Intensive Care Unit Management of the Adult with Congenital Heart Disease

Abstract

Purpose Adults with congenital heart disease (ACHD) are a rapidly growing population with ever-increasing complexity, and intensive care unit (ICU) management is often necessary. This review summarizes common cardiovascular and noncardiovascular complications in ACHD and provides a framework for ICU care. Recent Findings Heart failure is the leading cause of hospitalization and mortality in ACHD. Varied anatomy and repairs, as well as differing physiological complications, limit generalized application of management algorithms. Recent studies suggest that earlier mechanical support in advanced cases is feasible and potentially helpful. Cardiac arrhythmias are poorly tolerated and often require immediate attention. Other complications requiring intensive care include infections such as endocarditis and COVID-19, pulmonary hypertension, renal failure, hepatic dysfunction, coagulopathy, and stroke. Summary Successful ICU care in ACHD requires a multidisciplinary approach with careful consideration of anatomy, physiology, and associated comorbidities. Few studies have formally examined ICU management in ACHD and further research is necessary.

Improved Surgical Outcomes in Adults with Congenital Heart Disease and Decompensated Heart Failure: The Role of Perioperative Medical Optimization

“…Other than that, the role of diuretics is not totally clear. In preoperative treatment, the use of diuretics can result in symptomatic improvement, optimization of fluid and electrolyte imbalance, blood volume, pre-load and afterload, BMI, and organ perfusion, which greatly affect cardiac surgery and postoperative intensive care [ 26 – 29 ].…”

Medical Therapy for Heart Failure in Adult Congenital Heart Disease Patients

“…Short-term therapies, such as the use of vasoactive agents like vasopressin, norepinephrine, and milrinone, to improve hemodynamics and reverse end-organ dysfunction can be given as long as the patient’s underlying anatomy, physiology, and surgical history are considered. 76 Therapies should be targeted toward treating precipitating factors, such as arrhythmia, infection, or ischemia, with evaluation for potential therapies like mechanical circulatory support and/or cardiac transplantation reserved for specific populations. Early referral for advanced therapies should be performed given the disproportionate increase in mortality or de-listing in ACHD patients.…”

Intensive care of adults with congenital heart disease

“…Finally, it is not surprising that CHD complexity predicted worse outcomes and that patients requiring MCS, therefore sicker patients, also faced increased in-hospital mortality. Unfortunately, MCS is generally less used in the ACHD population (8.7% in patients with ACHD vs 24.8% in patients without ACHD7) owing to more complicated anatomy, the presence of significant comorbidities and the overall lack of clinical experience in this patient population. On the other hand, increased adverse events with MCS in patients with ACHD have been recorded, particularly for long-term therapies, including greater rates of hepatic and renal dysfunction 7.…”

“…Unfortunately, MCS is generally less used in the ACHD population (8.7% in patients with ACHD vs 24.8% in patients without ACHD7) owing to more complicated anatomy, the presence of significant comorbidities and the overall lack of clinical experience in this patient population. On the other hand, increased adverse events with MCS in patients with ACHD have been recorded, particularly for long-term therapies, including greater rates of hepatic and renal dysfunction 7. Although these findings can be at least partially attributed to the sequelae of advanced CHD, this may suggest a sicker cohort in which the decision for support is delayed too long and which experiences poor outcomes.…”