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A new heart at CHD

Thanks to innovative diagnostic and therapeutic methods, more and more people with congenital heart disease (CHD) are reaching an age at which they are more likely to develop advanced heart failure. However, it is difficult to decide when to have a heart transplant in these patients.
Often the cause of heart failure in patients with CHD is multifactorial. Diagnoses such as the presence of a systemic right ventricle, congenital corrected transposition, and other forms of univentricular heart are particularly prone to developing late ventricular dysfunction.
When a transplant comes in patients with CHD, the criteria are similar to those for candidates without CHD. A main indication criterion is symptomatic ventricular or biventricular dysfunction, which despite maximum medical therapy leads to several hospital stays due to heart failure or low cardiac output. Absolute contraindications are e.g. B. pulmonary vascular resistance> 5 wood units, cancer, chronic infections, addiction, and psychiatric or behavioral problems.
Most importantly, it is important for the transplant surgeon to understand the specific needs of patients with CHD. Planning should include a thorough review of the patient's surgical history and current anatomy in order to anticipate any additional interventions that may be required. Details about the systemic venous connections, pulmonary arteries, the distal aortic arch, the aortopulmonary collateral load, the patency of the femoral vessels and the presence of intracardial devices such as stents or occluders must be carefully examined. This is particularly important in Fontan's patients with univentricular circulation. The surgeon must be able to foresee the mediastinal dissection and the need for additional reconstruction that may be required prior to implantation of a structurally normal donor heart, while attempting to minimize ischemic time.
Perioperative mortality and morbidity are higher in transplant patients with CHD than in other recipients. This is probably due to the complexity of the implant reconstruction, the higher incidence of right ventricular dysfunction due to the increased pulmonary vascular resistance, more frequent bleeding and a lower systemic vascular resistance in the presence of a comorbid liver disease. OH
Source: Fynn-Thompson F: Heart transplantation in adults with congenital heart disease. Methodist Debakey Cardiovasc J 2019; 15 (2): 145-8