short-term survival of complex congenital heart disease continues to improve dramatically with advances in medical and surgical treatment, further efforts must be made to understand the long-term outcomes of our efforts. As survival continues to improve, cardiovascular morbidity and, equally importantly, neurodevelopmental and social outcomes must be a continual focus in our treatment of these complex patients. Further study of these effects is underway, and more is certainly warranted. Understanding should lead to modification of current techniques and management strategies, all with the ultimate goal of improving our patients' quality of life.

Impact of arrhythmias on health-related quality of life in adults with congenital cardiac disease

BACKGROUND

Health-related quality of life in adults with congenital cardiac disease appears to be impaired, but the determinants of this alteration remain largely unknown. The aim of our study was to examine the impact of arrhythmias on quality of life in patients late after the atrial redirection operation for transposition, or after complete correction of tetralogy of Fallot.

PATIENTS AND METHODS

We enrolled 32 patients with transposition, and 35 patients with tetralogy of Fallot, in a prospective study. Quality of life was assessed using RAND-36 questionnaires. Quality of life data were compared with those of an age-matched control population. Patients underwent 24-hour and 7-day electrocardiographic recordings, echocardiography, and exercise testing.

RESULTS

Patients without arrhythmias had quality of life comparable to that of the general population. All 8 domains in the questionnaire showed scores 22 to 51 percent lower in 12 patients with atrial tachyarrhythmias, and/or sinus nodal dysfunction, requiring insertion of a pacemaker in comparison with 55 patients without arrhythmias. In patients with transposition, low scores were not only associated with arrhythmias, but also correlated with impaired exercise capacity.

CONCLUSIONS

Atrial tachyarrhythmias, and sinus nodal dysfunction, requiring insertion of a pacemaker, were associated with impaired quality of life in adults late after atrial surgical correction of transposition or correction of tetralogy of Fallot.

Is sense of coherence a pathway for improving the quality of life of patients who grow up with chronic diseases? A hypothesis

A recent study indicated that the quality of life in adult patients with congenital heart disease was better than that of their healthy counterparts. A possible explanation for this is that these patients have a stronger sense of coherence than do their healthy counterparts. This enhanced sense of coherence develops in childhood through the successful application of generalized resistance resources. Here, we advance the hypothesis that sense of coherence may be a potential pathway for improving the quality of life in patients who grow up with a chronic health condition. This hypothesis needs to be tested in long-term longitudinal studies. If such studies can confirm the hypothesis, SOC can be an important target for interventions in childhood to improve patients' quality of life during adulthood.

Biopsychosocial experiences of adults with congenital heart disease: review of the literature

BACKGROUND

Approximately 1% of all newborns display some form of congenital heart disease (CHD). Successful medical and surgical management of CHD has allowed 85% of these children to survive into adulthood and produced a new set of challenges for both patients and doctors with an emphasis on quality of life and psychosocial functioning.

METHODS

The current paper has 3 aims: (1) to summarize the research literature examining the emotional adjustment among this population, (2) to detail the psychological, social, and quality-of-life factors that might result in an increased risk of psychological maladjustment, and (3) to provide clinical management strategies to optimize health outcomes.

RESULTS

Current empirical evidence has suggested that compared with same aged reference norms in US studies, adults with CHD had scores indicative of worse emotional functioning as assessed by both clinical interviews and self-report measures. Similar European studies have generally not demonstrated such differences. Additional research suggests that areas of functioning that may be particularly affected include neurocognitive functioning, body image, social and peer relationships, and mild delays in developmental functioning.

CONCLUSIONS

These studies suggest that patients with CHD are successfully engaging in full adult responsibilities and roles but do experience specific psychosocial challenges that may impact emotional functioning, self-perception, and peer relationships. Lifestyle considerations in young adulthood are significant and impinge on pregnancy considerations and exercise capabilities. Clinical management strategies include increased awareness and dialogue between patients with CHD and physicians regarding psychosocial concerns.

Employment and advice regarding careers for adults with congenital heart disease

AIMS

To compare the rates of employment, and advice offered concerning careers, in adults with congenital heart disease and controls. To assess the impact of the severity of the congenital cardiac malformation on the chances for employment.

METHODS

We solicited responses from 299 adults with congenitally malformed hearts, asking them to answer questions from a questionnaire posed at interview by a trained nurse. The adults were asked to give an identical questionnaire to a friend to act as a control. We received responses from 177 of the controls.

RESULTS

The responses showed that 51 of 156 (33 per cent) adults with congenital heart disease were unemployed, and 37 of 151 (25 per cent) had been unemployed for more than a year. This is significantly more than 25 of 156 (16 per cent) matched controls unemployed, and 5 of 151 (3 per cent) controls unemployed for more than a year. Almost one-fifth of the adults with congenital heart disease (19 per cent) had received advice regarding their career which they found helpful, which is significantly fewer than the 31 per cent of controls. More (42 per cent) had been given advice against certain occupations than controls (11 per cent). Receiving career advice was significantly associated with employment in the population with congenitally malformed hearts, with almost three-quarters (73 per cent) of those given advice being employed compared to 46 per cent of those not given advice. This pattern was not seen in controls. The severity of the congenital cardiac malformation did not significantly affect the rates of unemployment.

CONCLUSIONS

Whatever the severity of their disease, adults with congenitally malformed hearts are more likely to be unemployed than matched controls. They are less likely to receive useful advice regarding potential careers, and find the advice given less helpful, than controls, although receiving suitable advice is associated with being employed in the population with congenital cardiac disease.

Comparison of health related quality of life with cardiopulmonary exercise testing in adolescents and adults with congenital heart disease

OBJECTIVES

To compare self reported quality of life with measured exercise capacity in patients with congenital heart disease.

DESIGN

Prospective cross sectional clinical study.

SETTING

Tertiary referral centre for congenital cardiology.

PATIENTS AND METHODS

149 patients (60 female, 14-60 years old) with various congenital heart defects completed a health related quality of life questionnaire (medical outcomes study 36 item short form). Then they performed a cardiopulmonary exercise test on a bicycle in a sitting position.

RESULTS

Peak oxygen uptake correlated significantly with the physical functioning (r = 0.521, p < 0.0005) and general health scales (r = 0.313, p < 0.0005) but not with role-physical, bodily pain, vitality, social functioning, role-emotional, mental health, and health transition scales. Closer examination of the data showed that despite an overall good correlation a substantial number of patients overestimated their physical capabilities.

CONCLUSIONS

Exercise tests and quality of life instruments should be used together to get an appropriate overview of the health status of patients with congenital heart disease.

Current subjective state of health, and longitudinal psychological well-being over a period of 10 years, in a cohort of adults with congenital cardiac disease

OBJECTIVE

To examine the current subjective state of health, and the longitudinal course of psychological well-being, in adult patients with congenital cardiac malformations.

METHODS

Our study concerns the second follow-up of a cohort of patients with congenital cardiac malformations. We examined 362 consecutive patients, aged from 20 to 46 years, who underwent surgical procedures for treatment of congenital cardiac disease between 1968 and 1980, specifically for treatment of atrial and ventricular septal defects, tetralogy of Fallot, transposition, and pulmonary stenosis. The patients were submitted to extensive medical and psychological examination. During psychological examination, in which all patients were seen by the same psychologist (EvR), patients filled in questionnaires concerning their current subjective state of health, using the 36-item Short Form Health Survey (SF-36), and psychological well-being, answering the Heart Patients Psychological Questionnaire. The data we acquired at their first follow-up was used to measure the longitudinal course of psychological well-being over the intervening period of 10 years.

RESULTS

When compared to a reference group, the patients assessed their state of health less favourably concerning physical functioning, but more favourable with regard to social functioning, bodily pain, and limitations of role due to emotional problems. Younger female patients reported more limitations of role due to physical functioning than did the female patients who were older. Patients with transposition showed a negative trend for their subjective state of health, but reported the least bodily pain. Within the overall group of patients, displeasure had increased, while social inhibition had decreased, over the intervening period of 10 years.

CONCLUSION

Extra attention should be paid to the subjective experiences of young female patients with congenital cardiac disease. The patients with transposed arterial trunks seem overall to experience poorer physical health.

Individual quality of life in adults with congenital heart disease: a paradigm shift

AIMS

During the last decade, a paradigm shift has emerged in the measurement of quality of life, from the use of standard questionnaires towards a more individualized approach. Therefore, this study examined individual quality of life in adults with congenital heart disease and explored potential differences with those reported by matched, healthy control subjects.

METHODS AND RESULTS

We examined 579 adults with congenital heart disease. A subsample of 514 of these patients was matched for age, gender, educational level, and employment status with 446 healthy counterparts. Individual quality of life was assessed using the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW). Twelve domains affecting patients' quality of life were identified. Family, job/education, friends, health, and leisure time were the most prominent quality of life domains. Significantly fewer patients than control subjects considered financial means and material well-being and future to be important determinants of quality of life.

CONCLUSION

Assessment of quality of life in adults with congenital heart disease that focusses on the individual is appropriate for obtaining in-depth information on issues relevant for patients' quality of life. This represents a paradigm shift in the measurement of this concept.

Quality of life in children with pulmonary atresia and intact ventricular septum

OBJECTIVE

To measure quality of life in children with pulmonary atresia and intact ventricular septum, and make comparisons with a healthy group of children from the general Swedish population. An additional aim was to compare quality of life in two subgroups, children undergoing biventricular and univentricular repair, the latter by establishment of the Fontan circulation.

METHODS

Quality of life was measured using a mailed questionnaire, taking into consideration the three spheres of personal, interpersonal, and external living conditions. In all, 52 children received the questionnaire, and the answers were compared with those of a random sample of 1856 healthy Swedish children.

RESULTS

We received responses from 42 children and parents. The overall differences between groups were small, and no difference was found when comparing the children undergoing univentricular as opposed to biventricular surgical repair. In terms of personal quality of life, we found a higher level of psychosomatic complaints, and lower satisfaction with their own and parent-child activities, in those with the congenital anomaly than in their normal peers. In terms of the interpersonal sphere, more time was available for those with malformed hearts, but the experience of support from the relatives was significantly lower.

CONCLUSIONS

Overall, quality of life was equal between children with pulmonary atresia and intact ventricular septum and the children in the reference group. The personal psychological conditions were less favourable for children with pulmonary atresia and intact ventricular septum. The perceived lack of support from relatives was also higher in these families. No difference was found when comparing the children undergoing univentricular and biventricular surgical repair.

Quality of life in adults with congenital heart disease

OBJECTIVE

To examine the quality of life of adults with congenital heart disease.

DESIGN AND SETTING

Observational, cross sectional study conducted at one general hospital in Birmingham, UK.

PATIENTS

All 471 patients registered at the adult congenital heart disease clinic were sent the 36 item short form health survey (SF-36) to assess their quality of life. Questionnaires were completed by 276 (58.6%) patients (41.7% men; median (interquartile range) age 31.0 (26.3-36.0) years, range 16-85 years).

RESULTS

Surprisingly, patients deemed surgically cured (for example, atrial septal defect repair) had significantly poorer quality of life in all domains (all p < 0.05), except for pain, than the general population, as determined from population normative data. Patients who had received palliative treatment reported quality of life scores similar to those who had never required cardiac surgery and to the general population, although both patient groups had significantly poorer physical functioning and overall general health perception than the general population (all p < 0.01). Patients with inoperable conditions had significantly poorer physical functioning (all p < 0.01) and overall general health perception (all p < 0.05) than all other patients, and significantly worse quality of life in all domains than the similarly aged general population. Patients with cyanotic conditions had significantly worse quality of life than age and sex matched acyanotic patients (all p < 0.01).

CONCLUSIONS

Patients with inoperable or cyanotic conditions and, paradoxically, those deemed surgically cured, had the poorest quality of life among adults with congenital heart disease. However, all adults with congenital heart disease had significantly poorer levels of physical functioning and overall general health perception then similarly aged people in the general population.

Health related quality of life and health status in adult survivors with previously operated complex congenital heart disease

OBJECTIVE

To examine the impact of previously operated complex congenital heart disease on health related quality of life and subjective health status and to determine the relation between these parameters and physical status.

DESIGN

Cross sectional; information on medical follow up was sought retrospectively.

SETTING

Patients were randomly selected from the archives of the paediatric cardiology department, Leiden University Medical Centre, Leiden, The Netherlands, and approached irrespective of current cardiac care or hospital of follow up.

PATIENTS

Seventy eight patients with previously operated complex congenital heart disease (now aged 18-32 years) were compared with the general population.

MAIN OUTCOME MEASURES

Health related quality of life was determined with a specifically developed questionnaire (Netherlands Organisation for Applied Scientific Research Academic Medical Centre (TNO-AZL) adult quality of life (TAAQOL)) and subjective health status was assessed with the 36 item short form health survey (SF-36). Physical status was determined with the objective physical index, Somerville index, and New York Heart Association functional class.

RESULTS

Health related quality of life of the patients was significantly worse than that of the general population in the dimensions gross motor functioning and vitality (p < 0.01). Correlations between health related quality of life and physical status were poor. Patients had significantly worse subjective health status than the general population in the dimensions physical functioning, role functioning physical, vitality, and general health perceptions (p < 0.01). Correlations between subjective health status and physical indices were weak.

CONCLUSION

Adult survivors with previously operated complex congenital heart disease experienced limitations only in the physical dimensions of health related quality of life and subjective health status. Objectively measured medical variables were only weakly related to health related quality of life. These results indicate that, when evaluating health related quality of life, dedicated questionnaires such as the TAAQOL should be used.