Small atrial septal defects are associated with psychiatric diagnoses, emotional distress, and lower educational levels.

OBJECTIVE: For the first time, we wish to assess the psychiatric burden in adult patients living with small, unrepaired atrial septal defects (ASD) using register-based data, combined with self-reported measures on levels emotional distress and educational status. DESIGN: A descriptive study using both the unique Danish registries and validated psychiatric questionnaires and scales, including: The Symptom Checklist, Whiteley-7, and Brief Illness Perception Questionnaire. PATIENTS: Adult patients with small, unrepaired ASD, diagnosed between 1953 and 2011. OUTCOME MEASURES: Number of register-based psychiatric diagnoses. Additionally, symptoms of anxiety, depression, somatization, health anxiety, illness perception, and levels of educational attainment compared to age- and gender-matched individuals from the reference group. RESULTS: We identified 723 Danish patients with a small, unrepaired ASD. Approximately 17% of the patients eligible for inclusion had one or more psychiatric diagnoses. The most common diagnoses were neurotic, stress-related, and somatoform disorders. A total of 140 patients (mean age 33 years) was included for examination of their mental health using psychiatric questionnaires and scales. Patients with small ASD had higher scores of depression and anxiety when compared to the reference group (0.57 ± 0.67 vs 0.39 ± 0.52; P < .001). Furthermore, patients reported more symptoms of somatization (0.51 ± 0.48 vs 0.34 ± 0.39; P < .001). Finally, a higher percentage of patients with an unrepaired ASD had no education beyond high school when compared to the reference group (33.3% vs 14.3%; P < .001) and a smaller proportion of patients had completed a short-cycle higher education (6.5% vs 16.1%; P = .002). CONCLUSION: Patients with a small, unrepaired ASD in adult life have more symptoms of anxiety, depression, and somatization compared to the reference group. Furthermore, fewer patients had no education beyond high school. These results support the guidelines that adults with small ASD warrants regular lifelong follow-up in specialized clinics aware of not only adverse somatic outcome but also rates of depression and anxiety.

Regional variation in quality of life in patients with a Fontan circulation: A multinational perspective.

BACKGROUND: Impaired quality of life (QOL) is associated with congenital heart disease (CHD) and country of residence; however, few studies have compared QOL in patients with differing complexities of CHD across regional populations. The current study examined regional variation in QOL outcomes in a large multinational sample of patients with a Fontan relative to patients with atrial septal defects (ASDs) and ventricular septal defects (VSDs). METHODS: From the Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease-International Study (APPROACH-IS), 405 patients (163 Fontan and 242 ASD/VSD) across Asia, Europe, and North America provided consent for access to their medical records and completed a survey evaluating QOL (0 to 100 linear analog scale). Primary CHD diagnosis, disease complexity, surgical history, and documented history of mood and anxiety disorders were recorded. Differences in QOL, medical complications, and mood and anxiety disorders between Fontan and ASD/VSD patients, and across geographic regions, were examined using analysis of covariance. Hierarchical regression analyses were conducted to identify variables associated with the QOL ratings. RESULTS: Patients with a Fontan reported significantly lower QOL, and greater medical complications and mood and anxiety disorders relative to patients with ASD/VSD. Inpatient cardiac admissions, mood disorders, and anxiety disorders were associated with lower QOL among patients with a Fontan, and mood disorders were associated with lower QOL among patients with ASD/VSD. Regional differences for QOL were not observed in patients with a Fontan; however, significant differences were identified in patients with ASD/VSD. CONCLUSIONS: Regional variation of QOL is commonplace in adults with CHD; however, it appears affected by greater disease burden. Among patients with a Fontan, regional variation of QOL is lost. Specific attempts to screen for QOL and mood and anxiety disorders among CHD patients may improve the care of patients with the greatest disease burden.

Neurodevelopmental outcome after surgery for acyanotic congenital heart disease.

BACKGROUND: Inconsistent results on neuropsychological outcome in patients treated for acyanotic congenital heart disease (aCHD) questioned the clinical relevance of possible neurobehavioral sequelae in this group. This study was designed to objectify the neuropsychological profile and evaluate associations with medical data. METHODS: Patients with a corrected atrial or ventricular septal defect, ASD-II or VSD, (n=46; mean age 9 years, 2 months) and a matched control group were submitted to an intelligence test (Wechsler Intelligence Scale for Children, third edition, Dutch version) and evaluated with a neuropsychological test battery (Developmental Neuropsychological Assessment, second edition, Dutch version). Hospitalization variables were retrieved to evaluate associations with cognitive outcome. Parents completed a behavioral checklist (Achenbach Child Behavior Checklist for Children aged 6-18). RESULTS: ASD-II patients showed lower scores in domains of visuospatial processing, language, attention, and social perception. VSD patients displayed subtle problems in attention and visuospatial information processing. Only few perioperative medical factors, but also socioeconomic variables were associated with cognitive outcomes. Parents of ASD-II patients reported more school problems when compared to controls. CONCLUSIONS: After treatment for aCHD, subtle cognitive difficulties can present in domains of visuospatial information processing, language, attention, and social perception. These shortcomings might hamper school performances, as is suggested by lower school competence ratings. Ongoing follow-up and cognitive screening is warranted to promote developmental progress, in which both parents and clinicians share responsibility.

Neurodevelopment and behavior after transcatheter versus surgical closure of secundum type atrial septal defect.

OBJECTIVE: To assess the neuropsychological and behavioral profiles of school-aged children treated for atrial septal defect, secundum type (ASD-II) with open-heart surgery or catheterization. STUDY DESIGN: Patients (n = 48; mean age, 9 years, 3 months) and a matched healthy group (mean age, 9 years, 2 months) were evaluated with a shortened intelligence scale (Wechsler Intelligence Scale for Children, third edition, Dutch version) and a developmental neuropsychological test battery (Developmental Neuropsychological Assessment, second edition, Dutch version). Parents completed behavioral checklists (Achenbach Child Behavior Checklist for Children aged 6-18). Hospitalization variables were retrieved from medical files for studying associations with long-term neurodevelopment. RESULTS: Compared with the healthy matched controls, patients treated for ASD-II had significantly lower scores on subtasks underlying such Developmental Neuropsychological Assessment, second edition, Dutch version domains as Attention and Executive Functioning, Language, Working Memory, Sensorimotor Functioning, Social Cognition, and Visuospatial Information Processing. Only subtle differences, mainly in Visuospatial Information Processing, were found between the surgical repair and transcatheter repair groups. Socioeconomic status, longer hospital stay, and larger defect size were associated with neurocognitive outcome measures. Parents of patients reported more thought problems, posttraumatic stress problems, and lower school performance compared with parents of healthy peers. CONCLUSION: After treatment for ASD-II, children display a range of neuropsychologic difficulties that may increase their risk for learning problems and academic underachievement. Differences related to treatment were not found. Our results suggest that neurodevelopmental and behavioral follow-up at school age is warranted in this group.

Quality of life of patients with atrial septal defect following percutaneous closure.

INTRODUCTION: Quality of life has become an important outcome measure in addition to mortality and morbidity in patients with congenital heart disease. Atrial septal defect is a common congenital heart disease, and transcatheter atrial septal defect closure has become an accepted treatment modality. The aim of this study is to assess the quality of life of patients with atrial septal defect who underwent percutaneous closure. MATERIALS AND METHODS: We examined the quality of life of 69 patients with atrial septal defect and 69 healthy controls matched according to age, sex, educational level, and economic, marital, and employment status. Quality of life was investigated using the Turkish version of Short Form-36. RESULTS: The mean age of the patients was 39.7 ± 14.2 and 26% were male. The quality of life assessment was performed at a mean follow-up time of 18.0 ± 13.8 months after the intervention. The mean scores of the domains of the Short Form-36, namely, physical functioning, role functioning, social functioning, mental health, vitality, pain, and general health, were similar in patients with atrial septal defect who underwent percutaneous closure and the control group. CONCLUSION: Adult patients who underwent percutaneous atrial septal defect closure perceive their quality of life to be as good as their healthy counterparts.

[Informed consent in congenital defect heart surgery].

In pediatric cardiac surgery, informed consent is often obtained from the patient's parents. The parents are commonly under great stress due to being in a situation where they have to make the important decision of whether their child will undergo cardiac surgery. Cardiac surgery does not necessarily determine the patient's prognosis if he or she has other organ anomalies or systemic diseases. In such cases, communication among the cardiac surgeon, pediatrician, and family becomes even more crucial. In pediatric cardiac surgery, it is important to obtain informed consent with adequate explanations, an understanding of the parents' stressful situation, and knowledge of the patient's background. In this article, we introduce two examples of obtaining informed consent for two common pediatric cardiac operations, atrial septal defect closure and ventricular septal defect closure.

Atrial septal defect closure in the elderly is associated with excellent quality of life, functional improvement, and ventricular remodelling.

BACKGROUND: While atrial septal defect (ASD) closure is known to improve morbidity and mortality in children and adults, data are only beginning to emerge about its role in elderly cohorts. The goals of this study were to compare outcomes after device or surgical closure of ASDs in the elderly, and to quantitatively assess quality of life. METHODS: Patients>60 years old who underwent ASD repair were studied. Functional status, arrhythmia burden, biventricular size and function were compared before and after ASD closure. Quality of life after ASD closure was assessed with the RAND SF-36 instrument. RESULTS: Sixty-seven patients, mean age of 68 years (range 60-86 years), were followed for 3.3 years. Nineteen percent underwent surgical closure and 81% underwent device closure. Major complication rates were 23% and 7% respectively with no procedure- related deaths. After surgical and device closure, quality of life was comparable to age-matched healthy controls, right ventricular end-diastolic dimension decreased by 10 mm (P<0.001), left ventricular end-diastolic dimension increased by 4 mm (P=0.001), biventricular function improved (right ventricular, P<0.001; left ventricular, P=0.007) and New York Heart Association class improved (P<0.001). Prevalence of atrial arrhythmias however, was unchanged. Beneficial effects were similar for patients treated surgically or with device closure. CONCLUSIONS: Given the favorable structural, functional, and quality of life outcomes after ASD closure in the elderly, advanced age alone should not be a contraindication to recommending surgical or device closure of an ASD.

Quality of life in patients undergoing totally thoracoscopic closure for atrial septal defect.

BACKGROUND: Quality of life in patients undergoing totally thoracoscopic closure of atrial septal defect is unclear. METHODS: Thoracoscopic atrial septal defect repair was performed in 96 patients (37 males, aged 19.4 ± 8.7 years) without the aid of a computerized robotic surgical system. An additional 56 patients (23 males, aged 21.0 ± 16.1 years) undergoing conventional atrial septal defect closure through sternotomy were enrolled as a control group. Quality of life was assessed with the Medical Outcomes Study Short Form Survey on day 60 after surgery. RESULTS: Atrial septal defect closure was successful in all patients. There was no perioperative mortality or reoperation for bleeding. Total duration of operations (98 ± 11 versus 128 ± 21 minutes, p < 0.01) and hospital stays (5.3 ± 1.7 versus 6.9 ± 2.1 days, p = 0.024) were shorter in the study group than in the control group, respectively. At discharge, patients with moderate to severe incisional pain in the study and control groups was 11.6% and 62.5%, respectively (p = 0.008). The time interval between discharge and returning to school or work in the study group was shorter than in the control group (28 ± 4 versus 42 ± 7 days, p = 0.003). The mean scores of eight variables in the Short Form Survey, such as physical function, bodily pain, social function, and general or mental health in the study group were higher than in the control group (p < 0.05 or p < 0.01). CONCLUSIONS: Compared with conventional sternotomy, totally thoracoscopic atrial septal defect closure was associated with a faster recovery of physical function and a better quality of life.

Renal replacement therapy for children: a family decision.

Although Anne had many complex health issues and experienced considerable support from her extended family, she wanted freedom from the restrictions posed by peritoneal dialysis. Her quality of life changed after transplantation, with more opportunities to engage in leisure activities, ability to travel, a less restricted diet, and an improved self-image. She required fewer treatments, surgeries, and hospitalizations. She left behind the role of sick child and took up a role more like a healthy child. During the disease and decision-making process, Anne learned coping mechanisms, allowing her to gain autonomy to make decisions. The case study illustrates both the need to listen to children as well as to care for the entire family. The nursing management of this child and her family was continually changing, and multiple strategies were used to support the family. The nurse came to understand the roles of family members in constant change, the sources of their resources, and foci of tensions. Based on this knowledge, the nurse can act by mobilizing resources, strengthening the confidence of family members, and helping them develop coping mechanisms. In conclusion, care of the ill child must be family-centered. Stresses on the family have an impact on the child and vice versa. The potential to influence the quality of life of both the child and the family is considerable.

Psychological functioning and health-related quality of life (HRQoL) in older patients following percutaneous closure of the secundum atrial septal defect (ASD).

To characterize quality of life and psychological well-being in the new growing population of older patients who underwent trans-catheter closure of the secundum ASD. Twenty-seven patients, aged 60 years and older, who underwent trans-catheter ASD closure and 27 age and gender matched controls answered the hospital anxiety and depression scale and the cardiac-specific module of the health-related quality of life (HRQoL) questionnaire. Pre- and post-ASD closure pulmonary artery pressure (Pap), and the New York Heart Association (NYHA) functional capacity class were recorded from medical records. Almost 77% improvement in Pap and 57% improvement in functional status were found. More than 70% reported low/mild depressive symptoms and 59% reported low/mild anxiety in both groups. Almost 78% of ASD patients and 89% of controls reported high/very high levels of HRQoL. Significantly better QoL was reported by the controls. Lower post-ASD closure Pap scores were associated with better QoL, but were not significantly related to levels of depression and anxiety scores. Preoccupation with the ASD closure was related to higher pre-closure Pap scores, worse QoL, and higher depressive and anxiety symptoms. Following ASD closure, depression and anxiety symptoms were in the low range, and HRQoL scores for most patients were in the high range.

Comparison of incisions and outcomes for closure of ventricular septal defects.

BACKGROUND: Repair of ventricular septal defects (VSD) through a shorter right lateral thoracotomy has evolved for 10 years. However, outcomes of this surgery and patients' health-related quality of life have not been evaluated so far. METHODS: Four hundred eighty-eight patients aged 6 to 15 years who had undergone repair of VSD through a right thoracotomy were surveyed (right group) and 185 patients of the same age were surveyed who had undergone the repair through a median sternotomy (median group). Cardiopulmonary bypass, aortic cross-clamping and mechanical ventilation time, amount of drainage, postoperative hospital stay, and in-hospital mortality and morbidity were measured as short-term outcomes. Symptoms, physical signs, ultrasonic cardiogram, chest film, and electrocardiogram were followed up as long-term outcomes; and the patients' TNO-AZL Children's Quality of Life (TACQOL) were studied to evaluate their health-related quality of life. The TNO-AZL Children's Quality of Life (TACQOL) questionnaire is a 56-item child quality of life questionnaire designed by the TNO Institute of Prevention and Health and the Leiden University Hospital (TNO-AZL). RESULTS: Compared with the median group, the right group's short- and long-term outcomes were more satisfactory, with less drainage (106.71 +/- 85.20 mL versus 146.70 +/- 75.63 mL) and no pigeon chest (0 versus 3). The right group's TACQOL were higher than that of the median group in physical complaints (29.58 +/- 2.8 versus 28.07 +/- 2.95), motor functioning (31.23 +/- 1.09 versus 30.53 +/- 1.60), and cognitive functioning (29.93 +/- 3.22 versus 26.87 +/- 4.24). CONCLUSIONS: Repair of VSD through a right thoracotomy can provide more satisfactory outcomes and better health-related quality of life.

Thoracoscopic ASD closure is a reliable supplement for percutaneous treatment.

OBJECTIVE: To determine the feasibility and effectiveness of endoscopic atrial septal defect (ASD) closure when percutaneous ASD closure is impossible or has failed. PATIENTS: Between March 1997 and February 2003, 74 patients (63% female, mean (SD) age 44 (16) years) underwent an endoscopic ASD closure. Median preoperative New York Heart Association functional class was I. Clinical and echocardiographic follow up was obtained for all patients (mean (SD) 38 (19) months). Patients were assessed for scar aesthetics, procedure related pain, functional recovery, and overall patient satisfaction. RESULTS: ASD closure was successful in all patients (two primum ASD, 68 secundum ASD, four sinus venosus type). Patch repair was performed in 42%. Mean aortic cross clamp and cardiopulmonary bypass times were 54 (24) minutes and 98 (35) minutes, respectively. There were no in-hospital deaths and no conversions to sternotomy. Complications included one iliac vein stenting, one femoral arterioplasty, two revisions for suspected bleeding, and seven cases of atrial fibrillation. Two patients required late reoperation: one for atrial thrombus and another for tricuspid regurgitation. Echocardiographic control confirmed complete ASD closure in 71 patients and a small residual shunt in three patients. Ninety three per cent of the patients were highly satisfied with very low procedure related pain and 97% felt they had an aesthetically pleasing scar. CONCLUSION: Endoscopic ASD closure can be safely done with a high degree of patient satisfaction. It is now the authors' exclusive surgical approach whenever percutaneous treatment is not indicated or has failed.

Social role quality, physical health, and psychological well-being in women after heart surgery.

Women's social role quality may be an important factor in their adaptation after heart surgery. Relationships among different dimensions of role quality, physical health, and psychological well-being were examined in 157 midlife and older women who had undergone heart surgery. Overall, older women (n = 89) were similar to younger women (n=68) in physical recovery from heart surgery. Poorer health outcomes were associated with number of health problems, not age. Women with more health problems and lower subjective health perceptions had lower role quality. Multiple regression analyses indicated that, in general, role quality mediated the effects of physical health on psychological well-being. Regardless of the extent of physical health problems, women with higher role quality had higher levels of psychological well-being.

[Self-estimation of the quality of life in adult patients after surgical correction of atrial septal defect type II (ASD II)]. / Samoocena jakosci zycia doroslych po chirurgicznej korekcji ubytku w przegrodzie miedzyprzedsionkowej typu II (ASD II).

Health estimation was performed in 134 patients (where 67% were women), aged 17-70, mean 42 years, 2-3 years after surgical correction of atrial septal defect type II (ASD II). The study consists of clinical examination and self-estimation of the quality of life with help of a mall questionnaire, with return ratio of 90%. The improvement of health status was declared by 80% of patients, where 23% stated considerable improvement. While 15% did not confirm any significant changes and 5% noticed worsening quality of life status (mainly connected with postoperative pain). The physical condition improved similarly, with range of tolerable physical effort doubled. The frequency of dyspnea, chest pain and palpitation decreased from 72%, 67% and 87% to 47%, 43% and 47%, respectively, as well as their intensity. More over, the frequency of anxiety decreased from 70% to 62% with reduction of its intensity. Both, before and after surgery, the environmental estimation and self-estimation was very good (77% versus 78%, 78% versus 89%) respectively, and predominant were optimistic attitudes. Post-operative improvement of the quality of life correlating to the clinical state, confirms the suitableness of surgical correction of ASD II, independent of age.

Developmental outcome after surgical versus interventional closure of secundum atrial septal defect in children.

BACKGROUND: The assessment of the impact of cardiopulmonary bypass (CPB) on developmental outcomes in children who undergo open heart surgery is hampered by the absence of a suitable comparison group. The development of interventional catheterization techniques for the repair of certain types of congenital heart lesions provides the opportunity to study children who have not been exposed to CPB. METHODS AND RESULTS: We performed standardized neuropsychological testing on children after closure of a secundum atrial septal defect through the use of surgery (n=26) or a transcatheter device (n=19). Device patients, compared with surgical patients, were similar in age at defect closure (mean, 6 years) but older at follow-up testing (12.3 versus 10.6 years). The mean weight percentile at closure was greater and the defect size was smaller in the device patients. Families of device patients tended to have a higher parent IQ, higher level of maternal education, and higher level of maternal occupation. In general, however, children's IQ and achievement scores were in the normal range for both groups. In regression analyses with adjustment for age at testing and parent IQ, surgical repair was associated with a 9.5-point deficit in Full-Scale IQ (P=0. 03) and a 9.7-point deficit in Performance IQ (P=0.05). Block Design was the IQ subtest on which treatment groups differed the most (P=0. 01). Surgical patients achieved significantly better scores on errors of commission (P=0.05) and attentiveness index (P=0.03) on a continuous performance test of attention. Scores on tests of achievement and other neuropsychological domains did not differ significantly between the groups. Regression analyses within the surgical group failed to identify significant CPB-related risk factors. CONCLUSIONS: A prospective randomized trial or a study that includes prerepair and postrepair assessments is necessary to establish whether the observed advantages of device closure in neuropsychological outcome represent deleterious effects of CPB or a methodological artifact.

The effect of changing attitudes to Down's syndrome in the management of complete atrioventricular septal defects.

OBJECTIVES: To describe the evaluation, decision making, and care of children with a complete atrioventricular septal defect (CAVSD). STUDY DESIGN: Retrospective study of 136 consecutive cases from 1970 to 1996. RESULTS: A total of 115 (85%) children had Down's syndrome. Denial of surgery without obvious medical reasons was more common in the early years, as was parental refusal of offered surgery and institutional care of the children. Improved results in later years encouraged surgical treatment for all these patients, but more liberal attitudes towards patients with Down's syndrome preceded the improved results. The use of echocardiography as a screening method for all newborns with Down's syndrome made it possible to plan for correction within the 1st months of life. CONCLUSIONS: Changing attitudes in society and widespread use of echocardiography have significantly improved the management of children with a CAVSD and Down's syndrome.

Prevalence of panic disorder in mitral valve prolapse: a comparative study with a cardiac control group.

This study investigated the relationship between mitral valve prolapse (MVP) and panic disorder (PD), by comparing the prevalence of PD in 33 patients with MVP and 27 patients with haemodynamically insignificant atrial septal defect or patent ductus arteriosus. MVP was diagnosed using standard echocardiographic criteria and the presence of mental disorder was assessed blindly with the help of the Schedule for Affective Disorders and Schizophrenia. DSM-III criteria were used to diagnose PD. The two groups did not differ in age and sex; 12.1% of MVP patients and 3.7% of cardiac controls had PD (NS). Although the prevalence of PD in our sample of MVP patients was considerably higher than the prevalence of PD in the general population, this need not necessarily indicate a causal relationship between MVP and PD and may be due to studying a hospital-based sample. The absence of any significant difference in prevalence of PD between MVP patients and a carefully selected cardiac control group drawn from the same setting argues against any special relationship between PD and MVP.