Chapter 31: Congenital Heart Disease in Adults

Introduction

General Considerations

Congenital cardiac anomalies are the most common birth defects in humans, affecting approximately 0.8 in 100 live births. While the incidence of congenital heart disease (CHD) is expected to decline as a consequence of improved prenatal diagnosis, the number of patients surviving with CHD, both in the United States and worldwide, has increased significantly over the past three decades. Over 85% of infants born with cardiovascular anomalies now can expect to reach adulthood. Reduced mortality rates can be attributed to improved diagnostic abilities, enhanced surgical and nonsurgical therapies, and improvements in intensive care. Once the province of pediatric cardiology, CHD is now largely an adult phenomenon. As of 2010, 66% of patients with CHD in North America are adults.

The increase in the number of adults with CHD requires that internists and adult cardiologists develop a more sophisticated knowledge of the anatomy and physiology of these defects. These patients fall into several broad categories: those surviving into adulthood without intervention and perhaps without clinical recognition, those surviving with curative surgical or nonsurgical intervention, and those surviving with palliative surgical or nonsurgical intervention. Nonsurgical interventions may include catheter-based valvuloplasty, stenting, coiling, or device occlusion. The patients who are today making the transition into the adult CHD population have hemodynamic and cardiac problems differing from those in previous eras. Surgical techniques have evolved, intervention occurs earlier and is often definitive rather than palliative, and a greater number of patients with complex single-ventricle physiology and various modifications of cavopulmonary anastomoses (Glenn shunt, Fontan procedure) will reach adulthood. Because of the unique clinical conditions and needs of these patients, the American College of Cardiology and the American Heart Association have recommended that all patients with moderate or complex CHD be evaluated at least once by a physician with specialized training and expertise in adult CHD. Furthermore, it is recommended that diagnostic and interventional cardiac catheterization and electrophysiologic and surgical procedures in these patients be performed in regional adult CHD centers.

Acyanotic Congenital Heart Disease

The most common acyanotic congenital heart defects include abnormalities of the heart valves and great vessels, ventricular or atrial communications with left-to-right shunting, and such lesions as partial anomalous pulmonary veins and anomalous coronary arteries.

Congenital Aortic Valvular Disease

General Considerations

Congenital aortic stenosis is the most common anomaly encountered in the adult population and constitutes approximately 7% ...