Renal dysfunction: a predictor of adverse outcomes in ACHD patients with acute decompensated heart failure

Background

Renal dysfunction (RD) is a predictor of adverse outcomes in patients with acquired heart failure (HF). Studies in adult congenital heart disease (ACHD) have demonstrated the link between RD and increased mortality. However, there is a paucity of data regarding the prognostic significance of RD in ACHD and HF. We assessed the impact of RD on outcomes in ACHD patients presenting with acute decompensated HF requiring intravenous (IV) diuresis in a tertiary centre between 2010–2021.

Methods

This was a retrospective analysis on RD and outcomes during the index hospital admission and after discharge. Chronic kidney disease (CKD) was defined as an eGFR <60mL/min/1.73 m2 using the MDRD equation. Cox regression analysis was used to identify predictors of death after discharge.

Results

We included 176 HF admissions, 76 (43.2%) female, age 47.7±14.5 years. Complex CHD was present in 50.6%. The most frequent underlying congenital heart defects were: transposition of the great arteries (including congenitally corrected, 19.9%), univentricular (14.2%), and tetralogy of Fallot (13.6%). Eisenmenger syndrome was present in 18.8%, a systemic right ventricle in 22.2%, 40.9% had pulmonary arterial hypertension (PAH), and 38.1% were cyanotic. At the time of the index admission 92 (52.3%) had RD (eGFR <60 mL/min/1.73 m2 and/or serum creatinine >88 μmol/L), 63 (38.2%) had a history of CKD. Patients with RD on admission were older (49.8 [42.3–60.9] vs. 46.0 [33.8–53.6] years, p=0.02) and more likely to have a history of arrhythmia (71.7% vs. 53.6%, p=0.02), but did not differ to those without RD in terms of diabetes mellitus or systemic hypertension. Admission BNP was higher in patients with RD (594 [258–1216] vs. 354 [158–633] ng/L, p=0.01). Patients with RD were more likely to have at least moderate systemic (31.8% vs. 11.8%, p=0.005) or pulmonary (58.4% vs. 36.4%, p=0.01) ventricular dysfunction. They were also more likely to have systemic ventricular dilatation (28.6% vs. 11.8%, p=0.02) or a larger RA area (29 [21–34] vs. 21 [16–31] cm2, p=0.008). Inpatients with RD required higher doses of IV furosemide (160 [80–200] vs. 80 [70–160] mg, p=0.03) and there was a trend for more frequent inotropic support (19.6% vs. 8.3%, p=0.06). In-hospital mortality was relatively low (4.5%), however, 94 (56.0%) patients died and 73 (43.5%) were rehospitalised for HF at a median follow-up of 2.8 [0.01–12.0] years. CKD (HR 2.43, 95% CI: 1.59–3.71, p<0.0001) and RD on admission (HR 1.7, 95% CI: 1.13–2.58, p=0.01) were strong predictors of death (Figure 1). On multivariable Cox analysis, PAH, CKD, and peak inpatient diuretic dose remained predictive of mortality.

Conclusions

ACHD patients admitted with acute decompensated HF are a high-risk cohort for acute re-admission and mortality. Preexisting RD and need for high dose IV diuretics conveys an even worse prognosis. Earlier interventions based on evidence of RD in ACHD may modulate this spiral trajectory and warrants further investigation.

Funding Acknowledgement

Type of funding sources: None.

Predictors of adverse clinical outcome after hospitalisation for decompensated heart failure in ACHD patients

Background

As the ACHD population ages, an increasing number of patients are being admitted for heart failure. Management is complicated by the limited evidence on pharmacological and other therapies and lack of risk stratification tools. Improved surgical and medical treatment options in this patient cohort has improved life expectancy.

Purpose

Assess the mortality and rate of rehospitalisation in ACHD patients following admission with decompensated HF and identify clinical predictors of outcome.

Methods

All ACHD patients admitted for HF requiring IV diuresis from February 2016 to December 2020 in a single tertiary centre were included. Cox analysis was used to identify predictors of death after the index admission.

Results

91 patients were included: 44.0% female, 45.8±14.2 years. The most frequent underlying diagnoses were: 15.4% with primary valve or left ventricular outflow tract disease, 12.1% with transposition of the great arteries post-atrial switch, 9.9% with tetralogy of Fallot and 30.8% had a systemic right ventricle. Most (56.7%) patients had CHD of “great” complexity according to the Bethesda classification, whereas no patients had “simple” CHD. Cyanosis was present in 26.4%.

Heart failure was predominantly related to systemic ventricular dysfunction in 35.2%, subpulmonary ventricular dysfunction in 25.3%, biventricular dysfunction in 24.2% and univentricular dysfunction in 15.4%. Pulmonary hypertension was present in most (58.2%) patients, only half (46.0%) of these had pre-capillary pulmonary hypertension.

On admission, approximately half of patients were on standard heart failure therapy: 48.4% ACE-inhibitors or angiotensin receptor blockers, 54.9% beta-blockers, 54.9% mineralocorticoid receptor antagonists and 2% on sacubitril/valsartan.

In-hospital mortality was only 3.3% in this high-risk population. During a median follow-up of 22.1 [0.2–58.4] months, 37.5% patients were rehospitalised for HF and 37.5% patients died (22.7% mortality at 1 year). On univariable Cox analysis, the following parameters were predictors of mortality: pulmonary hypertension, cyanosis, unoperated or palliated CHD, chronic kidney disease (CKD), hyponatraemia, mineralocorticoid receptor antagonist use on admission, admission BNP>350ng/L and a maximum daily inpatient loop diuretic requirement >160mg (furosemide equivalents). On multivariable Cox analysis, pulmonary hypertension, cyanosis, hyponatraemia and CKD were independent predictors of mortality; patients with ≥2 of these risk factors had an 8-fold higher mortality (figure).

Conclusion

ACHD patients hospitalised for decompensated HF have a poor outlook with a quarter of patients dying within a median <2 years from discharge. We present clinical parameters that can identify patients at high risk of an adverse outcome who should be targeted for aggressive monitoring and advanced HF therapies, including transplantation.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Home fitting of electrocardiogram (ECG) ambulatory monitors during covid-19

Funding Acknowledgements

Type of funding sources: None.

Background

Interruption of health services during COVID-19 leading to increased risk to patients and a backlog for vital outpatient cardiac diagnostic services.

Purpose

To safely deliver ambulatory ECG monitors whilst reducing risk to patients and staff by providing monitors to be fitted at home.

Methods

A system was developed whereby monitors were set up for the patient/carer to collect a preassembled pack and fit at home using videos/written instructions. A retrospective evaluation was undertaken over four months (12/4/20 – 12/08/20) through feedback questionnaires containing closed and open-ended questions.

Results

Of a total of 726 ECG ambulatory monitors fitted in this period 60% were self-fitted. 97 patients gave feedback (13.3%). 84.4% of patients were satisfied with the process. 58.33% felt safer fitting it at home as 40% were fitted in-house due to limitations e.g. elderly/wheelchair/pregnant patients and/or those without access to view the videos. 6 monitors (<1%) were refitted due to artefact/early disconnection. Improvement suggestions implemented included simplifying instructions and adding specific information for female electrode placement.

Conclusions

This project enabled vital cardiac diagnostics whilst maintaining social distancing - reducing infection risk and achieving high patient satisfaction. Implementing a locker system will decrease differing instructions and positively impact waiting times to further reduce viral transmission risks.

Transition for patients with congenital heart disease in the UK: need for a universal model with adequate training and support

Background

Adolescence is a vulnerable period for patients with congenital heart disease (CHD). Transition is a process that guides these patients through adolescence and ensures a smooth transfer to adult services, in order improve adherence to medical care and reduce loss to follow-up. While the importance of a formal Transition process is widely recognised and a requirement for specialist services in the UK, the optimal structure and delivery of Transition remains a matter of debate.

Aims

To examine the different models of Transition currently in place in specialist CHD centres around the UK.

Methods

A survey of Adult CHD centres in the UK was performed. A focus was placed on the structure of the Transition service, relevant training and areas of perceived improvement.

Results

There were 10 responses to our survey covering 10 specialist CHD centres. All respondents were consultant adult CHD specialists, looking after patients from the age of 16 [14–17] years. All centres have a specialised Transition service, which runs from the age 13 [11–15] to 18 [16–25] years (duration of transition 5 [2–13] years). The majority of centres (80%) report providing transition care “well before” transfer to adult care, whereas 20% provide transition care at or immediately before transfer (i.e. first adult CHD appointment). Transition is delivered by physicians and clinical specialist nurses in approximately equal numbers in 9 (90%) centres and exclusively by clinical nurse specialists in 1 (10%) centre. A median of 2 [1–5] visits are planned for each patient, with 7 (70%) centres seeing patients at least twice during transition. The majority, but not all centres (70%) provide a health passport during transition. A significant number of centres felt they werer not receiving sufficient support in the following domains: financial (50%), training (30%), clinical space (30%), referrals from paediatrics (50%). All respondents felt that their Transition service had room for improvement. Other areas of improvement highlighted included reduction in loss to follow-up, difficulties in providing a Transition service to patients followed in peripheral hospitals, the need for more support from paediatric services in referring all appropriate patients, and dedicated administrative support. The vast majority of respondents (9, 90%) felt equipped with the appropriate skills to care for transition patients. However, few (2, 20%) had completed formal training in more than one area related to adolescent health and transition.

Conclusions

While all CHD centres have a Transition service, Transition models and delivery differs significantly. There is urgent need for research in this area to develop a unified model, greater financial support and relevant training to optimise care.

Figure 1. Participating UK centres

Funding Acknowledgement

Type of funding source: None