Adult congenital heart disease, Anaesthesia & Intensive Care Medicine

90% of children born with congenital heart disease survive to adulthood (previously up to 80% died in childhood). This article proposes a classification of adult congenital heart disease (ACHD) based on complexity of lesion as follows.

Simple ACHD are those cardiac lesions that confer no functional limitation. It includes patients who have undergone curative surgery. Some examples are isolated aortic valve disease, mild pulmonary stenosis or repaired ASD/VSD.

Moderate complexity ACHD is disease that may pose some day-to-day limitations. It includes patients who have undergone surgery likely to require re-operation. Some examples are TAPVD and Tetralogy of Fallot.

Severe complexity lesions confer significant functional limitation. Patients may have had palliative surgery or be deemed not amenable to intervention. Some examples are all types of cyanotic heart disease, Eisenmenger syndrome and pulmonary hypertension.

The paper identifies specific concerns in patients with ACHD, including arrhythmias (the most common cause of hospital admission in this patient group), heart failure, the need for antibiotic prophylaxis to reduce the risk of infective endocarditis, psychological impact and pregnancy.

Specific considerations for patients with ACHD having non-cardiac surgery are explored. These include careful titration of anaesthetic agents to mitigate their myocardial depressant effect, additional monitoring, management of bleeding and thromboprophylaxis, balancing the use of regional anaesthesia for post-operative pain relief with the risk of a decrease in systemic vascular resistance and consideration of post-operative HDU or ICU admission for ongoing monitoring.

Reviewed by Dr Maryann Turner