In what sense can ACHD be compared with a Tsunami
Transcript of In what sense can ACHD be compared with a Tsunami
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In what sense can ACHD be compared with a Tsunami ?
1- Fast increase in number of patients (waves)
2- Inability to cope with speed of the wave
3- ACHD patients get no timely help
= fast increase in morbidity & mortality
4- Also for ACHD there are warning signs and
systems
ACHDsafety
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Definition of ACHD
Patients with Congenital Heart Disease (CHD)
12 -14 - 18 yrs of age 18 yrs of age
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Incidence of Congenital Heart Disease
- 8/1000 live born
If left untreated
- 20-25% die during infancy
- 60% die during first years of life
- Only 15% survive into adulthood
General Remarks
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Natural & un-natural History of CHD
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Atrial SeptalDefect (ASD)
• Secundum ASD 70%• Primum 15%• Sinus Venosus 10%• Coronary Sinus (rare)
7 % (20%)Most common CHD in Adults
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Survival curve of Untreated ASD Patients vsGeneral Population
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25 %
dead before their 30's
75 %
dead by the age of 50 yrs
90 %
dead by the age of 60 yrs
Natural History of ASD
Campbell M. Natural history of atrial septal defect.
Br Heart J 1970;32: 820-6.
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Daniels, CJ. Congenital Heart Disease. ACCSAP V
Survival Following CHD Surgery
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Coarctation of Aorta: MRI
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Coarctation of Aorta: Surgery
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100
50
75
0 20
25
10
Survival after surgery by age at operation
years
Kirklin & Barratt Boyes
5 15 25
<1
1-20
20-40
>40
Aortic Coarctation
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Survival After Coarctation Repair
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Patients with uncorrected TOF
10% reach 3rd decade
3% reach 4th decade
Natural History
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Tetralogy: Palliation
In adults
- Surgery
If anatomy does not allow
complete repair
- Stent of MAPCA
- Stent of BT shunts
- BAP of RVOTO
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Natural History
Complete repair
Palliation
Natural History
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Survival Following Complete Repair
of Tetralogy of Fallot
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Only PDA Surgical ligation
deserves the term
“total correction“
otherwise there is
no total correction or
complete repair
PDA Surgical Ligation
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Perloff
“ There is no operation for CHD that is
corrective in the strictest sense, if, by
corrective, we mean that all sufferers are
restored to complete normality by operation.
The hard truth is …particularly sad..for those
who have undergone supposedly
corrective surgery”.
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Residua after Surgery
Residua
- Conditions that are ‘left-over,’ i.e. that are obligatory to or
consequences of the pre-operative diagnosis and state.
- They are not the result of surgery
Examples
- Systemic right ventricle in congenitally corrected
transposition
- Unrepaired anomalous coronary artery in tetralogy of
Fallot
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Sequelae after surgery
Sequelae
as a result
Examples
- Ventricular
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How to explain the increase
in ACHD patients ?
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Lawrence H. Cohn Circulation. 2003;107:2168-2170
Gibbon Heart-lung Machine
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Transportation
Interventions
Imaging
Imaging
Cardiac Surgery
Intensive Care
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- All this improved longevity
- Population
last 20 years
Adult Congenital Heart
Disease
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Adults outgrown Children with CHD
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1,300,000 –
–
–
1,000,000 –
–
–
700,000 –
–
500,000 –
–
300,000 –
–
100,000 –
0 –
1970 1980 1990 2000 2010
Adult
CHD
Patients
In USA
Patients Reaching Adulthood with CHD
325,000
500,000
750,000
1,000,000
1,300,000
Hoffman 1978 Kaiser
Fyler 1980 New England
Ferencz 1985 Baltimore-DC
Courtesy Michael Landzberg
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Gilboa S et al. Circulation 2016; 134:101
USA
Magnitude ACHD in 320 million
2.4 million: 1 million children; 1.5 million adults
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In most developing countries no clear
estimates of CHD patients
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World ACHD population
Webb G et al. Int J Cardiol 2015;195: 326
Our best estimates indicate that worldwide,
adults comprise 22 – 26 %
of the total CHD population
Relative proportion of adults within the
CHD population are 20% in Taiwan and
32 % in Thailand
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World ACHD population
Webb G et al. Int J Cardiol 2015;195: 326
Applying a prevalence
range of 1.7 to 4.1 / 1.000 adults
to a world population of 7.2 billion
= estimated worldwide12 to 34 million ACHD
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Bibliometric approach for
better estimating actual
situation of ACDH worldwide
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Abstract
To collect information on worldwide distribution
& volume of (ACHD) centers:
Centers assessed using bibliometric approach
Meeting the challenge: The evolving global landscape of
adult congenital heart disease
International journal of cardiology 168(6) · July 2013
Kempny A et al.
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Abstract
Between 1995 and 2011
identified
94,119 ACHD publications
International journal of cardiology 168(6) · July 2013
Kempny A et al.
Meeting the challenge: The evolving global landscape of
adult congenital heart disease
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Abstract
Steady increase in number of
publishing ACHD centers worldwide
Meeting the challenge: The evolving global landscape of
adult congenital heart disease
International journal of cardiology 168(6) · July 2013
Kempny A et al.
Results
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Abstract
Number of ACHD centers
per 10-million population
Europe (3.6)
North America (1.7)
Oceania (1.5)
South America (0.4)
Asia (0.3)
Africa (0.1)
Meeting the challenge: The evolving global landscape of
adult congenital heart disease
International journal of cardiology 168(6) · July 2013
Kempny A et al.
Results
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Webb G et al.
International Journal of Cardiology 195 ·
May 2015
The Care of Adults with Congenital Heart Disease Across
the Globe: Current Assessment and Future Perspective
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Possible explanations for
differences between developed
and developing countries in
regard to ACHD
Apart from the obvious
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1.Due to consanguinos marriage
2.Easiness of abortion
3.Yearly birth rate
Expected difference between
developed and developing countries
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Birth Rate - World
http://www.indexmundi.com/map/?v=25
Average annual no births /year/1.000 persons
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http://www.indexmundi.com/map/?v=31
Total Fertility Rate - World
Birth / woman
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Total Fertility Rate
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Total Fertility Rate
<
>
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Population Pyramid USA
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Population Pyramid Saudi Arabia
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Population Pyramid in comparison USA / Saudi Arabia
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What is 2020 of ACHA
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Begun as initiative of ACHA in Dec
2008, the goal of is to ensure that
every CHD survivor be able to receive
life long Adult Congenital Cardiac care
What is the ?
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Vision 2020 is: to make ACHD an
established, recognized field that will
deliver quality care to adults with CHD
throughout the USA
What is the ?
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www.achaheart.org.advocacy.Vision_2020.php
On turning 18, every complex CHD will
have access to life-long ACHD care which is:
High-Quality
Age-appropriate
Research- Based
Coordinated and integrated
Available in all regions
U T O P I A for many?
What does ACHA hope to achieve?
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“The data don’t
predict a tsunami
with absolute
certainty. I still
say we wait !!”
already 2016
ACHD -
GUCH
Most of the World acts like this
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Why it remains a problem ?role of patient organisations;
a cardiologists’ view
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Why There is Shortage of ACHD Specialists?
- Few cardiologists start their training with the idea of becoming a ACHD (GUCH) doctor
- ACHD is not a profitable subspecialty for the dept
- Often an academic career = less income for the Dr.
- No steering from Government/Health department
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The Problem: Shortage of ACHD Specialists
- Not
- Not
Dept Pediatric Cardiology
-It is a problem for patients!
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European Solution
The Problem is Bigger than just Cardiologists
- Who is going to take care of that?
The Patient:
Patient organisations
In Poorer Countries ?
The Doctor is defender of patient’s rights
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Adult Cardiologist very important
Adult Cardiologist has a very important role in the
management of Adults with Congenital Heart Disease
because
of high prevalence of ACHD and lack of enough centers
dealing with these patients
and because nobody else cares
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What is the real problem
[only?] in our area ?
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Adult Cardiologist do not want to
engage in this new specialty
They only want to close ASDs
Experience from two failed ACHD Centers
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They Need to Learn New Vocabulary
Atrial septal defect
Aortic Coarctation
Fontan, Mustard, Senning, Ross etc.
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Surgical Terminology in Adult Congenital Heart Disease
Congenital Heart Disease. ACCSAP V
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Understandable Reaction ?
Adult Cardiologist
ACHD
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Examples for Problems between
Pediatric Cardiologists and Adult
Cardiologists
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Case Presentation 1/2
21 years old lady, 117 kg, comes in a wheel chair to clinic
History: Primum ASD closed surgically at the age of 18 years
Following Problems:
Adipositas per Magna
Wheel chair bound
Atrial flutter
Systemic hypertension
Insulin dependent Diabetes mellitus
Treating Physician: Pediatric Cardiologist
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Solutions ?
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Who should we warn about
the ACHD Tsunami ?
All of us
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Causes of Tsunami ?
In our case?
Man made as we are
not patient centered
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ACHD - GUCH
We see the Problem but
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We continue doing this
Adult Cardiologist
ACHD
Adult CardioPediatr Cardio Administration Politicians
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Short-Term (to solve patients problems)
- Pediatric Cardiologist should treat ACHD
- Consult Adult Cardiologists for help
(BP, Arrhythmias, Diabetes etc.)
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Mid-Term Solutions
Encourage Fellows Pediatric Cardiologist
and/or Adult Cardiologist to specialize in ACHD
Address issues of ACHD with
Health care giver
MOH / Hospital Administrators etc.
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Long-Term Solutions
Obtain better Data to understand
the magnitude of the problem
Registries are needed to at least first establish
prevalence of CHD in most countries
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