The purpose of this paper was to present the results of a simple modification of the suture technique for pulmonary artery banding (PAB), which allows for stepwise debanding by use of balloon catheter.
During the period 1985-2007, PAB operations were performed in 227 children at Rikshospitalet. Of these children, 14.5% (n = 33) were treated by balloon dilatation of the PAB. Nine were treated twice. The intention of the procedure was total debanding in 17 and palliative treatment by stepwise dilatation of the PAB in 16 patients. Median follow up time was 59 months. The mean reduction of the gradient was more pronounced in the first group (37.0 ± 19.0 vs. 14.5 ± 10.3 mmHg, P
OBJECTIVE: The aim of the study was to evaluate the indications and outcomes of fetal echo (FE) and determine which indication has the highest detection rate for congenital heart disease (CHD). METHODS: The referral indications and results of FE performed in Iceland during 2003-2007 were reviewed. Information regarding gestational age at diagnosis, nuchal translucency, pregnancy outcome, autopsy results and postnatal diagnosis were obtained from medical records. RESULTS: During the five year period 1187 FE were performed. Structural heart defect was diagnosed in 73 fetuses. The most common referral indication was family history of CHD (631;53.2%) which led to diagnosis of 18 heart defects prenatally (2.9%). The second most common referral indication was increased nuchal translucency (159) and abnormal cardiac findings were present in 16 cases (10.1%). A total of 30 women were referred for FE because of abnormal four chamber view (AFCV) which resulted in the diagnosis of 22 (73.3%) major heart defects, either incompatible with life or requiring immediate intervention after birth. Other indications led mostly to the diagnoses of minor defects. CONCLUSIONS: AFCV is the most important predictor for diagnosis of structural heart defects. 2,5% were referred for FE due to AFCV which led to diagnosis of 30% of all heart defects, all of which were major. Key words: fetal echocardiography, indications, congenital heart disease.
To examine the evolving role of specialised outpatient services for adult patients with congenital heart disease.
A retrospective analysis of all patients attending the Toronto Congenital Cardiac Centre for Adults over three corresponding three month periods in 1987, 1992, and 1997.
A tertiary referral centre.
Patient demographics, residence, medical and surgical history, type and source of referral, and investigations performed.
In all, 570 patients were seen at the clinic during these three periods. There was a 44% and a 269% increase in workload between 1987 to 1992 and 1992 to 1997, respectively. There was a steady fall in mean age of patients seen at the clinic with time (38.5, 33.6, and 31.7 years in 1987, 1992, and 1997, respectively, p
Cites: Circulation. 1971 Aug;44(2):A205-195317856
Cites: Can J Cardiol. 1998 Mar;14(3):395-4529551034
Cites: Circulation. 1973 Mar;47(3):606-194266323
Cites: JAMA. 1983 Oct 21;250(15):2033-66620507
Cites: J Am Coll Cardiol. 1991 Aug;18(2):315-81856389
Cites: J Am Coll Cardiol. 1991 Aug;18(2):325-71856394
Cites: Circulation. 1991 Nov;84(5):1881-901934365
Cites: BMJ. 1991 Dec 7;303(6815):1413-41773141
Cites: Circulation. 1992 Aug;86(2):703-101638736
Cites: Circulation. 1994 Jun;89(6):2673-68205680
Cites: J Am Coll Cardiol. 1995 Jan;25(1):31-37798520
Cites: Can J Cardiol. 1996 Jun;12(6):600-28665423
Cites: Heart. 1996 Jul;76(1):60-28774329
Cites: Annu Rev Med. 1997;48:283-939046962
Cites: Heart. 1997 Jul;78(1):12-49290394
Cites: Heart. 1997 Jul;78(1):159290395
Cites: Am J Cardiol. 1997 Oct 1;80(7):906-139382007
Cites: Circulation. 1997 Nov 4;96(9):2789-949386139
More than 85% of children born today with chronic medical conditions will live to adulthood, and many should transfer from pediatric to adult health care. The numbers of adults with congenital heart defects (CHDs) are increasing rapidly. Current guidelines recommend that just over half of adult CHD patients should be seen every 12 to 24 months by a cardiologist with specific CHD expertise at a regional CHD center, because they are at risk for serious complications (eg, reoperation and/or arrhythmias) and premature mortality. The present study aimed to determine the percent of young adults with CHDs who successfully transferred from pediatric to adult care and examine correlates of successful transfer.
Cross-sectional study with prevalence data from an entire cohort.
All patients (n = 360) aged 19 to 21 years with complex CHDs who, according to current practice guidelines, should be seen annually at a specialized adult CHD center were identified from the database of the cardiology program at the Hospital for Sick Children in Toronto, Canada, a pediatric tertiary care center. Of these patients, 234 completed measures about health beliefs, health behaviors, and medical care since age 18 years.
All 15 specialized adult CHD centers in Canada formed the Canadian Adult Congenital Heart (CACH) Network. Attendance for at least 1 follow-up appointment at a CACH center before the age of 22 years was ascertained for all eligible patients. Attendance at a CACH center provides a clear criterion for successful transfer.
In the total cohort, 47% (95% confidence interval [CI]: 42-52) had transferred successfully to adult care. There was no difference in rates of successful transfer between patients consenting to complete questionnaires (48%) and those who declined (47%). More than one quarter (27%) of the patients reported having had no cardiac appointments since 18 years. In multivariate analyses of the entire cohort, successful transfer was significantly associated with more pediatric cardiovascular surgeries (odds ratio [OR]: 2.47; 95% CI: 1.40-4.37), older age at last visit to the Hospital for Sick Children (OR: 1.29; 95% CI: 1.10-1.51), and documented recommendations in the medical chart for follow-up at a CACH center. In multivariate analyses of the patients completing questionnaires, successful transfer was significantly related to documented recommendations and patient beliefs that adult CHD care should be at a CACH center (OR: 3.64; 95% CI: 1.34-9.90). Comorbid conditions (OR: 3.13; 95% CI: 1.13-8.67), not using substances (eg, binge drinking; OR: 0.18; 95% CI: 0.07-0.50), using dental antibiotic prophylaxis (OR: 4.23; 95% CI: 1.48-12.06), and attending cardiac appointments without parents or siblings (OR: 6.59; 95% CI: 1.61-27.00) also correlated with successful transfer.
This is the first study to document the percent of young adults with a chronic illness who successfully transfer to adult care in a timely manner. Patients were from an entire birth cohort from the largest pediatric cardiac center in Canada, and outcome data were obtained on all eligible patients. Similar data should be obtained for other chronic illnesses. There is need for considerable improvement in the numbers of young adults with CHDs who successfully transfer to adult care. At-risk adolescents with CHDs should begin the transition process before their teens, should be educated in the importance of antibiotic prophylaxis, should be contacted if a follow-up appointment is missed, and should be directed to a specific CHD cardiologist or program, with the planned timing being stated explicitly. Adult care needs to be discussed in the pediatric setting, and patients must acquire appropriate beliefs about adult care well before transfer. Developmentally appropriate, staged discussions involving the patient, with and without parents, throughout adolescence may help patients acquire these beliefs and an understanding of the need for ongoing care. Improved continuity of pediatric care and provision of clear details for adult follow-up might be sufficient to cause substantive improvements in successful transfer. An understanding of why patients drop out of pediatric care may be needed to improve the continuity of care throughout adolescence. Almost one quarter of the patients believed adult care should be somewhere other than at a CACH center despite opposite recommendations. For these patients, a single discussion of adult care during the final pediatric visit may be too little, too late. In addition to earlier discussions, multiple mechanisms such as referral letters and transition clinics are needed. Similarly, patients engaging in multiple risky or poor health behaviors such as substance use may need more intensive programs to make substantial changes in these behaviors, which hopefully would lead to successful transfer. Overall, these data support the view that transition to adult care (a planned process of discussing and preparing for transfer to an adult health center) is important and should begin well before patients are transferred. The future health of adults with chronic conditions may depend on our ability to make these changes.
To establish a process of referral for young adult patients with congenital heart disease from pediatric to adult centres.
Directors of pediatric cardiology units across Canada were asked to complete a questionnaire detailing their process of referral of young adult patients with congenital heart disease to adult centres. They were also asked to respond to specific case scenarios. Adult cardiologist members of the Canadian Adult Congenital Heart Network were asked to respond to the same case scenarios.
Most pediatric cardiology centres refer patients to adult cardiologists at 18 years of age. The process of referral generally involves a referral letter and relevant parts of the chart. Few centres arrange a booked appointment with the adult cardiologist, although this would be preferred by the majority of the responding adult cardiologists. Generally good agreement existed between pediatric and adult cardiologists with regard to the kind of patients who required specialized care at an adult congenital heart centre.
Within Canada, a process is rapidly evolving to facilitate the transfer of care of young adults with congenital heart disease.
A sample of 1377 physicians were surveyed by mailed questionnaire to study to what extent primary care physicians are involved in the long-term care of children with chronic disorders. The sample included all pediatricians practicing in the province of Quebec and a stratified random sample of general practitioners (10% sample in urban areas and 25% sample in rural areas). A response rate of 81% was achieved. Referral patterns were studied for asthma, congenital heart disease, and diabetes. Although pediatricians referred their patients less frequently than general practitioners, referral patterns depended mainly on the clinical condition. "No routine referral" was the most popular management strategy for asthma, whereas for congenital heart disease and diabetes more than 20% of physicians referred their patients for all aspects of care. Rural physicians tended to assume patient care to a greater extent than did urban physicians. Most pediatricians referred patients directly to subspecialists practicing in tertiary care centers, whereas general practitioners often sent patients to pediatricians practicing elsewhere, or to other specialists. These data suggest that the availability of medical resources in the community and accessibility to tertiary care centers also influence physicians' involvement in the long-term care of these children.
To identify risk factors for loss to cardiology follow-up among children and young adults with congenital heart disease.
We used a matched case-control design. Cases were born before January, 2001 with moderate or complex congenital heart disease and were previously followed up in the paediatric or adult cardiology clinic, but not seen for 3 years or longer. Controls had been seen within 3 years. Controls were matched 3:1 to cases by year of birth and congenital heart disease lesion. Medical records were reviewed for potential risk factors for loss to follow-up. A subset of cases and controls participated in recorded telephone interviews.
A total of 74 cases (66% male) were compared with 222 controls (61% male). A history of missed cardiology appointments was predictive of loss to follow-up for 3 years or longer (odds ratio 13.0, 95% confidence interval 3.3-51.7). Variables protective from loss to follow-up were higher family income (odds ratio 0.87 per $10,000 increase, 0.77-0.98), cardiac catheterisation within 5 years (odds ratio 0.2, 95% confidence interval 0.1-0.6), and chart documentation of the need for cardiology follow-up (odds ratio 0.4, 95% confidence interval 0.2-0.8). Cases lacked awareness of the importance of follow-up and identified primary care physicians as their primary source of information about the heart, rather than cardiologists. Unlike cases, controls had methods to remember appointments.
A history of one or more missed cardiology appointments predicted loss to follow-up for 3 or more years, as did lack of awareness of the need for follow-up. Higher family income, recent catheterisations, and medical record documentation of the need for follow-up were protective.