Sexual behavior and reproductive concerns among adolescents and young adults with congenital heart disease

Lifelong Care of Females With Congenital Heart Disease

Medical and surgical advancements of the past 70 years have resulted in a remarkable shift in the natural history of congenital heart disease (CHD) such that survival to adulthood is expected for >90% of children born with congenital heart defects, including those with complex CHD. There are now more adults than children living with CHD, a majority of them are female. As significant strides have been made in the management of adult patients with CHD, there has been an evolving understanding of the important role inherent sex-specific differences play in impacting long-term outcomes for females with CHD including differences in sexual and reproductive health, risk and incidence of acquired cardiovascular disease, and health surveillance. Notably, care for the female CHD patient is a continuum that is not isolated to discrete stages but cumulative of health exposures and experiences over a lifetime. This review aims to provide a brief overview of the current understanding of the unique health needs and considerations for females with CHD over their lifetime for both the pediatric and adult provider to help identify opportunities for care optimization, continue to raise awareness of the necessity of lifelong care and advocate for the critical need of research that prospectively evaluates pregnancy and other health-related exposures on long-term quality of life and survival for females with CHD.

Reproductive Health Counseling and Outcomes Among Women With Congenital Heart Defects: Results From the Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being, 2016-2019

BACKGROUND

Guidelines recommend tailored reproductive health counseling for women with congenital heart defects (CHDs) beginning in adolescence, yet provider adherence to recommendations remains understudied, particularly outside specialized cardiac care settings.

STUDY DESIGN

We conducted a cross-sectional cohort study among women aged 19 to 38 with CHDs, identified from active population-based birth defects registries in three states. Participants completed surveys from 2016 to 2019, including questions about contraception, pregnancy counseling, concerns, and experiences. Multivariable Poisson regression, adjusted for sociodemographic and health characteristics, assessed associations between CHD severity, counseling, and reproductive health outcomes.

RESULTS

Of 765 women, those with severe CHDs, compared with non-severe, were more likely to report receiving clinician counseling about safe contraceptive methods (44.0% and 13.7%; adjusted prevalence ratio [aPR] = 3.0; 95% confidence interval [95% CI] [2.2, 4.0]), pregnancy, (63.3% and 16.5%; aPR = 3.6; 95% CI [2.7, 4.6]), and pregnancy avoidance (32.0% and 6.4%; aPR = 4.3; 95% CI [2.9, 6.6]); be concerned about ability to have children (40.9% and 31.2%; aPR = 1.4; 95% CI [1.1, 1.8]), and delay/avoid pregnancy (26.6% and 10.7%; aPR = 2.2; 95% CI [1.5, 3.2]). No disparity was found in ever being pregnant (30.0% vs. 37.2%; aPR = 1.0; 95% CI [0.7, 1.2]). One-third of the respondents with any CHD reported concerns about their ability to have children (33.6%).

CONCLUSION

We found that only a minority of women with CHDs reported receiving counseling on safe contraception and pregnancy, and about a third reported concerns about their ability to have children. These findings highlight a gap between guideline recommendations and clinical practice, underscoring the need for improved reproductive health discussions for women with CHDs.

Sexual Health and Well-Being in Adults With Congenital Heart Disease: A International Society of Adult Congenital Heart Disease Statement

As health care outcomes improve the priority for those living with adult congenital heart disease have changed to a more holistic focus on quality of life and well-being. Although health care has embraced this, there are still areas where there is a deficit in advice, allyship, and advocacy. One of these deficits is in the area of sexual health and well-being. A healthy sexual life has a myriad of physical and psychosocial benefits. However, individuals with adult congenital heart disease may have significant barriers to achieving well-being in this aspect of their lives. These barriers and their potential solutions are outlined in this paper.

Characteristics and outcomes of socioeconomically disadvantaged pregnant individuals with adult congenital heart disease presenting to a Cardio-Obstetrics Program

BACKGROUND

Outcomes of individuals with adult congenital heart disease who are socioeconomically disadvantaged and cared for in cardio-obstetrical programs, are lacking.

OBJECTIVE

This study aimed to describe the clinical characteristics, maternal pregnancy outcomes, and contraceptive uptake in individuals with adult congenital heart disease in an urban cardio-obstetrical program.

STUDY DESIGN

Retrospective data were collected for individuals with adult congenital heart disease seen in the Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System between 2015 and 2021 and compared using modified World Health Organization class I, II vs the modified World Health Organization class ≥II/III.

RESULTS

Over 90% of individuals with adult congenital heart disease were pregnant at the time of referral. Modified World Health Organization class I, II (n=77, 62.4% Black or Hispanic/Latina) had a total of 94 pregnancies and modified World Health Organization class ≥II/III (n=49, 49.0% Black or Hispanic/Latina) had a total of 56 pregnancies. Over 25% of individuals in each group had a body mass index ≥30 (P=.78), and very low summary socioeconomic scores. Modified World Health Organization class ≥II/III were more likely to be anticoagulated in the first trimester than modified World Health Organization class I, II (10.7% vs 0.0%, P=.002) and throughout pregnancy (14.3% vs 3.2% P=.02). Modified World Health Organization class ≥II/III were more likely to require arterial monitoring during delivery than modified World Health Organization class I, II (14.3% vs 0.0%, P=.001) or delivery under general anesthesia (8.9% vs 1.1%, P=.03) but had a comparable frequency of cesarean delivery (35.8% vs 41.3%, P=.68). There were no in-hospital maternal deaths. There was no difference in the type of contraception recommended by modified World Health Organization class, however, modified World Health Organization class ≥II/III were more likely to receive long-acting types or permanent sterilization (35.6% vs 54.6%, P=.045).

CONCLUSION

In a socioeconomically disadvantaged cohort with adult congenital heart disease from a historically marginalized community, those with modified World Health Organization class ≥II/III had more complex antepartum and intrapartum needs but similar maternal and obstetrical outcomes as modified World Health Organization class I, II. The multidisciplinary approach offered by a cardio-obstetrics program may contribute to successful outcomes in this high-risk cohort, and these data are hypothesis-generating.

Congenital heart disease and the risk of impaired fertility: A Danish nationwide cohort study using time to pregnancy

BACKGROUND

The number of women with congenital heart disease (CHD) becoming pregnant are increasing. Although menstrual irregularities appear to occur more often in these patients, knowledge on their fertility is limited. In this nationwide cohort study, we evaluated the risk of impaired fertility in women with CHD compared with unaffected women using time to pregnancy (TTP).

METHODS

The Danish National Birth Cohort (DNBC) of pregnant women constituted the study population. Information on TTP and use of medically assisted reproduction (MAR) treatment was reported at a first trimester interview. Women with CHD were identified by linkage to the Danish National Patient Registry. TTP was divided into three categories; 0-5 months, 6-12 months (i.e. subfertile), and > 12 months or use of MAR treatment (i.e. infertile). Relative risk ratios (RRR) for subfertility and infertility with 95% confidence intervals were estimated using multinomial logistic regression.

RESULTS

Among 93,832 pregnancies in 84,922 women, CHD was diagnosed in 333 women (0.4%), contributing with 360 pregnancies. The CHD was of simple complexity in 291 women (87.4%). No association was found between CHD and longer TTP (RRR of 1.02 (95% CI: 0.75-1.40) for subfertility, and RRR of 0.86 (95% CI: 0.61-1.20) for infertility). Similar was observed when comparing women with simple CHD and unaffected women. The number of women with complex CHD was too low for evaluation.

CONCLUSIONS

Women with CHD had no increased risk of impaired fertility, assessed by TTP, when compared with unaffected women. Separate analysis of women with complex CHD was hampered by low numbers.

Sexual and Reproductive Health Care Experiences and Perceptions of Women with Congenital Heart Disease

Due to medical advances, women with congenital heart disease (CHD) are living longer, healthier lives and many are considering pregnancy. The hemodynamic changes of pregnancy present high risks of morbidity and mortality for many women with CHD. As little is known about these women's reproductive health experiences, this study explores their perceptions of pregnancy and family planning care as related to CHD. Women ages 18-45 years with a diagnosis of CHD associated with a World Health Organization (WHO) classification II-IV for pregnancy morbidity and mortality participated in individual, semi-structured interviews exploring their experiences, attitudes, and preferences toward parenthood, pregnancy, contraception and family planning care provision. Interviews were audio-recorded, transcribed verbatim. Two independent coders performed analysis using deductive and inductive coding approaches. Twenty women with CHD participated in interviews (average age 30.1 years, SD 5.85). Nine women had a prior pregnancy and 14 considered becoming a parent in the future. We identified 5 key themes among the women: (1) CHD impacted their reproductive health goals and decisions; (2) Women with CHD perceived a lack of safe contraceptive methods for their condition; (3) Women desired tailored, disease-specific sexual and reproductive health (SRH) information; (4) Women viewed their cardiologist as the primary source for SRH information and prefer provider-initiated discussions starting in adolescence; and (5) Women desire coordinated pre-pregnancy and intrapartum care between their cardiologists and women's health providers. These results provide a foundation for interventions to improve patient-centered interdisciplinary reproductive healthcare for this population.

Congenital Heart Disease and Fertility: A Danish Nationwide Cohort Study Including Both Men and Women

Background Despite an increasing number of patients with congenital heart disease (CHD) reaching reproductive age, the fertility of these patients remains undescribed. Therefore, the aim of the study was to evaluate the fertility in men and women with CHD by estimating the risk of infertility and comparing the birth rates, proportions of individuals becoming parents or remaining childless, and the number of children per parent with unaffected individuals. Methods and Results The study population consisted of individuals born between 1977 and 2000. Information on CHD, infertility, and live born children were obtained from the Danish health registries. Hazard ratios for infertility were analyzed using a Cox regression model. Differences of proportions and birth rates were calculated and compared between groups. Among 1 385 895 individuals, a total of 8679 (0.6%) were diagnosed with CHD. Men and women with simple or moderate CHD had no increased risk of infertility when compared with the reference population. Estimates for complex CHD groups were too imprecise for evaluation. Individuals with CHD were more often childless with consequently lower birth rates compared with unaffected individuals. However, those becoming parents had the same number of children as the reference population. Conclusions Men and women with simple or moderate CHD had the same risk of infertility as the reference population. Despite patients with CHD more often being childless, those becoming parents had the same number of children as parents without CHD. The current findings increase the knowledge regarding fertility in the CHD population.

Adolescent Women with Congenital Heart Disease: Self-Reported Reproductive Health Discussions with Health Care Providers

STUDY OBJECTIVE

This study evaluated self-reported discussions with health care providers (HCPs) among adolescent and young adult (AYA) women with congenital heart disease (CHD).

DESIGN

Data were collected through a one-time survey of AYA women.

SETTING

Participants were recruited from pediatric cardiology clinics.

PARTICIPANTS

AYA women with CHD, ages 14-21 (N = 107) INTERVENTIONS: None MAIN OUTCOME MEASURES: Questionnaires assessed adolescent characteristics and specific HCP discussions regarding transmissibility of a cardiac condition to the infant, risk of pregnancy, and hormonal contraception. Outcome measures were self-reported discussions with HCPs about these reproductive health topics.

RESULTS

Mean age was 16.8 years (SD = 2.1). Self-reported reproductive health discussions were infrequent, including discussions on transmissibility of a heart condition to their offspring (37%), risk of pregnancy to their offspring (34%), risks of pregnancy to their health (46%), and risks of hormonal contraception given their heart condition (21%). Reported discussions were most commonly with a cardiologist.

CONCLUSIONS

AYA women with CHD reported limited discussions about reproductive health topics important to those with CHD. Lack of appropriate and timely counseling could lead to poor maternal and child health outcomes. Targeted interventions that improve reproductive health discussions between HCPs and AYA women with CHD are needed to close critical information and service gaps.

Sexual health knowledge and needs among young adults with congenital heart disease

Advances in the treatment of congenital heart disease (CHD) have increased life expectancy, entailing medical surveillance for a considerable number of adolescents and young adults with CHD for issues arising in areas such as sexual health. This study aimed to assess the sexual knowledge and the needs for sexual health education among this group. The participants comprised 53 young adult outpatients (27 males, median age: 23 years) who had undergone surgical interventions (median: 3 times) for CHD. The Knowledge related to Safe Sex Practice scale (KSSP), an assessment tool containing 15 questions on sexual knowledge, was administered, and the rates of correct answers for each item and the overall scale were compared with the age and sex of a control group (n = 164). The overall mean KSSP score of the participant group (10.5 ± 1.8) was significantly lower than that of the control group (11.1 ± 1.9, p = .035). The KSSP scores of the participants with low peripheral oxygen saturation (SaO2 < 95%) were significantly lower (9.77 ± 1.85) than those with normal SaO2 (11.06 ± 1.85, p = .009). Regarding sexual health education, the participants reported receiving information about contraception as more important than other areas of sexual health. The rate of incorrect answers was higher for questions regarding natural ways of contraception utilizing infertile periods in the menstrual cycle. Based on an informed understanding of those with CHD, healthcare providers in this field should develop customized sexual health education for adolescents and young adults with CHD and implement customized sexual health education, including effective contraception methods.

Sexual Function in Men Living With a Fontan Circulation

Introduction: It is unknown if the Fontan circulation has an impact on sexual health in men. This study assessed self-reported sexual health and fertility in men with a Fontan circulation. Aims: In this prospective, cross-sectional study, Australian men ≥18 years enrolled in the Fontan Registry of Australia and New Zealand were invited to complete the International Index of Erectile Function (IIEF), alongside questions assessing fertility. These data were compared to historical, age-matched controls. Results: Of 227 eligible men, 54 completed the survey; of those 37 were sexually active and included in the final analysis. Mean age was 28 ± 3 years, age at Fontan was 5 ± 3 years. Fontan type was extra-cardiac conduit in 15 (41%), lateral tunnel in 12 (32%), and atriopulmonary connection (APC) in 10 (27%). Ventricular function was normal in 24 (83%), and all were New York Heart Association Class I (23 patients, 79%) and II (six patients, 21%). Nine participants (24%) had erectile dysfunction (IIEF-EF score ≤25). The severity was mild (IIEF 22-24) in six (16%), mild-moderate (IIEF 17-21) in two (5%), and moderate (IIEF 11-16) in one (3%). Baseline characteristics and current medication usage were similar in those with and without erectile dysfunction. Compared with historical control values, erectile function was not significantly impaired in the Fontan population (p =0.76). Men with a Fontan circulation had decreased levels of sexual desire and overall satisfaction (p < 0.001). There was no correlation between the presence of erectile dysfunction and any assessed parameter. Eleven (30%) of the cohort reported a pregnancy with a prior partner. Conclusion: In our cohort, overall erectile function was comparable between men with a Fontan circulation and historical controls, however sexual desire and overall satisfaction were reduced. There was no correlation between study parameters and the presence of erectile dysfunction. The proportion of the cohort who had a prior pregnancy was congruent with population data.

Menstrual Dysfunction and Treatment Among Adolescents With Congenital Heart Disease

STUDY OBJECTIVE

This study describes menstrual dysfunction and treatment among adolescent and young adult (AYA) females with congenital heart disease (CHD).

DESIGN

Data collected from a 1-time survey completed by AYA females (and mothers if AYA unable).

SETTING

Participants were recruited from pediatric cardiology clinics.

PARTICIPANTS

Female AYA with CHD, aged 14-21 years (N = 114).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

The questionnaire assessed sexual and reproductive health (SRH) concerns, behaviors, and management. Outcome measures were self-reported menstrual complaints, use of over-the-counter (OTC) pain relief medications for dysmenorrhea, reported visits with a clinician for a menstrual problem, and reported use of hormones for menstrual problems or birth control.

RESULTS

Mean age was 17.0 years (SD = 2.2). The majority of participants (83%) reported 1 or more menstrual complaints (67.5% cramping, 42.1% irregular menses, 46.5% heavy periods), and 88% reported any history of taking OTC medications for pain relief. Increased menstrual complaints were not associated with level of cardiac complexity, reported transplantation, or reported use of hormonal contraception. However, 32% of participants reported use of hormonal contraception for menstrual dysfunction. Combined oral contraceptive pills (COCs) were the most common; 2 of these women carried contraindications to estrogen.

CONCLUSIONS

A large majority of AYA females with CHD reported menstrual dysfunction. Use of OTC medication for menstrual pain and inappropriate use of estrogen creates concerns that menstrual disorders may be unaddressed or addressed inappropriately. Thus, gynecological needs of adolescents with CHD may need to be specifically targeted by providers who feel comfortable with this population and their complex needs.

Congenital Heart Disease and Women's Health Across the Life Span: Focus on Reproductive Issues

From adolescence to older age, women with congenital heart disease (CHD) face unique challenges. In this review we explore the ways in which CHD affects women's sexual and reproductive health and, in turn, how their sexual and reproductive history affects the course of their CHD. In adolescence, special attention must be paid to menstrual irregularities and concerns of developing sexuality and self-image. Discussions about sexuality and reproduction are an important part of transition planning and must be done with an awareness of the adolescent's developing understanding and maturity. Pregnancy imposes a hemodynamic load on the heart which may lead to cardiac, obstetric, and fetal/neonatal complications in women with CHD. Prepregnancy counselling must include an assessment of maternal and fetal risk according to several well developed models. Counselling should also include discussions about fertility and alternatives to pregnancy when appropriate. Recommendations for contraception must be made according to the patient's cardiac lesion. In caring for women with CHD during pregnancy, a multidisciplinary cardio-obstetrics team is recommended to optimize care. More research is needed into the long-term impact of pregnancy on the prognosis of patients with CHD. As women with CHD increasingly survive into old age, more attention will need to be directed toward the treatment of menopause and acquired heart disease in this population.

Risk-Taking Behaviors in Adolescents With Chronic Cardiac Conditions: A Scoping Review

PROBLEM

Advances in treatment and therapy for children with chronic cardiac conditions have extended their life expectancy. Risk-taking behavior among adolescents requires further exploration. Researchers conducted a scoping review to address a literature gap specific to risk-taking behavior among adolescents with chronic cardiac conditions.

ELIGIBILITY CRITERIA

Sources were limited to (1) human subjects, (2) English language or translatable to English, (3) adolescents without age restrictions, (4) all research designs and (5) presence of a chronic cardiac condition.

SAMPLE

Searches of six electronic databases (CINAHL Plus Full Text, PubMed, Web of Knowledge, Scopus, ProQuest and Grey Literature Report) were conducted to verify the empirical literature between 1975 and 2018. Seventeen sources were included in this review.

RESULTS

Among the 17 sources, 12 sources examined risk-taking behavior by self-report among adolescents with chronic cardiac conditions. Tobacco, alcohol and/or other drug use and physical inactivity were the most prevalent risk-taking behaviors identified through this review.

CONCLUSIONS

Findings from this scoping review describe the types of risk-taking behaviors that adolescents with chronic cardiac conditions are engaging in, highlight similarities when compared to other types of chronic conditions, and serve as a foundation for future research among this population.

IMPLICATIONS

Discussion of risk-taking behaviors should be integrated into each healthcare encounter beginning in early adolescence and continuing through transition to adulthood and adult health care. Qualitative research studies may serve as an effective method by which to explore risk-taking behavior among adolescents with chronic cardiac conditions in greater detail.

The "combined team" transition clinic model in endocrinology results in high adherence rates and patient satisfaction

Background A structured transition process for young adults with chronic medical conditions from pediatric to adult clinics is strongly promoted. However, the most appropriate transition model has not yet been determined. This study evaluated the effect of a "combined team" Endocrinology Transition Clinic model, including a joint meeting with the patient and pediatric and adult endocrinologists, regarding medical treatment, adherence to follow-up and patient satisfaction with the process. Methods Clinical and demographic data of patients admitted to the Endocrinology Transition Clinic were collected. The clinical impact of the transition meeting was evaluated based on treatment modifications and patient adherence to follow-up. Patient satisfaction was evaluated using a questionnaire. Results From September 2014 through November 2018, 107 patients attended the Endocrinology Transition Clinic, 85.0% were females, mean age 19.7 ± 2.2 years (range 16-29), 97.2% were unmarried. The most common endocrine disorders were obesity (41.1%), Hashimoto's thyroiditis (41.1%) and ovarian hyperandrogenism (38.3%). The Transition Clinic visit modified treatment and/or evaluation for 48 (44.8%) patients. Adherence to follow-up in the adult clinic was 82.9% and was not associated with gender (p = 0.366), ethnicity (p = 0.725), age at transition (p = 0.479) or obesity (p = 0.375). Overall satisfaction reported by 65/85 patients was high (86.8%), although higher among patients who were adherent to follow-up (89.4% vs. 65.6%, p = 0.006). Conclusions The "combined team" transition model in endocrinology requires relatively few resources and has considerable clinical impact, high adherence to follow-up and high patient satisfaction rate. Implementing this model at the interface of pediatric and adult endocrinology units, and possibly in other medical fields, is feasible and efficient.

Recurrent Congenital Heart Diseases Among Neonates Born to Mothers with Congenital Heart Diseases

The frequency of newborns with congenital heart disease (CHD) is approximately 1% in the general population; however, the recurrence rate of CHD in mothers with CHD differs in ethnicity and reports. We therefore aimed to determine the prevalence of CHD among neonates born to mothers with CHD in our institute in Japan. We reviewed the medical charts of 803 neonates delivered by 529 women with CHD at the National Cerebral and Cardiovascular Center from 1982 to 2016. They included isolated ventricular septal defect (VSD,31.4%), isolated atrial septal defect (ASD, 23.3%), tetralogy of Fallot (TOF,10.6%). We defined CHD in neonates as being diagnosed within 1 month of birth. We estimated that the average rate of the CHD recurrence was 3.1%. The recurrence ratios in each maternal CHD were 8.6%, 7.1%, 6.2%, 4.8%, 3.6%, and 1.5% for PS, CoA, TOF, atrioventricular septal defect, VSD, and ASD, respectively. The rate of CHD in offsprings whose mothers have CHD was 3 times greater than that of mothers with healthy hearts. Almost half of neonates with CHD had the same phenotype as their mother in our series. Especially, PS and CoA were closely related to the type of maternal CHD.

Quality of life and sexual well-being in patients with a Fontan circulation: An explorative pilot study with a mixed method design

OBJECTIVE

To get an impression of the quality of life (QOL) and sexual well-being in the Fontan population, and to generate hypotheses for future research.

METHODS

For this cross-sectional pilot study, questionnaires regarding health-related QOL, sexual function and fertility/pregnancy were completed by 21 patients with a Fontan circulation >16 years old, followed at the University Medical Center Groningen, the Netherlands. Semi-structured qualitative interviews were conducted in 8 patients.

RESULTS

Fontan patients scored significantly lower on general health than their healthy peers (t(19)=-3.0, P = .008), whereas their scores on other QOL domains and sexual well-being were comparable to normal values. During childhood, most patients experienced physical limitations and the feeling of being an outsider, and frequently faced bullying. Regarding sexual well-being, large interindividual differences were noted. Four interviewed patients (25-30 years) reported a good sexual well-being, whereas the other interviewed patients (33-47 years) reported erectile dysfunction, low self-esteem and avoidance of sexual intercourse. Both the QOL domains mental health and role restrictions due to emotional problems were associated with female avoidance (P = .083, respectively, P = .089) and dyspareunia (P = ns respectively P = .094). In males, role restrictions due to physical problems and health change were related to sexual dissatisfaction (P = .056) respectively nonsensuality (P = .025).

CONCLUSIONS

Overall, Fontan patients have a relatively preserved quality of life and sexual wellbeing but face more social isolation and bullying during childhood/adolescence than their healthy peers. Sexual problems were mainly associated with physical limitations in males and with psychosocial limitations in females. Finally, sexual dysfunction was more common in older Fontan patients, and future research has to clarify whether progressive attrition of the Fontan circulation affects the patients' QOL and sexual well-being.

Managing subfertility in patients with heart disease: What are the choices?

More women with heart disease are reaching reproductive age and will want to embark upon pregnancy. Furthermore, many of these women are delaying pregnancy until later in life when they may be exposed to a greater number of complications from their heart disease. A relatively high proportion of these women will pursue fertility treatment to achieve a pregnancy; consequently, the management of subfertile couples where the woman (or man) has heart disease is of growing importance. In this review, we discuss how fertility investigations and treatment can impact a women with heart disease and how some of the potential complications can be minimized or avoided. We also consider surrogacy, which is an important option when pregnancy is contraindicated.

Adult congenital heart disease nurse coordination: Essential skills and role in optimizing team-based care a position statement from the International Society for Adult Congenital Heart Disease (ISACHD)

BACKGROUND

Founded in 1992, the International Society for Adult Congenital Heart Disease (ISACHD) is the leading global organization of professionals dedicated to pursuing excellence in the care of adults with congenital heart disease (CHD) worldwide. Among ISACHD's objectives is to "promote a holistic team-based approach to the care of the adult with CHD that is comprehensive, patient-centered, and interdisciplinary" (http://www.isachd.org). This emphasis on team-based care reflects the fact that adults with CHD constitute a heterogeneous population with a wide spectrum of disease complexity, frequent association with other organ involvement, and varied co-morbidities and psychosocial issues.

METHODS

Recognizing the vital role of the adult CHD (ACHD) nurse coordinator (ACHD-NC) in optimizing team-based care, ISACHD established a task force to elucidate and provide guidance on the roles and responsibilities of the ACHD-NC. Acknowledging that nursing roles can vary widely from region to region based on factors such as credentials, scopes of practice, regulations, and local culture and tradition, an international panel was assembled with experts from North America, Europe, East Asia, and Oceania. The writing committee was tasked with reviewing key aspects of the ACHD-NC's role in team-based ACHD care.

RESULTS/CONCLUSION

The resulting ISACHD position statement addresses the ACHD-NC's role and skills required in organizing, coordinating, and facilitating the care of adults with CHD, holistic assessment of the ACHD patient, patient education and counseling, and support for self-care management and self-advocacy.

Menstrual Disturbances in Women With Congenital Heart Diseases

BACKGROUND

Women with congenital heart disease (CHD) may experience menstrual disturbances secondary to hemodynamic instability during the mensturation phase.

OBJECTIVES

We investigated the menstrual bleeding pattern and its relationship with certain clinical findings in adult women with CHD.

PATIENTS AND METHODS

Clinical data and menstrual bleeding pattern of adult women ≥15 years old who were referred to adult CHD clinic between March and September 2014 were recorded. Patients with syndromic congenital anomalies were excluded.

RESULTS

Data of 304 women (151 and 153 with simple and complex CHD groups, respectively) were recorded. Their mean (SD) age was 25.2 (1) years (range, 15 - 46 years). The median (IQR) age at menarche was 13 (12 - 14.25) years. Menarche was later in patients with CHD than in the normal population. Furthermore, the simple group showed earlier menarche than the complex group. The most common menstrual abnormality was menorrhagia in both groups (14.5% and 20.5% in the simple and complex groups, respectively). The incidence of menstrual abnormality was higher, though not significantly, in the complex group (40% vs. 25% in the simple group; P = 0.2). Menorrhagia was associated with the severity of oxygen desaturation (P = 0.007).

CONCLUSIONS

Menstrual abnormalities are common in women with CHD, and therefore this group of patients should be aware of the menstrual function and its abnormalities.

From adolescents to adults with congenital heart disease: the role of transition

Improved surgical care during the last decades, together with advances in medical management, led to a remarkable increase in survival of patients with congenital heart disease (CHD). However, aging of the CHD population brings new challenges, and loss of follow-up of adolescents and adults with CHD is a major concern. It is crucial to optimize the transfer of patients with CHD from paediatric to adult health care services to prevent loss to follow-up. The transition process plays a central role in the future health and follow-up of the patient. The aim of this review is to explain and discuss the clinical impact of the transition process in adolescents with CHD. We will also discuss specific CHD adolescents' problems.

CONCLUSION

Adolescence is a crucial phase for the formation of the personality. Understanding and acceptance of the responsibility for health at this stage through a transition process with a multidisciplinary team will determine the quality of future medical follow-up and probably limit psychosocial issues in their adult life.

WHAT IS KNOWN

• Aging of the congenital heart disease population brings new challenges to the organisation of care. • Loss of follow-up is a major concern for patients with congenital heart disease. What is new: • The quality of a formal transition process during adolescence will determine future outcomes in patients with congenital heart disease.

Recommendations for starting a grown up congenital heart disease (GUCH) unit

During the last decades, advances in diagnosis and treatment of congenital heart disease have allowed many individuals to reach adulthood. Due mainly to the great diagnostic diversity and to the co-morbidities usually present in this age group, these patients demand assistance in a multidisciplinary facility if an adequate attention is aimed. In this paper we reviewed, based in the international literature and also on the authors' experience, the structural conditions that should be available for these patients. We highlighted aspects like the facility characteristics, the criteria usually adopted for patient transfer from the paediatric setting, the composition of the medical and para- medical staff taking into account the specific problems, and also the model of outpatient and in-hospital assistance. We also emphasized the importance of patient data storage, the fundamental necessity of institutional support and also the compromise to offer professional training. The crucial relevance of clinical research is also approached, particularly the development of multicenter studies as an appropriate methodology for this heterogeneous patient population.

Lifetime prevalence of sexual intercourse and contraception use at last sex among adolescents and young adults with congenital heart disease

PURPOSE

Because of the increased risks associated with unplanned pregnancy for males and females with congenital heart disease (CHD), we investigated sexual intercourse and contraception use in these adolescents and young adults (AYA) and compared the same with national and state population data.

METHODS

We recruited 337 AYA with structural CHD aged 15-25 years (Mage = 19 years, standard deviation = 3.1; 53% male, 84% white) from an outpatient cardiology clinic to participate in a larger study assessing genetic knowledge and health behaviors. Cumulative lifetime prevalence of adolescent (aged 15-18 years) sexual intercourse was compared with the 2011 Youth Risk Behavior Surveillance System and the 2007 Ohio Youth Risk Behavior Survey. Cumulative lifetime prevalence of young adult (aged 19-25 years) sexual intercourse and contraception use at last sex were compared with the 2006-2008 National Survey of Family Growth.

RESULTS

Reported rates of ever having sexual intercourse, 26% of adolescents and 74% of young adults with CHD, were significantly lower than general population rates (47% and 86% respectively; p < .001). Similar to the general population, 77% of previously sexually active young adults with CHD reported using at least one effective method of contraception at last intercourse, whereas 25% used dual effective methods and 23% used no effective method.

CONCLUSIONS

Lower rates of ever having sexual intercourse in this population suggest that the psychosexual development of AYA with CHD may lag behind their peers. As nearly one in four participants reported using no effective method of contraception, health care providers should increase discussions of contraception with males and females with CHD.

Case studies of the perceptions of women with high risk congenital heart disease successfully completing a pregnancy

PURPOSE

Women even with moderate to severe congenital heart disease (CHD) seek motherhood despite posing significant health risks to themselves and their infant. This study explored their motivations and perceptions and compared them to those of women with low risk CHD who conceived.

PROCEDURES

Twenty women over 18 years with CHD who had a successful pregnancy were recruited, half of whom were identified as having a high risk cardiac abnormality. They completed a questionnaire and a semi-structured interview following which a thematic analysis was employed. Their medical records and clinical status were also reviewed and their current cardiac status graded by their attending cardiologist.

FINDINGS

Women with high risk (moderate to severe) CHD (n=10) appeared to have similar motivations for conceiving as women with low-risk (mild) CHD (n=10). Their decision to conceive seemed based on their own and at times unrealistic perceptions of the consequences of their CHD.

CONCLUSIONS

Women with mild or more severe CHD had similar motivations to conceive tending to down play the seriousness of their CHD. Their drive for motherhood appeared to be stronger than the drive for self care. It behoves clinicians, both obstetricians and cardiologists caring for women with high risk CHD to be knowledgeable of the effects of the CHD on the pregnancy and the impact of the pregnancy on the cardiac status.

Caring for a teen with congenital heart disease

Adolescents with congenital heart disease (CHD) are a rapidly growing population with complex medical needs and psychosocial challenges. Identity formation is an important developmental task accomplished during the teenage years. This article reviews different aspects of ongoing care that pertain to teenagers with CHD, with a particular focus on primary care issues and a summary of recommendations from various scientific societies. A successful smooth transition to the adult health care setting should achieve 2 important goals: to prevent loss of follow-up and to foster and encourage self-care behaviors.

Quality of life and congenital heart disease in childhood and adolescence

Advances in cardiac surgery techniques and early diagnosis have enabled the increased survival of individuals with congenital heart disease. The investigation of the quality of life in children and adolescents with congenital heart disease provides complementary information to clinical data that can assist in decision making on the part of health professionals. Although many studies have been conducted to investigate the quality of life of children and adolescents with congenital heart disease, the results prove to be contradictory; while some studies show that congenital heart disease can impact the quality of life, others describe a better perception of quality of life among children and adolescents who suffer from the disease when compared with healthy control subjects. The purpose of this study is to review the literature on the assessment of health related quality of life in children and adolescents with congenital heart disease, in order to systematize the existing knowledge on this topic today. It is observed that research seeks to investigate aspects of personality in cardiac patients, their coping strategies used and perceived social support, aiming at better understanding the association of these variables with the level of quality of life in this population.

Caring for teens with chronic illness: risky business?

PURPOSE OF REVIEW

With advances in medicine, more children with chronic illness are reaching adolescence and young adulthood. Research has shown that this group is not immune to the behavioral risks endorsed by healthy adolescents. Recent literature exploring the etiology of risk behaviors and their impact on chronic illness is presented.

RECENT FINDINGS

Risk taking may be the result of differential maturation of two distinct parts of the adolescent brain. Risk taking can be considered normal in adolescents with chronic illness, but there is some evidence that chronic illness affects normal psychosocial development. Moreover, evidence supports that chronic illness can lead to disparities in risk education and assessment because of disease focused management rather than a more comprehensive approach.

SUMMARY

Youth living with chronic illnesses face unique challenges in accomplishing the developmental tasks of adolescence. These challenges include risk behaviors, which jeopardize current and future health. The reasons for risk taking are multifactorial and require providers to make the adolescent and not the illness the center of management. More research is needed on how to improve developmentally appropriate and relevant interventions to aid in safe passage into adulthood.

Spectrum of cardiovascular findings during pregnancy and parturition at a tertiary referral center

AIM

To analyze the spectrum of cardiovascular diseases occurring during pregnancy and delivery at a tertiary referral center.

METHODS

All patients presenting at our institution with pre-existing or first diagnosis of cardiac disease were recruited. Cardiac and obstetric complications and maternal and neonatal outcomes were recorded.

RESULTS

Fifty-two pregnancies in 49 women, including three pregnancy terminations were analyzed. Cardiac lesions were congenital in 26 (53.1%) and acquired in nine (18.4%); six patients (12.2%) had cardiomyopathies, eight (16.3%) ar-rhythmic conditions. A total of 42 women (85.7%) had a pre-existing cardiac condition and seven (14.3%) presented with first manifestation. Overall 22 cardiac complications occurred: five in pregnancy, eight around parturition, nine during follow-up. They included >1 New York Heart Association functional class deterioration (n=5), congestive heart failure/cardiomyopathy (n=5), valve replacement (n=4), sustained arrhythmia (n=3), cerebral insult, aortic dissection, transplantation (one case each), and death (n=2). Mean gestational age at delivery was 36+6. The cesarean section rate was 77.5%; 31.6% were performed for cardiac indications. Obstetric complications happened in 23 pregnancies (46.9%). There was no perinatal loss; cardiac defects were diagnosed in 9.3% (n=5) of offspring.

CONCLUSION

Cardiovascular diseases occurring during pregnancy and parturition comprise a heterogeneous spectrum of conditions. Established scores aid in the identification of high-risk patients; however, in our series 14.3% women had been healthy previously.

Sexuality in adult patients with congenital heart disease and their partners

Data on relational and sexuality issues in adult patients with congenital heart disease (CHD) are scarce. The present study aimed to evaluate relational and sexual behaviors, satisfaction, and functioning in a representative sample of patients with CHD and their partners. In addition, we aimed to evaluate the relation between sexuality parameters and quality of life. Relational and sexuality issues were assessed using a sexuality questionnaire in 133 patients (52% men, 37 ± 13 years old) with CHD (43 with coarctation of the aorta, 42 with transposition of great arteries, 36 with Marfan syndrome, and 12 with Eisenmenger syndrome), and 74 partners. Quality of life was assessed using the Dutch translation of the Medical Outcomes Study Short Form 36-Item Health Survey. Data were compared to an age- and gender-matched control group (n = 3,642). Seventy-one percent of patients with CHD were involved in a relationship, which was significantly less compared to controls (79%, p < 0.05). Nonetheless, patients perceived their relationship as more satisfactory compared to controls (p < 0.05). Overall, sexual satisfaction was equal in patients compared to controls, although they perceived lower body esteem (p < 0.001), decreased sexual esteem (p < 0.05), and more distress during sex (p < 0.001). Patients reported no more erectile and lubrication problems compared to partners and to controls. We found significant associations between most relational and sexual parameters and quality of life. In conclusion, many aspects of sexuality are affected in adult patients with CHD, whereas their partners remain relatively unaffected. Moreover, sexuality is an important aspect of quality of life in these patients. We advise physicians to be receptive to discuss sexuality issues and provide patients with adequate therapy.

Erectile dysfunction in men with congenital heart disease

There has been a tremendous focus on gynecologic health with the increasing number of women with congenital heart disease (CHD). Conversely, experience in providing sexual health screening to men with CHD is lacking. The purpose of this study was to identify sexual health issues in men with CHD. An anonymous survey was distributed to men in our adult CHD clinic. Age, type of CHD, medications, detailed sexual history including cardiovascular symptoms with intercourse, erectile dysfunction (ED), and willingness to discuss ED with a physician was obtained. A logistic regression analysis was performed to analyze the relation between medications, CHD complexity, and ED; 86 men completed the survey with a mean age of 34 +/- 10 years. The prevalence of ED was 38%. Men were treated with cardiac medications including beta blockers (BB; 24%), angiotensin-converting enzyme (ACE) inhibitors (8%), calcium-channel blockers (6%), and combination BB and ACE inhibitor therapy (16%). Men on BB were 3.13 times more likely to report ED (p = 0.045). Complexity of CHD did not increase the likelihood of ED symptoms (p >0.10). Although most men attributed symptoms to their underlying CHD, most were willing to discuss issues of ED with their cardiologist. In conclusion, ED is prevalent in young men with CHD. Although an emotional component may contribute, certain medications may exacerbate symptoms.