Psychosocial functioning of young adults after surgical correction for congenital heart disease in childhood: a follow-up study

Clinical and Sociodemographic Factors Associated With Health-Related Quality of Life in Patients With Adult Congenital Heart Disease - A Nationwide Cross-Sectional Multicenter Study

BACKGROUND

Little is known about clinical or sociodemographic factors that influence health-related quality of life (HRQoL) in patients with adult congenital heart disease (ACHD).Methods and Results: We conducted a nationwide prospective cross-sectional multicenter study at 4 large ACHD centers in Japan. From November 2016 to June 2018, we enrolled 1,223 ACHD patients; 1,025 patients had an HRQoL score. Patients completed a questionnaire survey, including sociodemographic characteristics, and the 36-Item Short-Form Health Survey (SF-36). To determine factors associated with HRQoL, correlations between 2 SF-36 summary scores (i.e., physical component score [PCS] and mental component score [MCS]) and other clinical or sociodemographic variables were examined using linear regression analysis. In multivariable analysis, poorer PCS was significantly associated with 11 variables, including older age, higher New York Heart Association class, previous cerebral infarction, being unemployed, and limited participation in physical education classes and sports clubs. Poorer MCS was associated with congenital heart disease of great complexity, being part of a non-sports club, current smoking, and social drinking. Student status and a higher number of family members were positively correlated with MCS.

CONCLUSIONS

This study demonstrates that HRQoL in ACHD patients is associated with various clinical and sociodemographic factors. Further studies are needed to clarify whether some of these factors could be targets for future intervention programs to improve HRQoL outcomes.

Prevalence of anxiety and depression in adult patients with CHD

INTRODUCTION

CHD are among the most common congenital defects. Due to the chronic nature of CHD, patients face various risk factors that threaten their mental health. However, a comprehensive understanding of the medical and social predictors of mental health issues in adults with CHD is lacking. This study aims to investigate the prevalence of anxiety and depression in adults with CHD.

METHODS

This cross-sectional descriptive study focused on adults with CHD in Kerman, Iran. The participants completed demographic information alongside two psychological assessment tools: the Beck Anxiety Inventory (BAI) and the Depression Anxiety Stress Scales (DASS)-21. The data were analyzed using SPSS 26.

FINDINGS

The mean age of the participants was 29.94 ± 12.36 years, and 63.8% were female. According to the DASS, 73.4% did not have depression, 61% did not have anxiety, and 76.2% did not have stress. In total, 19% had mild stress, and 4.8% had moderate stress. According to the BAI, 27.6% did not have anxiety. Individual characteristics were not significantly associated with depression. However, gender, age, and type of surgery were significantly associated with anxiety. Cyanosis was significantly associated with stress.

CONCLUSION

The results show that mental disorders like depression, anxiety, and stress are highly prevalent in adults with CHD. The prevalence depends on individual factors such as age, gender, and disease severity. Therefore, it is recommended that mental disorders in this population be evaluated and treated accurately.

Executive functioning of patients with congenital heart disease: 45 years after surgery

BACKGROUND

Nowadays, more than 90% of patients with congenital heart disease (CHD) reach adulthood. However, long-term impact on neurodevelopment and executive functioning in adults with CHD are not completely understood.

PURPOSE

To investigate the self- and informant-reported executive functioning in adults with CHD operated in childhood.

MATERIAL AND METHODS

Longitudinal study of a cohort of patients (n = 194, median age: 49.9 [46.1-53.8]) who were operated in childhood (< 15 years old) between 1968 and 1980 (median follow-up time: 45 [40-53] years) for one of the following diagnoses: atrial septal defect (ASD), ventricular septal defect (VSD), pulmonary stenosis (PS), tetralogy of Fallot (ToF) or transposition of the great arteries (TGA). Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A) questionnaire was used to assess self- and informant-reported executive functioning.

RESULTS

40-53 years after surgery, the CHD group did show significantly better executive functioning compared to the norm data. No significant difference was found between mild CHD (ASD, VSD and PS) and moderate/severe CHD (ToF and TGA). Higher education, NYHA class 1 and better exercise capacity were associated with better self-reported executive functioning, whereas females or patients taking psychiatric or cardiac medications reported worse executive functioning.

CONCLUSIONS

Our findings suggest favorable outcomes (comparable to normative data) regarding executive functioning in adults with CHD, both self- and informant-reported. However, further study is warranted to explore more in detail the different cognitive domains of executive functioning in these patients.

Design and Harmonization Approach for the Multi-Institutional Neurocognitive Discovery Study (MINDS) of Adult Congenital Heart Disease (ACHD) Neuroimaging Ancillary Study: A Technical Note

Dramatic advances in the management of congenital heart disease (CHD) have improved survival to adulthood from less than 10% in the 1960s to over 90% in the current era, such that adult CHD (ACHD) patients now outnumber their pediatric counterparts. ACHD patients demonstrate domain-specific neurocognitive deficits associated with reduced quality of life that include deficits in educational attainment and social interaction. Our hypothesis is that ACHD patients exhibit vascular brain injury and structural/physiological brain alterations that are predictive of specific neurocognitive deficits modified by behavioral and environmental enrichment proxies of cognitive reserve (e.g., level of education and lifestyle/social habits). This technical note describes an ancillary study to the National Heart, Lung, and Blood Institute (NHLBI)-funded Pediatric Heart Network (PHN) "Multi-Institutional Neurocognitive Discovery Study (MINDS) in Adult Congenital Heart Disease (ACHD)". Leveraging clinical, neuropsychological, and biospecimen data from the parent study, our study will provide structural-physiological correlates of neurocognitive outcomes, representing the first multi-center neuroimaging initiative to be performed in ACHD patients. Limitations of the study include recruitment challenges inherent to an ancillary study, implantable cardiac devices, and harmonization of neuroimaging biomarkers. Results from this research will help shape the care of ACHD patients and further our understanding of the interplay between brain injury and cognitive reserve.

Daily life and psychosocial functioning of adults with congenital heart disease: a 40-53 years after surgery follow-up study

INTRODUCTION

Nowadays, more than 90% of patients with congenital heart disease (CHD) reach adulthood. However, knowledge about their psychosocial functioning is limited.

METHODS

Longitudinal cohort study of patients (n = 204, mean age: 50 years, 46.1% female) who were operated during childhood (< 15 years) between 1968 and 1980 for one of the following diagnoses: atrial septal defect, ventricular septal defect, pulmonary stenosis, tetralogy of Fallot or transposition of the great arteries. Psychosocial functioning was measured every 10 years, using standardized and validated questionnaires. Results were compared with the general Dutch population and over time.

RESULTS

After a median follow-up of 45 [40-53] years adults with CHD had a significantly lower educational level, occupation level and employment rate, but better health-related quality of life and emotional functioning compared with normative data. Patients with moderate/severe defects reported significantly more self-perceived physical restrictions and lack of physical strength due to their CHD. Compared to 2011, in 2021 patients considered their CHD as more severe and they felt more often disadvantaged.

CONCLUSIONS

Overall, despite a lower education, occupation level and employment rate, our sample of patients with CHD had a positive perception of their life and  their psychosocial functioning was even better than the norm. Although the quality of life was very good, their view on their disease was more pessimistic than 10 years ago, especially for patients with moderate/severe CHD.

Neurocognitive functioning in young adults with congenital heart disease: insights from a case-control study

BACKGROUND

While there is evidence that cognitive impairment of children with congenital heart disease (CHD) may persist into adolescence, little is known about the spectrum of neurocognitive functioning of young adults with this disorder. The aim of this study was to assess neurocognitive functioning in a population of young adults with different types of CHD.

METHODS

Cross-sectional cohort study in young adults with CHD and a group-matched healthy control group. We assessed neurocognitive and general intellectual functioning with a comprehensive battery of standardised neuropsychological tests. In addition to task-based assessments, questionnaire data of executive dysfunctions in everyday life were measured with the Behaviour Rating Inventory of Executive Function - Adult Version.

RESULTS

A total of 67 patients (55% men) with CHD and 55 healthy controls (51% men) were included for analysis. Mean age at assessment was 26.9 (3.68) and 26.0 (3.32) years, respectively. The CHD group performed poorer in the domains of Executive Functions, Memory, Attention & Speed, and general intellectual functioning. Patients with a CHD of severe complexity were more affected than patients with simple or moderate complexity. Behaviour Rating Inventory of Executive Function - Adult Version scores indicated that patients' self-rated deficits in behaviour regulation in everyday life was higher compared with healthy controls.

CONCLUSION

Our findings indicate lower neurocognitive functioning in young adults with a CHD, particularly in those with severe defect complexity. In view of the potentially enhanced risk for cerebrovascular and neurodegenerative disease in this patient group as reported in the literature, systematic longitudinal monitoring of cognitive functioning is recommended.

Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association

Life expectancy and quality of life for those born with congenital heart disease (CHD) have greatly improved over the past 3 decades. While representing a great advance for these patients, who have been able to move from childhood to successful adult lives in increasing numbers, this development has resulted in an epidemiological shift and a generation of patients who are at risk of developing chronic multisystem disease in adulthood. Noncardiac complications significantly contribute to the morbidity and mortality of adults with CHD. Reduced survival has been documented in patients with CHD with renal dysfunction, restrictive lung disease, anemia, and cirrhosis. Furthermore, as this population ages, atherosclerotic cardiovascular disease and its risk factors are becoming increasingly prevalent. Disorders of psychosocial and cognitive development are key factors affecting the quality of life of these individuals. It is incumbent on physicians who care for patients with CHD to be mindful of the effects that disease of organs other than the heart may have on the well-being of adults with CHD. Further research is needed to understand how these noncardiac complications may affect the long-term outcome in these patients and what modifiable factors can be targeted for preventive intervention.

Cognitive dysfunction in adult CHD with different structural complexity

OBJECTIVE

We carried out a cross-sectional study to assess cognitive function in a sample of adult CHD patients, within the Functioning in Adult Congenital Heart Disease study London. The association between cognitive functioning and disease complexity was examined.

METHODS

A total of 310 patients participated in this study. Patients were classified into four structural complexity groups - tetralogy of Fallot, transposition of the great arteries, single ventricle, and simple conditions. Each patient underwent neuropsychological assessment to evaluate cognitive function, including memory and executive function, and completed questionnaires to assess depression and anxiety.

RESULTS

Among all, 41% of the sample showed impaired performance (>1.5 SD below the normative mean) on at least three tests of cognitive function compared with established normative data. This was higher than the 8% that was expected in a normal population. The sample exhibited significant deficits in divided attention, motor function, and executive functioning. There was a significant group difference in divided attention (F=5.01, p=0.002) and the mean total composite score (F=5.19, p=0.002) between different structural complexity groups, with the simple group displaying better cognitive function.

CONCLUSION

The results indicate that many adult CHD patients display impaired cognitive function relative to a healthy population, which differs in relation to disease complexity. These findings may have implications for clinical decision making in this group of patients during childhood. Possible mechanisms underlying these deficits and how they may be reduced or prevented are discussed; however, further work is needed to draw conclusive judgements.

Neuropsychological and Psychiatric Outcomes in Dextro-Transposition of the Great Arteries across the Lifespan: A State-of-the-Art Review

Advances in prenatal diagnosis, perioperative management, and postoperative care have dramatically increased the population of survivors of neonatal and infant heart surgery. The high survival rate of these patients into adulthood has exposed the alarming prevalence of long-term neuropsychological and psychiatric morbidities. Dextro-transposition of the great arteries (d-TGA) is one of the most extensively studied cyanotic congenital heart defect (CHD) with regard to neurodevelopmental outcomes. Landmark studies have described a common neurodevelopmental and behavioral phenotype associated with d-TGA. Children with d-TGA display impairments in key neurocognitive areas, including visual-spatial and fine motor abilities, executive functioning, processing speed, and social cognition. As they grow older, they may face additional challenges with a worsening of deficits in higher order cognitive skills, problems in psychosocial adjustment and a higher-than-expected rate of psychiatric disorders, such as attention-deficit hyperactivity disorder, depression, and anxiety. The aim of this review is to summarize the available recent data on neuropsychological and psychiatric outcomes in individuals with d-TGA after the arterial switch operation. We present findings within a life-span perspective, with a particular emphasis on the emerging literature on adolescent and young adult outcomes. Finally, we propose avenues for future research in the CHD adult neuropsychology field. Among these avenues, we explore the potential mechanisms by which pediatric neurodevelopmental impairments may have lifelong adverse effects as well as alternative interventions that could optimize outcomes.

Health in adults with congenital heart disease

Since the introduction of cardiac surgery, the prospects for children born with a cardiac defect have improved spectacularly. Many reach adulthood and the population of adults with congenital heart disease is increasing and ageing. However, repair of congenital heart disease does not mean cure. Many adults with congenital heart disease encounter late complications. Late morbidity can be related to the congenital heart defect itself, but may also be the consequence of the surgical or medical treatment or longstanding alterations in hemodynamics, neurodevelopment and psychosocial development. This narrative review describes the cardiac and non-cardiac long-term morbidity in the adult population with congenital heart disease.

Longitudinal development of psychopathology and subjective health status in CHD adults: a 30- to 43-year follow-up in a unique cohort

OBJECTIVE

To determine longitudinal changes in psychopathology in a cohort of patients 30-43 years after their first cardiac surgery for Congenital Heart Disease (CHD) in childhood, to compare outcomes of the 30- to 43-year follow-up with normative data, and to identify medical predictors for psychopathology.

METHODS

This study is the third follow-up of this cohort. The first and second follow-ups of this same cohort were conducted in 1990 and 2001, respectively. At all three follow-ups, psychopathology was assessed with standardised, parallel questionnaires. In 2011, subjective health status was assessed by the Short Form-36. Medical predictor variables were derived from medical examinations and medical records.

RESULTS

In this third follow-up, a total of 252 patients participated. Of these, 152 patients participated in all three follow-ups. Over a 30-year period, proportions of patients showing psychopathology decreased significantly. At the 30- to 43-year follow-up, overall outcomes on psychopathology for the CHD sample were similar or even better compared with normative groups. Subjective health status was also better compared with normative data. No differences were found between cardiac diagnostic groups. Medical variables that predicted the course of psychopathology over time were as follows: the scar, as judged by the patient, results of the first cardiac surgery, and the number of hospitalisations.

CONCLUSIONS

Over a 30-year period, psychopathology decreased in patients with CHD. Levels of psychopathology in these patients, who are now aged between 30 and 54 years, were comparable or even better than normative data.

Sex differences in congenital heart defects and genetically induced arrhythmias

Sex medicine can be applied to define the effect of male or female sex-associated differences on the prevalence of congenital heart defects (CHDs), on clinical manifestation of the latter, on means of dealing with the defects and facing consequent surgical treatment, as well as on the success of surgery. The widespread use of modern databases has undoubtedly enhanced the possibility of these observations compared to the past, when findings were limited to case series from single cardiology or paediatric heart surgery units. The aim of the present review is to assess all publications present in the literature on sex differences and CHD, placing particular emphasis on both contradictory aspects and less acknowledged issues. Furthermore, a section of the review is devoted to the effect of sex differences on cardiac arrhythmias, particularly the largely genetically predetermined electrophysiological differences observed between men and women.

Style of coping and its determinants in adults with congenital heart disease in a developing country

OBJECTIVE

The objective of this study is to compare coping strategies between adults with and without congenital heart disease and to scrutinize the associations between different available resources (e.g., social support) and adoption of certain coping strategies.

DESIGN

The study has a cross-sectional case-control design.

SETTING

The study was conducted in two university-affiliated heart hospitals in Tehran, Iran.

PATIENTS

The participants comprised 347 persons (18-64 years) with and 353 individuals without congenital heart disease, matched by gender and age.

OUTCOME MEASURES

Coping strategies, assessed with the Utrecht Coping List-short form, were compared between both groups. Block-wise multiple regression analyses were conducted to scrutinize the associations between different independent variables (e.g., demographic/socioeconomic statuses) and adoption of certain styles of coping (dependent variables) among all participants and separately for each group.

RESULTS

The styles of coping in the patients were comparable with those of the control group. Multivariate analyses revealed that congenital heart disease per se was not associated with style of coping except for palliative reaction pattern. The active problem-solving coping style was associated with never married marital status, parenthood, unemployment, higher level of anxiety/somatic symptoms, lower level of depressive symptoms, and better social support. The avoidance behavior style was associated with having a low income, whereas the expression of emotion style was associated with higher anxiety symptoms, experience of financial strain, and income. None of the adopted coping strategies was related to the heart disease variables.

CONCLUSIONS

The adults with congenital heart disease coped as well as adults without congenital heart disease. Marital status, parenthood, annual income, financial strain, psychological adjustment, and perceived social support were important explanatory factors in adopting a certain style of coping among adults with congenital heart disease. However, longitudinal studies with repeated measures are warranted.

Association between N-terminal pro-brain natriuretic peptide and quality of life in adult patients with congenital heart disease

AIMS

Advances in medical treatment have resulted in increased life expectancy in congenital heart disease. Consequently, the focus of management has shifted from reducing mortality to reducing long-term morbidity with the goal of improving quality of life. A predictor of quality of life might be N-terminal pro-brain natriuretic peptide, a well-established marker for heart failure. We aimed to determine the association between N-terminal pro-brain natriuretic peptide and quality of life in patients with congenital heart disease.

METHODS

We collected blood samples from consecutive patients who were initially operated between 1968 and 1980 (47.8% women; mean age 40.2±5.4 years). The 36-item Short-Form Health Survey was completed to assess subjective health status as a measure of quality of life. Analysis was performed for the entire group and for subgroups defined as simple versus complex congenital heart diseases. Median N-terminal pro-brain natriuretic peptide level was 15.2 pmol/L (overall range 1.3-299.3 pmol/L). N-terminal pro-brain natriuretic peptide levels were associated with the subdomain physical functioning (β=-0.074, p=0.031). This association remained significant after adjustment for age and sex (β=-0.071, p=0.038) and after adjustment for age, sex, body mass index, left ventricular function, and renal function (β=-0.069, p=0.048). In complex congenital heart disease, the association between N-terminal pro-brain natriuretic peptide and physical functioning remained significant in multivariable analysis (β=-0.076, p=0.046). No associations were found in the simple congenital heart disease group or on the other health status subdomains.

CONCLUSION

In adults operated for congenital heart disease, N-terminal pro-brain natriuretic peptide is associated with the subdomain physical, primarily in the complex subgroup.

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.

Motor dysfunction and behavioural problems frequently coexist with congenital heart disease in school-age children

AIM

Patients with congenital heart disease are at risk of neurodevelopmental deficits. Impairments in motor and behavioural function occur frequently, but no information is available concerning the coexistence of deficits in these two developmental domains. This study explored the occurrence of motor and behavioural deficits and their coexistence in children with surgically corrected congenital heart disease.

METHODS

Outcome was assessed in 95 children with congenital heart disease who had undergone cardiopulmonary bypass surgery. Their mean age was 9.6 years (SD 2.5). Motor function was assessed with the Zurich Neuromotor Assessment and behaviour with the Strength and Difficulties Questionnaire.

RESULTS

Children with congenital heart disease performed poorer in all motor domains compared with the reference population (all p ≤ 0.001). Behaviour was affected in the domains 'emotional symptoms' and 'hyperactivity/inattention' (both p < 0.01), and 54% of the children with motor abnormalities showed behavioural deficits. Children with coexistent abnormalities in behaviour and motor function had higher rates of remedial school services and therapeutic support.

CONCLUSION

Children with congenital heart disease are at risk of long-term motor and behavioural problems, and there is a high rate of coexistence of problems in both domains. Early and longitudinal assessment of all developmental domains is necessary to provide adequate early support.

The impact of actual and perceived disease severity on pre-operative psychological well-being and illness behaviour in adult congenital heart disease patients

OBJECTIVES

The purpose of this study was to investigate whether the objective medical parameters related to congenital heart disease and patients' ratings of cardiac disease severity were related to psychological well-being and illness behaviour during the pre-operative period.

METHODS

A total of 143 patients (63 male patients; 16-73 years old) with congenital heart disease evaluated the severity of their cardiac condition using a numerical rating scale ranging from 0, indicating the least severe condition, to 100, indicating the most severe condition. Psychological well-being was assessed using the Psychological General Well-Being Index (total score ≤ 60 indicating severe distress) and illness behaviour using the Illness Behavior Questionnaire.

RESULTS

Pre-operative psychological well-being was not related to the objective medical parameters reflecting cardiac disease severity. In contrast, total psychological well-being scores correlated significantly with patients' subjective ratings of disease severity (p < 0.001). When compared with the reference values from the Italian population, the mean scores of the patients on psychological well-being were similar. As regards the Illness Behavior Questionnaire, the scores on denial were higher and those on hypochondria were lower compared with other hospitalised patients.

CONCLUSIONS

This study shows that the perception of cardiac disease severity, and not the medical parameters in congenital heart disease, is related to the patients' pre-operative psychological state. Thus, more importance needs to be given to assessing the patients' pre-operative perception and psychological state independently of cardiac severity. Targeted interventions with regard to the cardiac condition are recommended.

What do we know about cognitive functioning in adult congenital heart disease?

With the advent of improved medical and surgical care in congenital heart disease, there has been an increase in the number of patients who survive into adulthood, giving rise to a new patient population 'Adults with congenital heart disease'. In the past, morbidity and mortality were the primary concerns for this group. However, with improvements in outcome attention has shifted to other factors such as psychosocial and cognitive functioning. This paper reviews the literature on the cognitive functioning in adult congenital heart disease patients. A total of five relevant articles were retrieved via electronic searches of six databases, including MEDLINE, EMBASE, CINAHL, AMED, PsychINFO, and PubMed. The results displayed a consensus on the presence of some cognitive difficulties in adult congenital heart disease patients. The aetiology of cognitive dysfunctions appears to be multifactorial. The literature is limited by the very small number of studies looking at adults with congenital heart disease, with the majority focusing on cognitive functioning among children with congenital heart disease. However, the presence of cognitive dysfunctions and the resulting impact on the patient's day to day lives warrant for a more detailed and prospective research to enhance the understanding of its aetiology and impact.

Associations between knowledge of disease, depression and anxiety, social support, sense of coherence and optimism with health-related quality of life in an ambulatory sample of adolescents with heart disease

INTRODUCTION

Advances in overall management have led to an increasing number of adolescents with congenital heart disease reaching adulthood. This study aimed to evaluate the health-related quality of life in adolescents with heart disease, and examine its relationship with the adolescents' knowledge and understanding of their congenital heart disease, its severity, and its relationship to the degree of anxiety and depression, feeling of optimism and sense of coherence experienced by the adolescents together with their social support.

METHODS AND RESULTS

Adolescents with heart disease were recruited from an ambulatory setting at a tertiary centre. Patients completed self-report questionnaires including the Paediatric Quality of Life Inventory 3.0-Cardiac Module, a questionnaire assessing the adolescents' knowledge of their cardiac condition, the Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support, Life Orientation Test-Revised, and Sense of Coherence-13, supplemented by clinical information provided by the attending cardiologists. A total of 114 patients aged 12-20 years were recruited over 15 months. In all, 98% of patients were in New York Heart Association class I. Their health-related quality of life was found to positively correlate with a low level of anxiety and depression (Pearson correlation, r = -0.57, p < 0.001), a good knowledge of their cardiac condition (r = 0.31, p < 0.01), feelings of optimism (r = 0.39, p < 0.001), adequate social support (r = 0.27, p < 0.01), and a strong sense of coherence (r = 0.24, p < 0.01).

CONCLUSIONS

Adolescents' knowledge and understanding of their cardiac abnormality together with an improved sense of well-being had a positive influence on their health-related quality of life.

The mental health and quality of life of adult patients with congenital heart disease

BACKGROUND

The quality of life (QoL) of adults with congenital heart disease (CHD) has gained significant interest. In addition to medical problems, many patients with CHD face psychosocial, educational, and behavioral challenges. However, few studies have examined the relationship between disease severity and QoL in adults with CHD.

METHODS

Eighty-five patients (50 men, 35 women) aged 20-52 years (median, 26.5 years) were enrolled. Patients underwent a QoL, Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) survey. The scores were compared with those of age- and gender-matched population data according to the degree of underlying CHD. Disease severity was classified in relation to initial diagnosis, illness course, and current functional status (New York Heart Association [NYHA] class, ability index, CHD functional index, ventricular ejection fraction, and peak VO2).

RESULTS

There was no significant correlation between disease severity and current functional status assessed by BDI and BAI. Patients who stated that they were religious had better scores for resilience (p=0.031), physical QoL (p=0.008), and environmental QoL (p=0.025). Environmental QoL scores were higher in patients who fully understood their disease (p=0.004). Current NYHA functional class was associated with scores for psychological resilience.

CONCLUSIONS

CHD severity had a detrimental impact on resilience only when measured in terms of poor functional status. The initial diagnosis and course of the illness influence QoL and perceived health. Good psychosocial adaptation could be the result of close family relationships and involvement, making mental adjustment easier.

Motor training of sixty minutes once per week improves motor ability in children with congenital heart disease and retarded motor development: a pilot study

OBJECTIVE

Delay and impairment of motor development is reported in patients with congenital heart disease. This pilot study addressed the feasibility and effect of a low-dose motor training programme of 60 min once per week on motor ability in preschool children with congenital heart disease.

PATIENTS AND METHODS

In all, 14 children--including four girls, in the age group of 4-6 years--with various types of congenital heart disease performed the motor developmental test MOT 4–6 before and after 3 months of a playful exercise programme of 60 min once a week.

RESULTS

At baseline, the motor quotient ranged from normal to slightly impaired (median 92.0; Quartile 1: 83.75; Quartile 3: 101.25). After intervention, motor quotient did not change significantly for the entire group (95.0 (88.0, 102.5); p50.141). However, in the subgroup of nine children with retarded motor development at baseline (motor quotient lower 100), seven children had an improved motor quotient after 3 months of intervention. In this subgroup, motor quotient increased significantly (p50.020) by 5%.

CONCLUSIONS

Overall, a short intervention programme of 60 min only once a week does not improve motor ability in all children with congenital heart disease. However, those with retarded motor development profit significantly from this low-dose intervention.

Trajectories of loneliness in adolescents with congenital heart disease: associations with depressive symptoms and perceived health

PURPOSE

Acquiring close peer relationships is an important developmental task in adolescence. This task may be particularly demanding for adolescents with congenital heart disease (CHD), who face disease-specific challenges putting them at risk for social isolation and loneliness. This study compared cross-sectional levels of loneliness in adolescents with and without CHD; examined the longitudinal course of loneliness and identified different developmental trajectory classes in adolescents with CHD; and investigated to what extent these trajectory classes are accompanied by differences in depressive symptoms and perceived health.

METHODS

A total of 429 adolescents with simple to complex CHD participated in the present longitudinal study consisting of three measurement waves with 9-month intervals (M(age) = 15.75 years at T1; 53.4% boys). The control sample at time 1 (T1) consisted of 403 adolescents who were matched in terms of age and sex.

RESULTS

Patients and controls did not differ in loneliness levels at T1. In adolescents with CHD, latent class growth analysis identified five trajectory classes (i.e., chronically high, high decreasing, moderate stable, low increasing, and stable low), which were meaningfully distinguished on depressive symptoms and several domains of perceived health. In general, adolescents in the chronically high loneliness trajectory reported the most depressive symptoms and the poorest perceived health, whereas adolescents in the low stable trajectory reported the opposite pattern.

CONCLUSIONS

Findings demonstrate that chronic feelings of loneliness are associated with worsened perceived health in adolescents with CHD. Intervention programs targeting patients' adjustment should be sensitive to the presence of such feelings.

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.

Anxiety, depressive and somatic symptoms in adults with congenital heart disease

OBJECTIVE

Despite the improvement in life-expectancy of adults with congenital heart disease, they may experience unique medical and social challenges that could impact on their psychological functioning. The aims of this study were to address the experience of anxiety, depressive and somatic symptoms among adults with congenital heart disease in comparison with that of non-heart diseased persons considering the role of various factors (e.g. socio-economic).

METHODS

In cross-sectional case-control study, the participants consisted of 347 patients with congenital heart disease (18-64 years, 52.2% female) and 353 matched (by sex/age) non-heart diseased persons. The participants completed a questionnaire. The data were analyzed with bivariate and multivariate methods.

RESULTS

In bivariate analyses, scores in anxiety and somatic symptoms were higher among patients than the healthy controls (both at p≤0.001), whereas the groups did not differ in depressive symptoms. Following multiple-linear-regression-analyses, only the association between congenital heart disease and somatic symptoms was confirmed. Among the patients, perceived financial strain was significantly related to anxiety, depressive and somatic symptoms; lower perceived social support to anxiety and depression; and low annual income to somatic symptoms. Additionally, somatic symptoms were associated with anxiety and depressive symptoms, and vice versa. And no medical variables were related to anxiety, depressive and somatic symptoms.

CONCLUSIONS

Congenital heart disease was only independently associated with somatic symptoms. Financial strain, social support and co-existence of emotional distress with somatic symptoms should be considered in developing appropriate interventions to improve the well-being of patients with congenital heart disease. However, longitudinal research is warranted to clarify causality.

The prevalence and predictors of anxiety and depression in adolescents with heart disease

OBJECTIVE

To evaluate the prevalence and contributory factors of depression and anxiety in adolescents with heart disease.

STUDY DESIGN

A cohort of adolescents was recruited from an ambulatory cardiology clinic at a tertiary center and from such clinics run privately. Questionnaires included the Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support, Life Orientation Test-Revised, and Sense of Coherence-13.

RESULTS

A total of 119 adolescents aged 12-20 years were recruited. Most of the participants (90%) had congenital heart disease. Nearly all (98%) were in New York Heart Association Functional Classification class I. Approximately one-half of the participants had had previous surgeries and/or catheter interventions. Eleven patients (9%) were above the cut-off score for likely depression, and 32 (27%) had likely anxiety. A feeling of optimism was the most significant factor in reducing anxiety and depression, followed by good social support and a strong sense of coherence (multiple regressions, β = -0.38, -0.2, -0.17, respectively).

CONCLUSIONS

Depression and anxiety were found to be common in a relatively well adolescent population with heart disease. None of those affected had been clinically assessed and appropriately treated by a mental health professional. Protective factors against depression and anxiety need be developed as well as appropriate assessment and intervention.

Clinical and scientific progress related to the interface between cardiology and psychology: lessons learned from 35 years of experience at the Thoraxcenter of the Erasmus Medical Center in Rotterdam

In November 1975, as the first in the Netherlands, a full-time psychologist was employed at the Department of Cardiology of the Thoraxcenter of the Erasmus Medical Center. This innovative decision was consistent with a view to treat the patient as a whole rather than the heart as a single body part in need of repair, combined with the understanding that the heart and mind interact to affect health. The present selective review addresses the broad range of contributions of 35 years of psychology to clinical cardiology and cardiovascular research with a focus on research, teaching, psychological screening and patient care. The review ends with lessons to be learned and challenges for the future with respect to improving the care and management of patients with heart disease in order to enhance secondary prevention and the role of behavioural and psychological factors in this endeavour.

Minor symptoms of depression in patients with congenital heart disease have a larger impact on quality of life than limited exercise capacity

OBJECTIVE

In patients with congenital heart disease quality of life is only marginally associated with exercise capacity. The aim of this study was to determine the prevalence of depression and its impact on quality of life and exercise capacity.

PATIENTS AND METHODS

From November 2007 to October 2009 a total of 767 patients (352 female, 14-67 years) with various congenital heart diseases (37 palliated/native cyanotic, 57 Fontan, 74 Transposition of the Great Arteries (TGA) after atrial switch, 50 other TGA, 136 Fallot, 38 Ebstein, 47 Pulmonic stenosis/regurgitation, 68 aortic coarctation, 103 aortic stenosis, 90 isolated shunts, 67 other) completed the health-related quality of life questionnaire SF-36 and the German translation of the "Center for Epidemiologic Studies Depression Scale" (CES-D) to assess depressive symptoms. Afterwards a cardiopulmonary exercise test was performed.

RESULTS

Only 66 patients (8.6%) showed depressive symptoms fulfilling the CES-D definition for depression. The total prevalence of depression was lower than in the general population (Wilcoxon test, p<0.001) and did not differ substantially in between the diagnostic subgroups (Kruskal-Wallis test, p=0.195). CES-D score was correlated to all of the nine dimensions of quality of life (r=-0.170 to r=-0.740, p<0.001) and less pronounced to exercise capacity (r=-0.164, p<0.001). Correlation of peak oxygen uptake to quality of life was weaker than the CES-D scores in all subscales of life quality.

CONCLUSIONS

Patients with congenital heart disease are rarely depressive. However, even minor depressive symptoms have a stronger impact on quality of life than limited exercise capacity as seen in many patients.

Measuring health-related quality of life in Hungarian children attending a cardiology clinic with the Pediatric Quality of Life Inventory

The aim of the study was to evaluate health-related quality of life (HRQoL) of Hungarian children attending a pediatric cardiology outpatient unit with the Pediatric Quality of Life Inventory (PedsQL) questionnaire. The PedsQL Generic Core Scales and Cardiac Module were administered to 254 families including 195 children during a pediatric cardiology outpatient visit, and 525 families including 373 children from the general population were examined by the PedsQL Generic Core Scale by a postal survey. The relationships between PedsQL scores and patient characteristics were analyzed. Hungarian children attending a cardiology outpatient unit as an entire group and patients with severe heart diseases report significantly lower physical functioning than the general population, while more HRQoL dimensions are negatively affected according to the parents' opinion. Children with congenital heart disease of mild and great complexity also report impaired psychosocial functioning. HRQoL impairment is concentrated to the age of 5-7 years. Comparing our results with previous ones on U.S. pediatric cardiologic samples, we found significantly lower scores mainly for the physical functioning and heart symptoms subscales. This HRQoL study with an internationally well-validated instrument on children with heart disease in a Central European country highlights certain aspects of the health-care system and brings the possibility for the assessment of pediatric cardiology outcomes in a more comprehensive way.

Children and adolescents with congenital heart disease: assessment of behavioural and emotional problems

OBJECTIVE

The objective of the study was to assess behavioural and emotional problems in children and adolescents with congenital cardiac disease.

DESIGN

From the database of Paediatric Heart Section, Rikshospitalet University Hospital, Norway, 430 patients and their parents were included and received questionnaires of youth self-report and child behavior checklist. The response rate was 71.4%.

RESULTS

Compared to their parents children with congenital heart disease reported more behavioural and emotional problems. Boys scored significantly higher than girls in total problem score and externalising scores with more social problems, attention problems, delinquent behaviour and aggressive behaviour. No gender difference was found regarding internalising problem score. Compared to healthy boys, no differences were found in total problem, externalising or internalising score. In girls lower values were found in patients than healthy children for total problem, externalising and internalising scores.

CONCLUSIONS

In the present study boys scored themselves higher with regard to total problem score than girls. No effect was found of due to different diagnoses. The data indicate that the children experience more problems than the parents are aware of. However, the behaviour problem scores in children with cardiac disease are significantly lower than in healthy children. A close parental follow-up and an experience of being exposed to life-threatening situation may play a role for the latter results.

[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.

Motor development in children with congenital cardiac diseases compared to their healthy peers

Their perceptual and motor experiences determine the physical and motor development of children, and impact also on their emotional, psychosocial, and cognitive development. Our aim, therefore, was to evaluate motor development in children with congenitally malformed hearts compared to their healthy peers. We compared 194 children, with a mean age of 10.0 years, and standard deviation of 2.7 years, representing the entire spectrum of congenital cardiac disease, to a control group of 455 healthy children, having a mean age 9.6 years, with standard deviation of 2.17 years. The bodily coordination test for children was used to examine motor development. Of the children with congenitally malformed hearts, 26.8% showed moderate, and 31.9% had severe disturbances of motor development, compared to 16.5% and 5.5% of the control group, the p-value for these differences being less than 0.001. The mean motor quotient adjusted for age and gender was lower in the children with congenitally malformed hearts than in their healthy peers, at 79.6, with standard deviation of 18.9 as opposed to 96.6, with standard deviation of 15, this difference having a p-value of less than 0.001. Depending on the presence, and/or the degree, of residual sequels, the children with congenitally malformed hearts were divided into two subgroups, with either no or mild residual sequels, or with significant sequels. The mean motor quotient was lower in those with significant residual sequels, at 75, with standard deviation of 19.3, as opposed to 83, with standard deviation of 17.9, the p-value for this difference being less than 0.01. In both subgroups, the mean motor quotient was lower, with a p-value of less than 0.01, than in the control group. Our findings show that children with congenitally malformed hearts have deficits in their motor development, these being found in the presence of no or mild sequels, as well as with significant residual sequels. Parental overprotection may contribute to these findings.

Behavior and self-perception in children with a surgically corrected congenital heart disease

OBJECTIVE

We sought to combine parental and child reports in order to describe the behavior, self-perception, and emotional profile of children with a surgically corrected congenital heart disease (CHD).

METHODS

Forty-three children with a surgically corrected CHD were selected and compared to an age- and sex-matched healthy group. The parents of the CHD children completed a behavior rating scale, the Child Behavior Checklist. Children 8 years and older (n = 23) completed a self-report questionnaire concerning perceived competence, their anxiety level, and feelings of depression.

RESULTS

Compared to parents of healthy children, those of CHD children report significantly lower school results (p < .01), more school problems in general (p < .01), and a higher percentage of their children repeated a school year (p < .01). They also reported more social (p < .01) and attention problems (p < .01) and more aggressive behavior (p < .05). On self-perception and state anxiety questionnaires, no significant differences were found between the patient group and the healthy group. On a depression scale, however, children with a surgically corrected CHD reported more depressive feelings than healthy controls (p < .01).

CONCLUSION

Parents of children with CHD rate their child's school competence to be weaker than healthy peers, they report more attention and social problems and more aggressive behavior. Children themselves did not report differences on perceived competence or anxiety but they do indicate more depressive symptoms than healthy peers.

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.