Adults With Congenital Heart Disease: Trends in Event-Free Survival Past Middle Age

B-type natriuretic peptide levels predict long-term mortality in a large cohort of adults with congenital heart disease

BACKGROUND AND AIMS

Many adult patients with congenital heart disease (ACHD) are still afflicted by premature death. Previous reports suggested natriuretic peptides may identify ACHD patients with adverse outcome. The study investigated prognostic power of B-type natriuretic peptide (BNP) across the spectrum of ACHD in a large contemporary cohort.

METHODS

The cohort included 3392 consecutive ACHD patients under long-term follow-up at a tertiary ACHD centre between 2006 and 2019. The primary study endpoint was all-cause mortality.

RESULTS

A total of 11 974 BNP measurements were analysed. The median BNP at baseline was 47 (24-107) ng/L. During a median follow-up of 8.6 years (29 115 patient-years), 615 (18.1%) patients died. On univariable and multivariable analysis, baseline BNP [hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.15-1.18 and HR 1.13, 95% CI 1.08-1.18, respectively] and temporal changes in BNP levels (HR 1.22, 95% CI 1.19-1.26 and HR 1.19, 95% CI 1.12-1.26, respectively) were predictive of mortality (P < .001 for both) independently of congenital heart disease diagnosis, complexity, anatomic/haemodynamic features, and/or systolic systemic ventricular function. Patients within the highest quartile of baseline BNP (>107 ng/L) and those within the highest quartile of temporal BNP change (>35 ng/L) had significantly increased risk of death (HR 5.8, 95% CI 4.91-6.79, P < .001, and HR 3.6, 95% CI 2.93-4.40, P < .001, respectively).

CONCLUSIONS

Baseline BNP and temporal BNP changes are both significantly associated with all-cause mortality in ACHD independent of congenital heart disease diagnosis, complexity, anatomic/haemodynamic features, and/or systolic systemic ventricular function. B-type natriuretic peptide levels represent an easy to obtain and inexpensive marker conveying prognostic information and should be used for the routine surveillance of patients with ACHD.

Comparison and Agreement between Cardiovascular Computed Tomography-Derived Mid-Diastolic and End-Diastolic Ventricular Volume in Patients with Congenital Heart Disease

Prospective electrocardiogram (ECG)-triggered cardiovascular computed tomography (CCT) is primarily utilized for anatomical information in congenital heart disease (CHD) and has not been utilized for calculation of the end-diastolic volume (EDV); however, the mid-diastolic volume (MDV) may be measured. The objective of this study was to evaluate the feasibility and agreement between ventricular EDV and MDV. 31 retrospectively ECG-gated CCT were analyzed for the study of the 450 consecutive CCT. CCT images were processed using syngo.via with automatic contouring followed by manual adjustment of the endocardial borders of the left ventricles (LV) and right ventricles (RV) at end-diastolic and mid-diastolic phase (measured at 70% of cardiac cycle). The correlation and agreements between EDV and MDV were demonstrated using Spearman rank coefficient and intraclass correlation coefficient (ICC), respectively. Mean age ± SD was 28.8 ± 12.5 years, 19 were male (61.3%) and tetralogy of Fallot (TOF) was the most common diagnosis (58.1%), 35% (11/31) patients with a pacemaker, ICD or other such contraindication for a CMRI, 23% (7/31) with claustrophobia, and 6.5% (2/31) with developmental delay with refusal for sedation did not have a previous CMRI. The mean ± SD indexed LV EDV and LV MDV were 91.1 ± 24.5 and 84.8 ± 22.3 ml/m2, respectively. The mean ± SD indexed RV EDV and RV MDV were 136.8 ± 41 and 130.2 ± 41.5 ml/m2, respectively. EDV and MDV had a strong positive correlation and good agreement (ICC 0.92 for LV and 0.95 for RV). This agreement was preserved in a subset of patients (21) with dilated RV (indexed RV EDV z-score > 2). Intra-observer reliability (0.97 and 0.98 for LV and RV MDV, respectively) and inter-observer reliability (0.96 and 0.90 for LV and RV MDV, respectively) were excellent. In a select group of patients with CHD, measuring MDV by CCT is feasible and these values have good agreements with EDV. This may be used to derive functional data from prospectively ECG-triggered CCT studies. Further large-scale analysis is needed to determine accuracy and clinical correlation.

Outcomes after cancer diagnosis in children and adult patients with congenital heart disease in Sweden: a registry-based cohort study

OBJECTIVE

Patients with congenital heart disease (CHD) have an increased cancer risk. The aim of this study was to determine cancer-related mortality in CHD patients compared with non-CHD controls, compare ages at cancer diagnosis and death, and explore the most fatal cancer diagnoses.

DESIGN

Registry-based cohort study.

SETTING AND PARTICIPANTS

CHD patients born between 1970 and 2017 were identified using Swedish Health Registers. Each was matched by birth year and sex with 10 non-CHD controls. Included were those born in Sweden with a cancer diagnosis.

RESULTS

Cancer developed in 758 out of 67814 CHD patients (1.1%), with 139 deaths (18.3%)-of which 41 deaths occurred in patients with genetic syndromes. Cancer was the cause of death in 71.9% of cases. Across all CHD patients, cancer accounted for 1.8% of deaths. Excluding patients with genetic syndromes and transplant recipients, mortality risk between CHD patients with cancer and controls showed no significant difference (adjusted HR 1.17; 95% CI 0.93 to 1.49). CHD patients had a lower median age at cancer diagnosis-13.0 years (IQR 2.9-30.0) in CHD versus 24.6 years (IQR 8.6-35.1) in controls. Median age at death was 15.1 years (IQR 3.6-30.7) in CHD patients versus 18.5 years (IQR 6.1-32.7) in controls. The top three fatal cancer diagnoses were ill-defined, secondary and unspecified, eye and central nervous system tumours and haematological malignancies.

CONCLUSIONS

Cancer-related deaths constituted 1.8% of all mortalities across all CHD patients. Among CHD patients with cancer, 18.3% died, with cancer being the cause in 71.9% of cases. Although CHD patients have an increased cancer risk, their mortality risk post-diagnosis does not significantly differ from non-CHD patients after adjustements and exclusion of patients with genetic syndromes and transplant recipients. However, CHD patients with genetic syndromes and concurrent cancer appear to be a vulnerable group.

Palliative Care in Adult Congenital Heart Disease-Associated Advanced Heart Disease

The practice of palliative care (PC) strives to mitigate patient suffering through aligning patient priorities and values with care planning and via improved understanding of complex physical, psychosocial, and spiritual stressors and dynamics that contribute to patient-centered outcomes. Through representative 'case examples' and supportive data, the role and value of a PC consultant, within the framework of a comprehensive adult congenital heart disease (ACHD) team caring for ACHD with advanced heart disease, are reviewed.

Progression of Valvular Pulmonic Stenosis in Adulthood: Never Say Never

•Historic data indicate mild valvar PS in adults does not progress. •The prevalence of older adults with CHD is increasing. •Valvular calcification may lead to progression of PS in later life. •Echocardiography should be used for routine follow-up for PS.

Severe Symptomatic Aortic Stenosis in an Octogenarian with Congenitally Corrected Transposition of the Great Arteries

•ccTGA accounts for 0.5%-1.4% of patients with congenital heart disease. •Patients with isolated ccTGA can remain undiagnosed for decades. •Very rarely, patients with ccTGA develop symptomatic AS. •Management of severe AS in patients with ccTGA presents unique challenges. •Transcatheter options are limited due to the unique anatomy.

Biological Age in Congenital Heart Disease-Exploring the Ticking Clock

Over the past 50 years, there has been a major shift in age distribution of patients with congenital heart disease (CHD) thanks to significant advancements in medical and surgical treatment. Patients with CHD are, however, never cured and face unique challenges throughout their lives. In this review, we discuss the growing data suggesting accelerated aging in this population. Adults with CHD are more often and at a younger age confronted with age-related cardiovascular complications such as heart failure, arrhythmia, and coronary artery disease. These can be related to the original birth defect, complications of correction, or any residual defects. In addition, and less deductively, more systemic age-related complications are seen earlier, such as renal dysfunction, lung disease, dementia, stroke, and cancer. The occurrence of these complications at a younger age makes it imperative to further map out the aging process in patients across the spectrum of CHD. We review potential feasible markers to determine biological age and provide an overview of the current data. We provide evidence for an unmet need to further examine the aging paradigm as this stresses the higher need for care and follow-up in this unique, newly aging population. We end by exploring potential approaches to improve lifespan care.

Increased cesarean section rate and premature birth according to modified WHO maternal cardiovascular risk in pregnant women with congenital heart disease

BACKGROUND

During pregnancy and delivery, hemodynamics are altered and complex congenital heart disease has been associated with adverse maternal and neonatal outcomes. We sought to investigate pregnancy outcome and complications in relation to complexity of heart condition.

MATERIALS AND METHODS

We studied women with ACHD discussed at multidisciplinary conferences at Lund University Hospital March 2009-May 2021. We studied 149 pregnancies in 101 women. We scored each woman retrospectively according to the modified World Health Organization (mWHO) risk classification and included patients in risk class I (n = 36, 24.1%), II (n = 43, 28.9%), II-III (n = 43, 28.9%), III (n = 24, 16.1%) and IV (n = 3, 2.0%).

RESULTS

Women with mWHO class ≥III underwent cesarean section more often than women in less complex mWHO classes, (OR, 5.1; 95% CI, 2.0-12.5; p<0.001). The odds of premature delivery were significantly higher among pregnant women with mWHO class ≥III (OR, 6.7; 95% CI, 2.6-17.4; p<0.001). We found no difference in incidence of preeclampsia, gestational hypertension, gestational diabetes, hemorrhage >1000 ml or cardiac defect in the neonate depending on WHO-class. Women in mWHO classes III-IV had a higher rate of fetal growth restriction (FGR) compared to women in mWHO classes I, II, II-III (p<0.007).

CONCLUSIONS

Our findings indicate that women with more complex heart disease (mWHO classes III or IV) tend to have a higher rate of cesarean section, premature birth and FGR.

Life expectancy and end-of-life communication in adult patients with congenital heart disease, 40-53 years after surgery

Aims

Although survival of patients with congenital heart disease (CHD) improved significantly over time, life expectancy is still not normal. We aimed to investigate how adult patients, their partners, and treating cardiologists estimated the individual life expectancy of CHD patients. Furthermore, preferences regarding end-of-life (EOL) communication were investigated.

Methods and results

In this study, we included 202 patients (age: 50 ± 5) who were operated in childhood (<15 years old) 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. A specific questionnaire was administered to both the patients and their partners, exploring their perceived life expectancy and EOL wishes. Two cardiologists independently assessed the life expectancy of each patient. Most adults with CHD believed their life expectancy to be normal. However, significant differences were found between estimated life expectancy by the cardiologist and patients (female: P = 0.001, male: P = 0.002) with moderate/severe defects, as well as for males with mild defects (P = 0.011). Regarding EOL communication, 85.1% of the patients reported that they never discussed EOL with a healthcare professional. Compared with patients with mild CHD, significantly more patients with moderate/severe defect discussed EOL with a physician (P = 0.011). The wish to discuss EOL with the cardiologist was reported by 49.3% of the patients and 41.7% of their partners.

Conclusion

Adult patients, especially with moderate/severe CHD, perceived their life expectancy as normal, whereas cardiologists had a more pessimistic view than their patients. Increased attention is warranted for discussions on life expectancy and EOL to improve patient-tailored care.