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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Synonyms: adult congenital heart disease (ACHD), grown-up congenital heart (GUCH) disease
The topic covers a very wide range of diseases:
- Fallot's tetralogy.
- Transposition of the great arteries.
- Atrial septal defect (ASD).
- Ventricular septal defect.
- Coarctation of the aorta.
- Valvular defects (usually aortic valve disease or mitral valve disease, as right heart valve disease including pulmonary valve disease is very much rarer).
- Patent ductus arteriosus.
- Primary pulmonary hypertension.
Some of these are not strictly diseases of the heart but they are certainly the domain of the cardiologist. As more patients with congenital heart disease (CHD) survive into adult life, paediatric cardiologists have to pass over their patients to adult cardiologists but the role of the general practitioner or primary care physician becomes more important.
The British Heart Foundation (BHF) recommends that:
- Management of adults with CHD is complex and requires close liaison between primary and secondary care.
- Secondary care should be provided at the level of an adult Cardiology Department for most patients but complex cases should be seen by specialist Adult Congenital Heart Disease units.
- The main medical issues are the risk of infective endocarditis, the management of contraception, pregnancy, the occurrence of arrhythmias and the complications of hypoxaemia.
This is echoed by the Department of Health (DH) but in a much more circuitous fashion.
CHD is the most common inborn defect, with a worldwide incidence of 1%. Some have lesions that permit survival into adult life (indeed 10% are first diagnosed in adulthood) but others would have died in childhood without the advent of cardiothoracic surgery. In 2008, 3.69 babies per 1,000 live births were notified as having CHD.About half of these will not need any treatment. About 90% of those born with CHD now survive into adult life, compared with 20% in the 1950s.
The DH says that there are around 135,000 young people and adults currently living in England with CHD. The 32nd Bethesda Conference report estimated that there were approximately 2,800 adults with CHD per 1 million population and that more than half of them have a moderate or high complexity defect.
There are a number of recurring and particular medical issues in patients with adult CHD, highlighted by the BHF and the DH. Even patients who have had surgery may have significant haemodynamic impediment but there are specific areas of danger, such as Eisenmenger's syndrome or infective endocarditis. There are also specific problems regarding contraception and cardiac disease in pregnancy.
- This occurs when a left-to-right shunt is converted into a right-to-left shunt due to pulmonary hypertension.
- Typical causes of shunts include: large ventricular septal defect (VSD) - as originally described, patent ductus (PD) and, less commonly, other abnormalities.
- Compensating polycythaemia, associated with a high haematocrit, can cause problems such as deep vein thrombosis. This may cause not only pulmonary embolism but systemic emboli via the shunt. The result will depend upon where the embolus lodges but, if it goes to the brain, a stroke will result. Venesection may be required if there are symptoms such as headache, faintness, blurred vision, amaurosis fugax, fatigue, myalgia or paraesthesia.
This group may also have raised uric acid and require allopurinol to protect from gout.
There have been important changes in the recommendations on the prevention of infective endocarditis. Routine prophylaxis is now no longer recommended and antibiotics would only be given to treat active infection (of whatever type) whilst awaiting (or with) microbiological advice. See separate Infective Endocarditis and Prevention of Infective Endocarditis articles.
Identification of at-risk patients is still clinically relevant. Patients at high, moderate and low risk of infective endocarditis can be identified:
- Highest-risk patients include:
- Those with all types of prosthetic valve.
- Previous infective endocarditis.
- Surgically produced systemic or pulmonary shunts.
- Congenital cyanotic heart disease.
- Moderate-risk patients are:
- Congenital cardiac conditions (other than cyanotic) but excluding isolated atrial septal defects (ASDs) and surgical repairs of ASDs or patent ductus arteriosus over six months previously.
- Bicuspid aortic valves.
- Acquired valve disease, including rheumatic heart disease, mitral stenosis and calcific aortic stenosis.
- Hypertrophic cardiomyopathy.
- Mitral valve prolapse with regurgitation and with or without thickened leaflets.
- Low-risk patients include:
- Mitral valve prolapse without significant regurgitation.
- Implanted pacemakers, defibrillators and coronary stents.
- Innocent murmurs (except elderly patients where this may represent an at-risk calcified leaflet).
- In some conditions, the combined oral contraceptive pill (COCP) is contra-indicated but the risks of pregnancy are even greater and so an alternative but reliable form of contraception must be used.
- Eisenmenger's syndrome, polycythaemia and primary pulmonary hypertension are important risk factors and exogenous oestrogens in the COCP or hormone replacement therapy (HRT) should be avoided.
- Emergency contraception and the progestogen-only contraceptive pill are permissable.
- The intrauterine contraceptive device (IUCD) and intrauterine system (IUS) are also acceptable, although they are more difficult to fit in a nulliparous uterus and it is important to give appropriate antibiotic cover for a genitourinary procedure.
- Depot and implant contraception are also permissible and antibiotic cover may also be wise.
- Barrier contraceptives are not a problem, although when contraception methods are compared, they tend to have a higher failure rate than others. They can be good when used meticulously.
- If there is no chance that the woman will wish to have a baby in the foreseeable future then sterilisation is a rational option, although the failure rate can be no better than reversible forms of contraception and it requires the dangers of a general anaesthetic. For this reason, vasectomy of the husband may seem an attractive alternative but, if the life expectancy of the wife is limited, they may wish to consider the possibility of the husband remarrying.
As more people with CHD survive into adult life, grown-up congenital heart (GUCH) disease and pregnancy become more common, and it affects more pregnancies. In the last reported triennium (2006-2008) cardiac disease was the most common cause of indirect maternal death and this has not changed significantly since 2003-2005 at 6.72 per 100,000 maternities.Physiological changes in pregnancy include a 30% increase in resting cardiac output as well as further demands that may occur with such complications as hypertension in pregnancy. Normal labour with an active management of the 3rd stage sees a boost to the circulation as the uterus contracts.
- The risk is dependent upon the nature of the lesion and complications such as Eisenmenger's syndrome or cardiomegaly where mortality may be as high as 25% to 50%. Primary pulmonary hypertension and cyanotic disease can also have a maternal mortality of 50%.
- It is essential that any woman who has heart disease undergo pre-pregnancy counselling, not just to assess her risk but also to review medication.
- Pregnancy is contra-indicated in pulmonary hypertension, Marfan's syndrome with a dilated aortic root, severe aortic or mitral valve stenosis and in any patient with poor ventricular function.
- Peripartum cardiomyopathy and Marfan's syndrome may be less dangerous than once thought.
- There may be a genetic element in some forms of heart disease in that the chance of the fetus having CHD is increased between 2- and 20-fold.
- Any delay is usually managed by intervention with forceps to prevent exhaustion.
- If the woman takes warfarin, this should be converted to heparin, as the former crosses the placenta causing fetal loss or abnormalities. The rate of pregnancy loss in women with prosthetic or biomechanical valves is very high if they take warfarin but conversion to heparin gives a very favourable outcome, except that the risk of thromboembolic events is increased.
- Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor antagonists are both severely teratogenic.
Figures about maternal mortality need to be treated with caution. The nature and severity of the lesion are important. Management is improving all the time and some statistics are from countries with less well-developed health services and perhaps still a significant volume of rheumatic heart disease.
Coarctation of the aorta
Coarctation of the aorta is a narrowing of the aorta most commonly found just distal to the origin of the left subclavian artery. See also separate Coarctation of the Aorta article.
- It represents 5% to 10% of all congenital cardiac lesions and 7% of critically ill infants with heart disease.
- Surgical treatment is usually with a patch graft but morbidity remains.
- There is increased risk of berry aneurysm that can cause subarachnoid haemorrhage.
- If coarctation is not repaired, fewer than 20% reach the age of 50.
- If it is repaired before the age of 14, that figure is just over 90% but, if it is repaired after the age of 14, it is just under 80%.
- After operation, an increased pressure gradient at the site of the lesion persists but quality of life is good with nearly all patients being classified as New York Heart Association (NYHA) grade I (no symptoms on ordinary physical activity).
- After repair of coarctation, blood pressure remains elevated and there is risk of re-stenosis or rupture.
- As with all disease of the aorta and aortic valve, strenuous and prolonged isometric activities are dangerous. The risk of dissection remains significant even after repair and may be increased with isometric activity.
- Pregnancy represents a significant risk to both mother and fetus if it has not been repaired.
- After repair, there is an increased risk of dissection of the aorta and rupture of a cerebral aneurysm in the third trimester and peripartum period, due to haemodynamic and hormonal changes.
- There is a significant risk of hypertensive disease of pregnancy or pre-eclampsia.
- A Dutch study found an excess of miscarriages and a 4% rate of CHD in the offspring. An American study found similar results, including a high incidence of hypertension in pregnancy.
- All pregnant women with a history of coarctation, whether repaired or not, should be considered high-risk.
- Significant stenosis, whether unrepaired, residual or recurrent, is a contra-indication to pregnancy.
- Unrepaired coarctation of the aorta has significant maternal mortality.
Palpitations and arrhythmias
Palpitations and arrhythmias are very common in the general population but, with CHD, they can have sinister significance. Arrhythmias are the most common cardiological reason for admission to the hospital.
- Palpitations may indicate atrial fibrillation or ventricular extrasystoles or a tachyarrhythmia.
- Atrial tachyarrhythmias may occur in those who have had ASD, even if it was repaired.
- Ventricular dysrhythmias are likely after repair of Fallot's Tetralogy or in the patient, in their third or fourth decade, with ventricular dysfunction.
- The onset of arrhythmias often heralds haemodynamic deterioration and requires full assessment.
- Atrial tachyarrhythmias can be poorly tolerated and are potentially life-threatening in those with Fontan's circulation or repair for transposition of the great vessels, a single ventricle or with ventricular dysfunction.
- Bradycardia may require a pacemaker.
Exercise and lifestyle
Patients with CHD generally have impaired exercise tolerance but they should be encouraged to exercise within the limits of their abilities. Even after surgery, serious problems remain.
- Exercise should only be discouraged in those with pulmonary hypertension or severe obstructive lesions of the left side of the heart.
- Commercial air travel is usually safe, even with cyanosis.
- Few patients will have a normal life expectancy.
- Pregnancy may be troublesome or dangerous but adoption agencies do not look favourably on a potential mother who may die young.
- The demands for management vary considerably according to the complexity of the problem and the degree of surgical correction. About 20% to 25% are complex or rare and require lifelong expert supervision. About 35% to 40% require access to expert supervision and the other 40% require little or no expert supervision.
- The organisation of care currently requires a more rational basis but the British Cardiovascular Society (BCS) is keen to foster a more rational structure. Transition from paediatric to adult care can be a problem for adolescents.
Further reading and references
Adult Congenital Heart Disease - A commissioning guide for services for young people and Grown Ups with Congenital Heart Disease (GUCH)); Dept of Health, 2006 (archived content)
Congenital anomaly statistics 2008; Office for National Statistics
Management of grown-up congenital heart disease; European Society of Cardiology (2010)
Prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures; NICE Clinical Guideline (March 2008 - last updated July 2016)
Saving Mothers' Lives. Reviewing maternal deaths to make motherhood safer: 2006-2008; Centre for Maternal and Child Enquiries (CMACE), BJOG, Mar 2011
Head CE, Thorne SA; Congenital heart disease in pregnancy. Postgrad Med J. 2005 May81(955):292-8.
Lupton M, Oteng-Ntim E, Ayida G, et al; Cardiac disease in pregnancy. Curr Opin Obstet Gynecol. 2002 Apr14(2):137-43.
Gei AF, Hankins GD; Cardiac disease and pregnancy. Obstet Gynecol Clin North Am. 2001 Sep28(3):465-512.
Sadler L, McCowan L, White H, et al; Pregnancy outcomes and cardiac complications in women with mechanical, bioprosthetic and homograft valves. BJOG. 2000 Feb107(2):245-53.
Hoimyr H, Christensen TD, Emmertsen K, et al; Surgical repair of coarctation of the aorta: up to 40 years of follow-up. Eur J Cardiothorac Surg. 2006 Dec30(6):910-6. Epub 2006 Oct 23.
Bowater SE, Thorne SA; Management of pregnancy in women with acquired and congenital heart disease. Postgrad Med J. 2010 Feb86(1012):100-5.
Vriend JW, Drenthen W, Pieper PG, et al; Outcome of pregnancy in patients after repair of aortic coarctation. Eur Heart J. 2005 Oct26(20):2173-8. Epub 2005 Jun 9.
Beauchesne LM, Connolly HM, Ammash NM, et al; Coarctation of the aorta: outcome of pregnancy. J Am Coll Cardiol. 2001 Nov 1538(6):1728-33.
Borghi A, Ciuffreda M, Quattrociocchi M, et al; The grown-up congenital cardiac patient. J Cardiovasc Med (Hagerstown). 2007 Jan8(1):78-82.
Colonna P, Manfrin M, Cecconi M, et al; Follow-up and physical activity in postoperative congenital heart disease. J Cardiovasc Med (Hagerstown). 2007 Jan8(1):83-7.
No authors listed; Grown-up congenital heart (GUCH) disease: current needs and provision of service for adolescents and adults with congenital heart disease in the UK. Heart. 2002 Sep88 Suppl 1:i1-14.