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Circulation

AHA/ACC GUIDELINE

2018 AHA/ACC Guideline for the Management


of Adults With Congenital Heart Disease
A Report of the American College of Cardiology/American Heart
Association Task Force on Clinical Practice Guidelines

WRITING COMMITTEE MEMBERS* Developed in Collaboration With


Karen K. Stout, MD, FACC, Chair† the American Association for Tho-
Curt J. Daniels, MD, Vice Chair*†‡ racic Surgery, American Society of
Jamil A. Aboulhosn, MD, FACC, FSCAI*§ Echocardiography, Heart Rhythm
Society, International Society for
Biykem Bozkurt, MD, PhD, FACC, FAHA‖
Adult Congenital Heart Disease,
Craig S. Broberg, MD, FACC*† Society for Cardiovascular Angi-
Jack M. Colman, MD, FACC† ography and Interventions, and
Stephen R. Crumb, DNP, AACC† Society of Thoracic Surgeons
Joseph A. Dearani, MD, FACC¶
ACC/AHA Task Force Members,
Stephanie Fuller, MD, MS, FACC# see page e772
Michelle Gurvitz, MD, FACC**
Paul Khairy, MD, PhD*†
Michael J. Landzberg, MD, FACC*†
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Arwa Saidi, MB, BCH, FACC*†


Anne Marie Valente, MD, FACC, FAHA, FASE††
George F. Van Hare, MD, FACC‡‡

*Writing committee members are required to recuse themselves from voting on sections to which their specific rela-
tionships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Key Words:  AHA Scientific Statements
Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions ◼ arrhythmias ◼ cardiac catheterization
Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Represen- ◼ cardiac defects ◼ congenital heart
tative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures disease ◼ congenital heart surgery
Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. ◼ unoperated/repaired heart defect
The American Heart Association requests that this document be cited as follows: Stout KK, Daniels CJ, Aboulhosn © 2018 by the American Heart
JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Association, Inc., and the American
Valente AM, Van Hare GF. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: a College of Cardiology Foundation.
report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Circulation. 2019;139:e698–e800. doi: 10.1161/CIR.0000000000000603 https://www.ahajournals.org/journal/circ

e698 April 2, 2019 Circulation. 2019;139:e698–e800. DOI: 10.1161/CIR.0000000000000603


Stout et al 2018 ACHD Guideline

TABLE OF CONTENTS 4.2. Left-Sided Obstructive Lesions . . . . . . . . . . . . . e736

CLINICAL STATEMENTS
4.2.1. Cor Triatriatum . . . . . . . . . . . . . . . . . . . . e736
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e700

AND GUIDELINES
4.2.2. Congenital Mitral Stenosis . . . . . . . . . . . e736
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e701 4.2.3. Subaortic Stenosis . . . . . . . . . . . . . . . . . e737
1.1. Methodology and Evidence Review . . . . . . . . . . e701 4.2.4. Congenital Valvular Aortic Stenosis . . . . e738
1.2. Organization of the Writing Committee . . . . . . e702 4.2.4.1.  Turner Syndrome . . . . . . . . . . . e739
1.3. Document Review and Approval . . . . . . . . . . . . e703 4.2.4.2. Aortopathies . . . . . . . . . . . . . . e739
1.4. Scope of the Guideline . . . . . . . . . . . . . . . . . . . e703 4.2.5. Supravalvular Aortic Stenosis . . . . . . . . . e740
1.5. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . e705 4.2.6. Coarctation of the Aorta . . . . . . . . . . . . e741
2. Background and Pathophysiology . . . . . . . . . . . . . . . e705 4.3. Right-Sided Lesions . . . . . . . . . . . . . . . . . . . . . . e743
2.1. Anatomic and Physiological Terms . . . . . . . . . . e705 4.3.1. Valvular Pulmonary Stenosis . . . . . . . . . . e743
2.2. Severity of ACHD . . . . . . . . . . . . . . . . . . . . . . . e705 4.3.1.1. Isolated PR After Repair of PS . . e745
2.3. The ACHD Anatomic and Physiological 4.3.2. Branch and Peripheral Pulmonary
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . e705 Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . e745
3. General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . e709 4.3.3. Double-Chambered Right Ventricle . . . . e746
3.1. ACHD Program . . . . . . . . . . . . . . . . . . . . . . . . . e709 4.3.4. Ebstein Anomaly . . . . . . . . . . . . . . . . . . e747
3.2. Access to Care . . . . . . . . . . . . . . . . . . . . . . . . . e709 4.3.5. Tetralogy of Fallot . . . . . . . . . . . . . . . . . . e749
3.3. Delivery of Care . . . . . . . . . . . . . . . . . . . . . . . . e710 4.3.6. Right Ventricle to Pulmonary
3.4. Evaluation of Suspected and Known CHD . . . . . e710 Artery Conduit . . . . . . . . . . . . . . . . . . . . e752
3.4.1. Electrocardiogram . . . . . . . . . . . . . . . . . e713 4.4. Complex Lesions . . . . . . . . . . . . . . . . . . . . . . . . e754
3.4.2. Ionizing Radiation Principles . . . . . . . . . . e713 4.4.1. Transposition of the Great Arteries . . . . . e754
3.4.3. Echocardiography . . . . . . . . . . . . . . . . . e713 4.4.1.1. Transposition of the Great
3.4.4. CMR Imaging . . . . . . . . . . . . . . . . . . . . . e714 Arteries With Atrial Switch������� e754
3.4.5. Cardiac Computed Tomography . . . . . . . e714 4.4.1.2. Transposition of the Great
3.4.6. Cardiac Catheterization . . . . . . . . . . . . . e715 Arteries With Arterial Switch ������e756
3.4.7. Exercise Testing . . . . . . . . . . . . . . . . . . . e715 4.4.1.3. Transposition of the Great
3.5. Transition Education . . . . . . . . . . . . . . . . . . . . . e716 Arteries With Rastelli Type
3.6. Exercise and Sports . . . . . . . . . . . . . . . . . . . . . . e716 Repair ������������������������������������� e758
3.7. Mental Health and Neurodevelopmental 4.4.1.4. Congenitally Corrected
Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e717 Transposition of the Great
3.8. Endocarditis Prevention . . . . . . . . . . . . . . . . . . e717 Arteries ����������������������������������� e758
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3.9. Concomitant Syndromes . . . . . . . . . . . . . . . . . e717 4.4.2. Fontan Palliation of Single Ventricle


3.10. Acquired Cardiovascular Disease . . . . . . . . . . . . e718 Physiology (Including Tricuspid Atresia
3.11. Noncardiac Medical Issues . . . . . . . . . . . . . . . . e719 and Double Inlet Left Ventricle) . . . . . . . e759
3.12. Noncardiac Surgery . . . . . . . . . . . . . . . . . . . . . e719 4.4.3. Hypoplastic Left Heart
3.13. Pregnancy, Reproduction, and Sexual Syndrome/Norwood Repair . . . . . . . . . . e763
Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e720 4.4.4. Truncus Arteriosus . . . . . . . . . . . . . . . . . e763
3.13.1. Pregnancy . . . . . . . . . . . . . . . . . . . . . . e720 4.4.5. Double Outlet Right Ventricle . . . . . . . . . e763
3.13.2. Contraception . . . . . . . . . . . . . . . . . . . e722 4.4.6. Severe PAH and Eisenmenger
3.13.3. Infertility Treatment . . . . . . . . . . . . . . . e722 Syndrome . . . . . . . . . . . . . . . . . . . . . . . e763
3.13.4. Sexual Function . . . . . . . . . . . . . . . . . . e722 4.4.6.1. Severe PAH . . . . . . . . . . . . . . . . e763
3.14. Heart Failure and Transplant . . . . . . . . . . . . . . . e723 4.4.6.2.  Eisenmenger Syndrome . . . . . . e765
3.14.1. Heart Failure . . . . . . . . . . . . . . . . . . . . e723 4.4.7. Coronary Anomalies . . . . . . . . . . . . . . . . e767
3.14.2. Heart Transplant . . . . . . . . . . . . . . . . . e723 4.4.7.1. Anomalous Coronary Artery
3.14.3. Multiorgan Transplant . . . . . . . . . . . . . e723 Evaluation ������������������������������� e768
3.15. Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . e724 4.4.7.2. Anomalous Aortic Origin
3.16. Cyanosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e724 of Coronary Artery������������������� e769
3.17. Pharmacological Therapy for ACHD . . . . . . . . . e725 4.4.7.3. Anomalous Coronary Artery
4. Specific Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e726 Arising From the PA����������������� e769
4.1. Shunt Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . e726 4.4.8. Coronary Artery Fistula . . . . . . . . . . . . . . e770
4.1.1. Atrial Septal Defect . . . . . . . . . . . . . . . . e726 5. Evidence Gaps and Future Directions . . . . . . . . . . . . e772
4.1.2. Anomalous Pulmonary Venous References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e773
Connections . . . . . . . . . . . . . . . . . . . . . . e729 Appendix 1 Author Relationships With Industry
4.1.3. Ventricular Septal Defect . . . . . . . . . . . . e730 and Other Entities (Relevant)��������������������� e796
4.1.4. Atrioventricular Septal Defect . . . . . . . . . e732 Appendix 2 Reviewer Relationships With Industry
4.1.5. Patent Ductus Arteriosus . . . . . . . . . . . . e734 and Other Entities (Comprehensive)����������� e798

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Stout et al 2018 ACHD Guideline

PREAMBLE when appropriate, flow diagrams or additional tables.


CLINICAL STATEMENTS

References are provided at the end of the document


AND GUIDELINES

Since 1980, the American College of Cardiology (ACC)


in their respective sections. Additionally, this format
and American Heart Association (AHA) have translat-
will facilitate seamless updating of guidelines with fo-
ed scientific evidence into clinical practice guidelines
cused updates as new evidence is published, as well as
(guidelines) with recommendations to improve cardio-
content tagging for rapid electronic retrieval of related
vascular health. These guidelines, which are based on
recommendations on a topic of interest. This evolved
systematic methods to evaluate and classify evidence,
approach format was instituted when this guideline
provide a cornerstone for quality cardiovascular care.
was near completion; therefore, the present document
The ACC and AHA sponsor the development and pub-
represents a transitional format that best suits the text
lication of guidelines without commercial support, and
as written. Future guidelines will fully implement this
members of each organization volunteer their time to
format, including provisions for limiting the amount of
the writing and review efforts. Guidelines are official
text in a guideline.
policy of the ACC and AHA.
Recognizing the importance of cost–value consid-
erations in certain guidelines, when appropriate and
Intended Use feasible, an analysis of the value of a drug, device, or
Practice guidelines provide recommendations applica- intervention may be performed in accordance with the
ble to patients with or at risk of developing cardiovas- ACC/AHA methodology.P-3
cular disease. The focus is on medical practice in the To ensure that guideline recommendations remain
United States, but guidelines developed in collabora- current, new data are reviewed on an ongoing basis,
tion with other organizations can have a global impact. with full guideline revisions commissioned in approx-
Although guidelines may be used to inform regulatory imately 6-year cycles. Publication of new, potentially
or payer decisions, they are intended to improve pa- practice-changing study results that are relevant to an
tients’ quality of care and align with patients’ interests. existing or new drug, device, or management strategy
Guidelines are intended to define practices meeting the will prompt evaluation by the Task Force, in consul-
needs of patients in most, but not all, circumstances tation with the relevant guideline writing committee,
and should not replace clinical judgment. to determine whether a focused update should be
commissioned. For additional information and policies
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regarding guideline development, we encourage read-


Clinical Implementation ers to consult the ACC/AHA guideline methodology
Management in accordance with guideline recommenda- manualP-4 and other methodology articles.P-5–P-8
tions is effective only when followed by both practitioners
and patients. Adherence to recommendations can be Selection of Writing Committee Members
enhanced by shared decision-making between clinicians
and patients, with patient engagement in selecting in- The Task Force strives to avoid bias by selecting experts
terventions on the basis of individual values, preferences, from a broad array of backgrounds. Writing commit-
and associated conditions and comorbidities. tee members represent different geographic regions,
sexes, ethnicities, races, intellectual perspectives/biases,
and scopes of clinical practice. The Task Force may also
Methodology and Modernization invite organizations and professional societies with re-
The ACC/AHA Task Force on Clinical Practice Guidelines lated interests and expertise to participate as partners,
(Task Force) continuously reviews, updates, and modi- collaborators, or endorsers.
fies guideline methodology on the basis of published
standards from organizations, including the Institute of
Relationships With Industry
Medicine,P-1, P-2 and on the basis of internal reevaluation.
Similarly, the presentation and delivery of guidelines are and Other Entities
reevaluated and modified on the basis of evolving tech- The ACC and AHA have rigorous policies and meth-
nologies and other factors to facilitate optimal dissemi- ods to ensure that guidelines are developed without
nation of information to healthcare professionals at the bias or improper influence. The complete relationships
point of care. with industry and other entities (RWI) policy can be
Toward this goal, this guideline continues the intro- found online. Appendix 1 of the present document
duction of an evolved format of presenting guideline lists writing committee members’ relevant RWI. For the
recommendations and associated text called the “mod- purposes of full transparency, writing committee mem-
ular knowledge chunk format.” Each modular “chunk” bers’ comprehensive disclosure information is available
includes a table of related recommendations, a brief online. Comprehensive disclosure information for the
synopsis, recommendation-specific supportive text, and Task Force is also available online.

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Stout et al 2018 ACHD Guideline

Evidence Review and Evidence 1. INTRODUCTION

CLINICAL STATEMENTS
Review Committees

AND GUIDELINES
1.1. Methodology and Evidence Review
In developing recommendations, the writing commit-
The recommendations listed in this guideline are,
tee uses evidence-based methodologies that are based
whenever possible, evidence-based. An initial exten-
on all available data.P-4–P-7 Literature searches focus on
sive evidence review, which included literature de-
randomized controlled trials (RCTs) but also include
rived from research involving human subjects, pub-
registries, nonrandomized comparative and descriptive
lished in English, and indexed in MEDLINE (through
studies, case series, cohort studies, systematic reviews,
PubMed), EMBASE, the Cochrane Library, the Agency
and expert opinion. Only key references are cited.
for Healthcare Research and Quality, and other select-
An independent evidence review committee (ERC)
ed databases relevant to this guideline, was conduct-
is commissioned when there are 1 or more questions
ed from April 2014 to November 2014. Key search
deemed of utmost clinical importance that merit formal
words included but were not limited to the follow-
systematic review. The systematic review will determine
ing: adult congenital heart disease, anesthesia, aortic
which patients are most likely to benefit from a drug,
aneurysm, aortic stenosis, atrial septal defect, arterial
device, or treatment strategy and to what degree. Cri-
teria for commissioning an ERC and formal systematic switch operation, bradycardia, bicuspid aortic valve,
review include: a) the absence of a current authoritative cardiac catheterization, cardiac imaging, cardiovas-
systematic review, b) the feasibility of defining the ben- cular magnetic resonance, cardiac reoperation, car-
efit and risk in a time frame consistent with the writing diovascular surgery, chest x-ray, cirrhosis, coarctation
of a guideline, c) the relevance to a substantial number of the aorta, congenital heart defects, congenitally
of patients, and d) the likelihood that the findings can corrected transposition of the great arteries, con-
be translated into actionable recommendations. ERC traception, coronary artery abnormalities, cyanotic
members may include methodologists, epidemiologists, congenital heart disease, dextro-transposition of the
healthcare providers, and biostatisticians. The recom- great arteries, double inlet left ventricle, Ebstein a-
mendations developed by the writing committee on the nomaly, echocardiography, Eisenmenger syndrome,
basis of the systematic review are marked with “SR.” electrocardiogram, endocarditis, exercise test, Fon-
tan, heart catheterization, heart defect, heart failure,
infertility, l-transposition of the great arteries, medical
Guideline-Directed Management
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therapy, myocardial infarction, noncardiac surgery,


and Therapy patent ductus arteriosus, perioperative care, physical
The term guideline-directed management and therapy activity, postoperative complications, pregnancy, pre-
(GDMT) encompasses clinical evaluation, diagnostic operative assessment, psychosocial, pulmonary arte-
testing, and pharmacological and procedural treat- rial hypertension, hypoplastic left heart syndrome,
ments. For these and all recommended drug treat- pulmonary regurgitation, pulmonary stenosis, pul-
ment regimens, the reader should confirm the dosage monary valve replacement, right heart obstruction,
by reviewing product insert material and evaluate the right ventricle to pulmonary artery conduit, single
treatment regimen for contraindications and interac- ventricle, supravalvular pulmonary stenosis, surgical
tions. The recommendations are limited to drugs, de- therapy, tachyarrhythmia, tachycardia, tetralogy of
vices, and treatments approved for clinical use in the Fallot, transplantation, tricuspid atresia, Turner syn-
United States. drome, and ventricular septal defect. Additional rele-
vant studies published through January 2018, during
the guideline writing process, were also considered
Class of Recommendation and Level by the writing committee, and added to the evidence
of Evidence tables when appropriate. The final evidence tables,
The Class of Recommendation (COR) indicates the included in the Online Data Supplement, summarize
strength of the recommendation, encompassing the es- the evidence used by the writing committee to for-
timated magnitude and certainty of benefit in propor- mulate recommendations. References selected and
tion to risk. The Level of Evidence (LOE) rates the quality published in this document are representative and
of scientific evidence that supports the intervention on not all-inclusive.
the basis of the type, quantity, and consistency of data As noted in the preamble, an independent ERC was
from clinical trials and other sources (Table 1).P-4–P-6 commissioned to perform a formal systematic review
Glenn N. Levine, MD, FACC, FAHA of critical clinical questions related to adult congen-
Chair, ACC/AHA Task Force on Clinical Practice ital heart disease (ACHD), the results of which were
Guidelines considered by the writing committee for incorporation

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Stout et al 2018 ACHD Guideline

Table 1.  Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient
CLINICAL STATEMENTS

Care* (Updated August 2015)


AND GUIDELINES
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into this guideline. Concurrent with this process, writ- A Systematic Review (Part 2) for the 2018 AHA/ACC
ing committee members evaluated study data relevant Guideline for the Management of Adults With Con-
to the rest of the guideline. The findings of the ERC genital Heart Disease”S1.1-2 are published in conjunction
and the writing committee members were formally with this guideline.
presented and discussed, and then recommendations
were developed. The systematic review reports on
“Medical Therapy for Systemic Right Ventricles: A Sys-
1.2. Organization of the Writing
tematic Review (Part 1) for the 2018 AHA/ACC Guide- Committee
line for the Management of Adults With Congenital The writing committee consisted of pediatric and adult
Heart Disease”S1.1-1 and “Interventional Therapy Versus congenital cardiologists, interventional cardiologists,
Medical Therapy for Secundum Atrial Septal Defect: electrophysiologists, surgeons, and an advance prac-

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Stout et al 2018 ACHD Guideline

tice nurse. The writing committee included represent- The prevalence of ACHD is growing because of

CLINICAL STATEMENTS
atives from the ACC, AHA, and American Association the success of pediatric cardiology and congenital

AND GUIDELINES
for Thoracic Surgery (AATS), American Society of Ech- cardiac surgery in diagnosing and treating congen-
ocardiography (ASE), Heart Rhythm Society (HRS), In- ital heart defects in children. Improved survival to
ternational Society for Adult Congenital Heart Disease adulthood is most striking for those with the most
(ISACHD), Society for Cardiovascular Angiography and severe disease, with survival to age 18 years now ex-
Interventions (SCAI), and the Society of Thoracic Sur- pected for 90% of children diagnosed with severe
geons (STS). CHD.S1.4-3–S1.4-5 Patients with ACHD are a heteroge-
neous population, both in underlying anatomy and
physiology, as well as surgical repair or palliation.
1.3. Document Review and Approval Consequently, although the prevalence of ACHD is in-
This document was reviewed by 3 official reviewers creasing, the population of patients with a given con-
each nominated by the ACC and AHA, and 1 to 2 genital abnormality or specific repair may be relatively
reviewers each from the AATS, ASE, HRS, ISACHD, small.S1.4-3,S1.4-6–S1.4-8
SCAI, STS; and 32 individual content reviewers. Re- Patients with CHD are not cured of their disease
viewers’ RWI information was distributed to the writ- after successful treatment in childhood. Almost all
ing committee and is published in this document patients with ACHD will have sequelae of either
(Appendix 2). their native CHD or its surgical repair or palliation,
This document was approved for publication although these sequelae can take decades to man-
by the governing bodies of the ACC and the AHA ifest. The heterogeneity of the population and the
and endorsed by the AATS, ASE, HRS, ISACHD, SCAI, long, symptom-free intervals constrain the ability to
and STS. generate data applicable across the population of
ACHD or to adults with specific lesions or repairs.
Despite the difficulty in studying ACHD populations,
1.4. Scope of the Guideline there is a growing body of high-quality data in these
The 2018 ACHD guideline is a full revision of the patients to guide the care of this relatively “new”
“2008 ACC/AHA Guidelines for the Management of population and, whenever feasible, these data were
Adults with Congenital Heart Disease,”S1.4-1 which was used to develop recommendations. Recommenda-
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the first US guideline to be published on the topic. tions are made based on the available data; however,
This revision uses the 2008 ACHD guideline as a when important clinical issues lacked data, first prin-
framework and incorporates new data and growing ciples, extrapolation from data in other populations,
ACHD expertise to develop recommendations. Con- and expert consensus are used to guide care. Patients
genital heart disease (CHD) encompasses a range with ACHD may have concomitant disease to which
of structural cardiac abnormalities present before other existing guidelines apply, such as coronary ar-
birth attributable to abnormal fetal cardiac develop- tery disease, HF, and arrhythmias. The data from ac-
ment but does not include inherited disorders that quired heart disease populations may apply to some
may have cardiac manifestations such as Marfan syn- patients with ACHD, and those circumstances are
drome or hypertrophic cardiomyopathy. Also not in- acknowledged in these recommendations and refer-
cluded are anatomic variants such as patent foramen enced accordingly.
ovale. Valvular heart disease (VHD) may be congen- Patients with ACHD who are cared for in ACHD cen-
ital, so management overlaps with the “2014 AHA/ ters have better outcomes than those cared for in cen-
ACC Guidelines for the Management of Patients With ters without ACHD expertise,S1.4-9 and this need for spe-
Valvular Heart Disease,”S1.4-2 particularly for bicuspid cialized care is noted throughout the guideline. These
aortic valve (BAV) disease. Where overlap exists, this recommendations are intended to provide guidance
document focuses on the diagnosis and treatment of to a wide variety of providers caring for patients with
congenital valve disease when it differs from acquired ACHD, including general, pediatric, and ACHD cardiol-
valve disease, whether because of anatomic differ- ogists, as well as surgeons, primary care providers, and
ences, presence of concomitant lesions, or differences other healthcare providers.
to consider given the relatively young age of patients In developing the 2018 ACHD guideline, the writing
with ACHD. This guideline is not intended to apply to committee reviewed previously published guidelines
children (<18 years of age) with CHD or adults with and related scientific statements. Table 2 contains a list
acquired VHD, heart failure (HF), or other cardiovas- of publications and scientific statements deemed per-
cular diseases. tinent to this writing effort; it is intended for use as a

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Stout et al 2018 ACHD Guideline

Table 2.  Associated Guidelines and Statements


CLINICAL STATEMENTS

Publication Year
AND GUIDELINES

Title Organization (Reference)


Guidelines
 Syncope ACC/AHA/HRS 2017S1.4-10
  Supraventricular tachycardia ACC/AHA/HRS 2015S1.4-11
  Cardiopulmonary resuscitation and emergency cardiovascular care—Part 8: post–cardiac arrest care AHA 2015S1.4-12
  Non–ST-elevation acute coronary syndromes AHA/ACC 2014S1.4-13
  Perioperative cardiovascular evaluation and noncardiac surgery ACC/AHA 2014S1.4-14
  Atrial fibrillation AHA/ACC/HRS 2014S1.4-15
  Stable ischemic heart disease ACC/AHA/ACP/AATS/PCNA/SCAI/STS 2014,S1.4-16 2012S1.4-17
  Assessment of cardiovascular risk ACC/AHA 2014S1.4-18
  Blood cholesterol to reduce atherosclerotic cardiovascular risk in adults ACC/AHA 2014S1.4-19
  Overweight and obesity in adults AHA/ACC/TOS 2014S1.4-20
  Lifestyle management to reduce cardiovascular risk AHA/ACC 2014S1.4-21
  Valvular heart disease AHA/ACC 2017S1.4-22
  High blood pressure in adults ACC/AHA/AAPA/ABC/ACPM/AGS/ 2017S1.4-23
APhA/ASH/ASPC/NMA/PCNA
  Aortic valve and ascending aorta STS 2013S1.4-24
  ST-elevation myocardial infarction ACC/AHA 2013S1.4-25
  Heart failure ACC/AHA/HFSA 2017S1.4-26
  Device-based therapy for cardiac rhythm abnormalities ACC/AHA/HRS 2012S1.4-27
  Coronary artery bypass graft surgery ACC/AHA 2011S1.4-28
  Percutaneous coronary intervention ACC/AHA/SCAI 2011S1.4-29
  Secondary prevention and risk reduction therapy AHA/ACC 2011S1.4-30
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  Cardiovascular disease in women AHA/ACC 2011S1.4-31


  Grown-up congenital heart disease ESC 2010S1.4-32
  Thoracic aortic disease ACC/AHA/AATS/ACR/ASA/SCA/ 2010S1.4-33
SCAI/SIR/STS/SVM
  Adult congenital heart disease CCS 2010S1.4-34
  Infective endocarditis ESC 2009S1.4-35
Scientific statements
  Imaging for patients with transposition of the great arteries ASE 2016S1.4-36
  Cardiac chamber quantification by echocardiography ASE 2015S1.4-37
  Consensus on arrhythmia management in ACHD PACES/HRS 2014S1.4-38
  Imaging for patients with repaired tetralogy of Fallot ASE 2014S1.4-39
  Thoracic aortic disease CCS 2014S1.4-40
  Promotion of physical activity for children and adults with CHD AHA 2013S1.4-41
  Neurodevelopmental outcomes in children with CHD AHA 2012S1.4-42
  Pregnancy in women with heart disease ESC 2011S1.4-43
  Transition to adulthood for adolescents with CHD AHA 2011S1.4-44
  Pulmonary hypertension ACC/AHA 2009S1.4-45
  Prevention of infective endocarditis AHA 2007S1.4-46

AATS indicates American Association for Thoracic Surgery; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACHD, adult
congenital heart disease; ACP, American College of Physicians; ACPM, American College of Preventive Medicine; ACR, American College of Radiology; AGS,
American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASA, American Stroke Association; ASE, American
Society of Echocardiography; ASH, American Society of Hypertension; ASPC, American Society of Preventive Cardiology; CCS, Canadian Cardiovascular Society;
CHD, congenital heart disease; ESC, European Society of Cardiology; HFSA, Heart Failure Society of America; HRS, Heart Rhythm Society; NMA, National Medical
Association; PACES, Pediatric and Congenital Electrophysiology Society; PCNA, Preventive Cardiovascular Nurses Association; SCA, Society of Cardiovascular
Anesthesiologists; SCAI, Society for Cardiovascular Angiography and Interventions; SIR, Society of Interventional Radiology; STS, Society of Thoracic Surgeons;
SVM, Society for Vascular Medicine; and TOS, The Obesity Society.

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Stout et al 2018 ACHD Guideline

resource and does not repeat existing guideline recom- Abbreviation Meaning/Phrase

CLINICAL STATEMENTS
mendations.

AND GUIDELINES
TTE transthoracic echocardiography

VHD valvular heart disease


1.5. Abbreviations VSD ventricular septal defect

Abbreviation Meaning/Phrase VT ventricular tachycardia

3D 3-dimensional

AAOCA anomalous aortic origin of the coronary artery

ACHD adult congenital heart disease 2. BACKGROUND AND


AP anatomic and physiological PATHOPHYSIOLOGY
AR aortic regurgitation 2.1. Anatomic and Physiological Terms
ASD atrial septal defect
The International Society for Nomenclature of Pediatric
AVSD atrioventricular septal defect and Congenital Heart Disease (also known as the No-
BAV bicuspid aortic valve menclature Working Group) defined, codified, mapped,
CCT cardiac computed tomography and archived examples of nomenclatures and devel-
CCTGA congenitally corrected transposition of the great
oped standards for terminology.S2.1-1–S2.1-5 The Interna-
arteries tional Paediatric and Congenital Cardiac Code (IPCCC)
CHD congenital heart disease
nomenclature for anatomic lesions and repairs is used
in this guideline (http://ipccc.net).S2.1-6
CMR cardiovascular magnetic resonance

CoA coarctation of the aorta

CPET cardiopulmonary exercise test 2.2. Severity of ACHD


CT computed tomography In a patient with CHD, severity of disease is deter-
CTA computed tomography angiography mined by native anatomy, surgical repair, and current
physiology. Prior documents, including the 2008 ACHD
d-TGA dextro-transposition of the great arteries
guideline,S2.2-1 relied primarily on anatomic classifica-
ECG electrocardiogram
tions to rank severity of disease. However, patients with
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ERC evidence review committee the same underlying anatomy may have very different
GDMT guideline-directed management and therapy repairs and experienced variable physiological conse-
HF heart failure quences of those repairs. For example, a patient with
ICD implantable cardioverter-defibrillator
tetralogy of Fallot (TOF) after a valve-sparing primary re-
pair may have excellent biventricular function with nor-
IE infective endocarditis
mal exercise capacity and no arrhythmias, whereas an-
LV left ventricular
other patient of the same age with TOF may have had
LVOT left ventricular outflow tract palliative shunting followed by a transannular patch
PA pulmonary artery repair resulting in severe pulmonary regurgitation (PR)
PAH pulmonary arterial hypertension with right ventricular (RV) enlargement, biventricular
dysfunction, and ventricular tachycardia (VT). To cate-
PDA patent ductus arteriosus
gorize disease severity in CHD in a more comprehensive
PR pulmonary regurgitation
way, the writing committee developed an ACHD Ana-
PS pulmonary stenosis tomic and Physiological (AP) classification system (Ta-
QoL quality of life bles 3 and 4) that incorporates the previously described
Qp:Qs pulmonary–systemic blood flow ratio CHD anatomic variables as well as physiological vari-
RCT randomized controlled trial
ables, many of which have prognostic value in patients
with ACHD.
RV right ventricular

RVOT right ventricular outflow tract

SCD sudden cardiac death 2.3. The ACHD AP Classification


SubAS subaortic stenosis The ACHD AP classification (Tables 3 and 4), newly elab-
TEE transesophageal echocardiography orated in this guideline, is intended to capture the com-
plexity of ACHD anatomy and physiology, which are
TGA transposition of the great arteries
not always correlated. Certain anatomic abnormalities
TOF tetralogy of Fallot
of clinical importance are shared across diagnoses (eg,
TR tricuspid regurgitation aortic enlargement), which may be found in patients
(Continued ) with BAV, coarctation of the aorta (CoA), transposition

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Stout et al 2018 ACHD Guideline

Table 3.  Physiological Variables as Used in ACHD AP Classification


CLINICAL STATEMENTS

Variable Description
AND GUIDELINES

Aortopathy Aortic enlargement is common in some types of CHD and after some repairs. Aortic enlargement may be progressive over a lifetime.
There is no universally accepted threshold for repair, nor is the role of indexing to body size clearly defined in adults, as is done in
pediatric populations. For purposes of categorization and timing of follow-up imagingS2.2-2–S2.2-4:
  Mild aortic enlargement is defined as maximum diameter 3.5–3.9 cm
  Moderate aortic enlargement is defined as maximum diameter 4.0–4.9 cm

  Severe aortic enlargement is defined as maximum diameter ≥5.0 cm


Arrhythmia Arrhythmias are very common in patients with ACHD and may be both the cause and consequence of deteriorating hemodynamics,
valvular dysfunction, or ventricular dysfunction. Arrhythmias are associated with symptoms, outcomes, and prognosis,S2.2-5–S2.2-8 thus
are categorized based on presence and response to treatment.
  No arrhythmia: No documented clinically relevant atrial or ventricular tachyarrhythmias
 Arrhythmia not requiring treatment: Bradyarrhythmia, atrial or ventricular tachyarrhythmia not requiring antiarrhythmic therapy,
cardioversion, or ablation
  Arrhythmia controlled with therapy:
   Bradyarrhythmia requiring pacemaker implantation
   Atrial or ventricular tachyarrhythmia requiring antiarrhythmic therapy, cardioversion, or ablation
   AF and controlled ventricular response
   Patients with an ICD
  Refractory arrhythmias:
   Atrial or ventricular tachyarrhythmia currently unresponsive to or refractory to antiarrhythmic therapy or ablation
Concomitant VHD Severity defined according to the 2014 VHD guideline.S2.2-2
  Mild VHD
  Moderate VHD
  Severe VHD
End-organ dysfunction Clinical and/or laboratory evidence of end-organ dysfunctionS2.2-9–S2.2-11 including:
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  Renal (kidney)
  Hepatic (liver)
  Pulmonary (lung)
Exercise capacity Patients with ACHD are often asymptomatic notwithstanding exercise limitations demonstrated as diminished exercise capacity
when evaluated objectively.S2.2-12–S2.2-14 Thus, assessment of both subjective and objective exercise capacity is important (see NYHA
classification system below). Exercise capacity is associated with prognosis.S2.2-15–S2.2-17
 Abnormal objective cardiac limitation to exercise is defined as an exercise maximum ventilatory equivalent of oxygen below the
range expected for the specific CHD anatomic diagnosis.S2.2-18
 Expected norms for CPET values should take into account age, sex, and underlying congenital diagnosis. Published studies with
institution-specific norms can be used as guides, bearing in mind variability among institutional norms and ranges.
Hypoxemia/hypoxia/ See Section 3.16. for detailed definition of cyanosis.
cyanosis
  Hypoxemia is defined as oxygen saturation measured by pulse oximetry at rest ≤90%.
  Severe hypoxemia is defined as oxygen saturation at rest <85%.
 In patients with normal or high hemoglobin concentrations, severe hypoxemia will be associated with visible cyanosis (which
requires ≥5 g/L desaturated hemoglobin to be appreciated).
 The terms cyanosis and hypoxemia (or hypoxia) are sometimes used interchangeably. Such interchangeability would not apply;
however, in the presence of anemia, severe hypoxemia can be present without visible cyanosis.
NYHA functional Class Functional Capacity
classification
I Patients with cardiac disease but resulting in no limitation of physical activity. Ordinary physical activity does not cause
systemS2.2-19
undue fatigue, palpitation, dyspnea, or anginal pain.
II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary
physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than
ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of HF
or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort increases.

(Continued )

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Stout et al 2018 ACHD Guideline

Table 3. Continued

CLINICAL STATEMENTS
Variable Description

AND GUIDELINES
Pulmonary Pulmonary hypertension is a broad term that encompasses pulmonary arterial hypertension, which is pulmonary hypertension with
hypertension increased pulmonary vascular resistance. This document defines PH and PAH as they are used in the field of pulmonary hypertension.
Pulmonary hypertension is defined as:

  Mean PA pressure by right heart catheterization ≥25 mm Hg.


PAH is defined as:

 Mean PA pressure by right heart catheterization ≥25 mm Hg and a pulmonary capillary wedge pressure ≤15 mm Hg and pulmonary
vascular resistance ≥3 Wood unitsS2.2-20
Shunt An intracardiac shunt is hemodynamically significant if:
(hemodynamically
  There is evidence of chamber enlargement distal to the shunt
significant shunt)
  And/or evidence of sustained Qp:Qs ≥1.5:1
  An intracardiac shunt not meeting these criteria would be described as small or trivial
Venous and arterial Aortic recoarctation after CoA repair
stenosis
Supravalvular aortic obstruction
Venous baffle obstruction
Supravalvular pulmonary stenosis
Branch PA stenosis
Stenosis of cavopulmonary connection
Pulmonary vein stenosis

ACHD indicates adult congenital heart disease; AF, atrial fibrillation; AP, anatomic and physiological; CHD, congenital heart disease; CoA, coarctation of the
aorta; CPET, cardiopulmonary exercise test; HF, heart failure; ICD, implantable cardioverter-defibrillator; NYHA, New York Heart Association; PA, pulmonary artery;
PAH, pulmonary arterial hypertension; Qp:Qs, pulmonary–systemic blood flow ratio; and VHD, valvular heart disease.

of the great arteries, and TOF, amongst others. In every and perhaps new components, resulting in a scheme
patient, anatomic and physiological variables should be that ever more precisely tracks overall severity of di-
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considered. In using Tables 3 and 4, a patient should be sease and need for more or less intensive follow-up
classified based on the “highest” relevant anatomic or and management.
physiological feature. For example, a normotensive pa- Similar to the New York Heart Association (NYHA)
tient with repaired CoA, normal exercise capacity, and classification of functional status, patients may move
normal end-organ function would be ACHD AP classifi- from one ACHD AP classification to another over time.
cation IIA, whereas an otherwise similar patient with as- If clinical status worsens, the classification will change
cending aortic diameter of 4.0 cm would be ACHD AP to a higher severity group, but improvement in status,
classification IIB, and if moderate aortic stenosis were for example after an intervention such as valve replace-
also present, the ACHD AP classification would be IIC. ment or control of arrhythmia, can result in change to
Patients with ACHD may have baseline exercise a lower severity classification. Such movement among
limitations, cyanosis, end-organ dysfunction, or other classes is unlike the AHA HF A to D classification,S2.3-17 in
clinically important comorbidities related to their CHD. which patients move in only one direction. This ACHD
They are also at risk of HF, arrhythmias, sudden car- AP classification is used throughout this document, par-
diac death (SCD), and development or progression of ticularly when considering follow-up visits and need for
cardiac symptoms such as dyspnea, chest pain, and testing. As the ACHD AP classification worsens because
exercise intolerance. Concomitant valvular disease or of changes in physiology (eg, development of arrhyth-
aortic pathology may be present. There are growing mias, HF, end-organ disease), the nature and frequency
data regarding the prognostic implications of these of recommended follow-up visits and testing will also
variables in patients with ACHD, but not the abun- change, adapting to the patient’s changing circum-
dance of data available for patients with acquired stance instead of depending solely on a description of
heart disease.S2.3-1–S2.3-16 anatomic disease, which may not adequately discrimi-
The variables forming part of the ACHD AP classifi- nate physiological changes that alter severity over time.
cation (Table 3) were selected because data exist sug- Some patients with ACHD may have substantial ac-
gesting their importance in prognosis, management, quired comorbidities unrelated to CHD and, as a conse-
or quality of life (QoL). As new data become availa- quence, their follow-up strategies might be more appro-
ble, we expect changes in the relative weights attrib- priately based on other existing guidelines for acquired
uted to the components of the ACHD AP classification heart disease. For example, an 80-year-old patient who

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Stout et al 2018 ACHD Guideline

Table 4.  ACHD AP Classification (CHD Anatomy + Physiological Table 4. Continued


CLINICAL STATEMENTS

Stage = ACHD AP Classification)


CHD Anatomy* (Continued)
AND GUIDELINES

CHD Anatomy*
III: Great Complexity (or Complex) (Continued)
I: Simple
 Pulmonary atresia (all forms)
  Native disease
 TGA (classic or d-TGA; CCTGA or l-TGA)
   Isolated small ASD
 Truncus arteriosus
   Isolated small VSD
 Other abnormalities of atrioventricular and ventriculoarterial connection
   Mild isolated pulmonic stenosis (ie, crisscross heart, isomerism, heterotaxy syndromes, ventricular inversion)
  Repaired conditions Physiological Stage
   Previously ligated or occluded ductus arteriosus  A
  Repaired secundum ASD or sinus venosus defect without significant   NYHA FC I symptoms
residual shunt or chamber enlargement
  No hemodynamic or anatomic sequelae
  Repaired VSD without significant residual shunt or chamber
enlargement   
No arrhythmias

II: Moderate Complexity   Normal exercise capacity

  Repaired or unrepaired conditions   Normal renal/hepatic/pulmonary function

   Aorto-left ventricular fistula  B

   Anomalous pulmonary venous connection, partial or total   NYHA FC II symptoms

   Anomalous coronary artery arising from the pulmonary artery   Mild hemodynamic sequelae (mild aortic enlargement, mild ventricular
enlargement, mild ventricular dysfunction)
   Anomalous aortic origin of a coronary artery from the opposite sinus
  Mild valvular disease
   AVSD (partial or complete, including primum ASD)
  Trivial or small shunt (not hemodynamically significant)
   Congenital aortic valve disease
  Arrhythmia not requiring treatment
   Congenital mitral valve disease
  Abnormal objective cardiac limitation to exercise
   Coarctation of the aorta
 C
  Ebstein anomaly (disease spectrum includes mild, moderate, and
severe variations)   NYHA FC III symptoms
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  Infundibular right ventricular outflow obstruction   Significant (moderate or greater) valvular disease; moderate or greater
ventricular dysfunction (systemic, pulmonic, or both)
  Ostium primum ASD
  Moderate aortic enlargement
  Moderate and large unrepaired secundum ASD
  Venous or arterial stenosis
  Moderate and large persistently patent ductus arteriosus
  Mild or moderate hypoxemia/cyanosis
  Pulmonary valve regurgitation (moderate or greater)
  Hemodynamically significant shunt
  Pulmonary valve stenosis (moderate or greater)
  Arrhythmias controlled with treatment
  Peripheral pulmonary stenosis
  Pulmonary hypertension (less than severe)
  Sinus of Valsalva fistula/aneurysm
  End-organ dysfunction responsive to therapy
  Sinus venosus defect
 D
  Subvalvar aortic stenosis (excluding HCM; HCM not addressed in
these guidelines)   NYHA FC IV symptoms
  Supravalvar aortic stenosis   Severe aortic enlargement
  Straddling atrioventricular valve   Arrhythmias refractory to treatment
  Repaired tetralogy of Fallot   Severe hypoxemia (almost always associated with cyanosis)
  VSD with associated abnormality and/or moderate or greater shunt   Severe pulmonary hypertension
III: Great Complexity (or Complex)   
Eisenmenger syndrome
 Cyanotic congenital heart defect (unrepaired or palliated, all forms)   Refractory end-organ dysfunction
 Double-outlet ventricle *This list is not meant to be comprehensive; other conditions may be
 Fontan procedure important in individual patients.
ACHD indicates adult congenital heart disease; AP, anatomic and
 Interrupted aortic arch physiological; ASD, atrial septal defect; AVSD, atrioventricular septal
 Mitral atresia defect; CCTGA, congenitally corrected transposition of the great arteries;
CHD, congenital heart disease; d-TGA, dextro-transposition of the
 Single ventricle (including double inlet left ventricle, tricuspid atresia, great arteries; FC, functional class; HCM, hypertrophic cardiomyopathy;
hypoplastic left heart, any other anatomic abnormality with a l-TGA, levo-transposition of the great arteries; NYHA, New York Heart
functionally single ventricle) Association; TGA, transposition of the great arteries; and VSD, ventricular
septal defect.
(Continued )

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Stout et al 2018 ACHD Guideline

Table 5.  Key Personnel and Services Recommended for ACHD


3. GENERAL PRINCIPLES

CLINICAL STATEMENTS
Programs

AND GUIDELINES
Personnel
See Online Data Supplements 1 and 2 for additional
data supporting this section.
  ACHD board-eligible/board-certified cardiologists
  Congenital cardiac surgeons
  Nurses/physician assistants/nurse practitioners 3.1. ACHD Program
  Cardiac anesthesiologists with CHD training/expertise Patients with complex CHD have generally better out-
  Multidisciplinary teams: comes when cared for in an integrated, collaborative,
  High-risk obstetrics
and multidisciplinary program.S3.1-1 Many medical is-
sues in patients with ACHD involve cardiac sequelae,
  Pulmonary hypertension
and the diagnosis and management may require car-
  HF/transplant
diac anesthesiologists, electrophysiologists, and in-
  Genetics terventional cardiologists; imaging services such as
  Hepatology cardiovascular magnetic resonance (CMR)/cardiac
  Cardiac pathology computed tomography (CCT); and pulmonary hy-
  Rehabilitation services pertension services with expertise in ACHD (Table
  Social services 5). Appropriate specialty care must be available to
address pregnancy, acquired cardiovascular disease,
  Psychological services
and acute noncardiac illness complicating CHD, man-
  Financial counselors
agement of which is frequently more complicated in
Services
patients with ACHD.
  Echocardiography, including TEE and intraoperative TEE* Although individual providers may be communi-
  CHD diagnostic and interventional catheterization* ty-based affiliates, ACHD programs are inpatient,
  CHD electrophysiology/pacing/ICD implantation*: outpatient, and hospital-based with staffing and ex-
  Exercise testing pertise available on-site or accessible when needed
  Echocardiographic
(Table 5).
  Radionuclide
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  Cardiopulmonary 3.2. Access to Care


  Cardiac imaging/radiology*:
Recommendation for Access to Care
  CMR Referenced studies that support the recommendation are
  CCT summarized in Online Data Supplement 3.

  Nuclear medicine COR LOE Recommendation

  Information technology: 1. Physicians caring for patients with ACHD


should support access to care by a) assuring
  Data collection B-NR smooth transitions for adolescents and
young adults from pediatric to adult
  Database support
I providersS3.2-1,S3.2-2 (Level of Evidence:
   Quality assessment review/protocols B-NR); and b) promoting awareness of the
C-EO need for lifelong specialized care through
*These modalities must be supervised/performed and interpreted by outreach and educational programs (Level of
clinicians with expertise and/or training in CHD. Evidence: C-EO).
ACHD indicates adult congenital heart disease; CCT, cardiac computed
tomography; CHD, congenital heart disease; CMR, cardiovascular magnetic
resonance; HF, heart failure; ICD, implantable cardioverter-defibrillator; and
TEE, transesophageal echocardiography. Synopsis
As patients with ACHD grow beyond the pediatric age
has a small atrial septal defect (ASD), but whose symp- group, continued access to specialized cardiovascular
toms are related to diastolic HF, chronic kidney disease care presents several challenges:
caused by hypertension and diabetes mellitus, and mod- • Lack of guided transfer from pediatric to adult
erate aortic stenosis is well-suited to be followed ac- care;
cording to existing guidelines for those diseases, rather • Insufficient availability of ACHD programs;
than according to the ACHD AP classification for the • Inadequate insurance coverage;
ASD. Nevertheless, the added hemodynamic complexity • Deficient education of patients and caregivers
brought by the ASD must be kept in mind. regarding ACHD;
Throughout this document, the ACHD AP classifica- • Inadequate resources for patients with cognitive or
tion is used to help guide resource utilization, including psychosocial impairment;
ACHD consultation and routine diagnostic studies. • Lack of comprehensive case management; and

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Stout et al 2018 ACHD Guideline

• Different needs for evaluation and management differ from those applicable to adults without
CLINICAL STATEMENTS

compared with adults with acquired cardiovascular ACHD who have valve disease, HF, or arrhythmias.
AND GUIDELINES

disease. From a practical perspective, it may be difficult


to identify clinicians with expertise in ACHD, and
expertise in ACHD varies across medical and sur-
Recommendation-Specific gical specialties. Some specialties, such as cardi-
Supportive Text ology and congenital heart surgery, have defined
1. Many patients with CHD face gaps in care during ACHD fellowship training and board certification,
and after adolescence.S3.2-2 Common reasons include whereas for others, ACHD expertise is gained by
lack of knowledge regarding need for follow-up, in- focused experience during training and practice.
ability to find specialized providers, insurance issues, In 2012, the American Board of Medical Spe-
and feeling well.S3.2-1 Patients with gaps in care are cialties approved ACHD as a subspecialty of in-
more likely to develop medical problems requir- ternal medicine (“adult”) cardiology and pedi-
ing intervention than those receiving continuous atric cardiology. Therefore, for cardiologists, one
care.S3.2-3,S3.2-4 Canadian patients with CHD in special- marker of ACHD expertise is board eligibility/board
ized care programs had lower mortality than those certification in ACHD. There are expert ACHD cli-
in centers without ACHD expertise.S3.2-5 Improving nicians who are not board-certified, including
transition programs and recognizing the importance those whose expertise was acquired before the
of long-term care will hopefully improve access to development of formal certification programs and
specialty care. Insurance barriers and lack of spe- those trained outside the United States who may
cialty providers for the large number of patients are also have different pathways to achieve ACHD ex-
issues; thus, relationships with regulatory agencies to pertise. Expertise in the surgical management of
address these challenges are important. patients with ACHD may be identified through
board eligibility/board certification in congenital
heart surgery. There are expert ACHD surgeons
3.3. Delivery of Care who are not board-certified, including those sur-
Recommendations for Delivery of Care
geons trained in other countries who are not eligi-
Referenced studies that support recommendations are summarized ble for certification in the United States.
Specific ACHD training options are not gen-
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in Online Data Supplements 3, 4, and 5.


COR LOE Recommendations erally available for cardiac anesthesiologists, but
1. Patients with ACHD AP classification IB-D, many of them develop expertise through training
I B-NR IIA-D, and IIIA-D* should be managed in in pediatric anesthesiology, cardiac anesthesiology,
collaboration with an ACHD cardiologist.S3.3-1 mentoring, and practice experience. Other provid-
2. Cardiac surgery, catheter-based ers involved in the care of patients with ACHD (eg,
interventional cardiac procedures, and
obstetricians, pulmonologists, radiologists, nurse
electrophysiological procedures involving
congenital heart lesions in patients with practitioners, physician assistants) derive expertise
I C-LD
ACHD should be performed by operators from training and/or practice. Individual provid-
with expertise in CHD procedures and in
ers may gain ACHD expertise in a specific area or
collaboration with an ACHD
cardiologist.S3.3-1,S3.3-2 discipline, such as intraoperative transesophageal
echocardiography (TEE) or interpretation of CMR.
*See Tables 3 and 4 for details on the ACHD Anatomic and Physiological
classification system. 2. Patients with ACHD who are undergoing in-
vasive cardiovascular procedures in specialized
ACHD centers generally have better outcomes,
Recommendation-Specific
including survival, than those managed in other
Supportive Text care settings.S3.3-2 Special attention is required to
1. Patients with ACHD, particularly those with more ensure appropriate periprocedural care, including
severe CHD, cared for in specialized centers have identification of procedure-related risk factors
lower mortality than those managed without spe- and availability of ancillary imaging.S3.3-3–S3.3-10
cialized care.S3.3-1 Although clinical practice guide- Table 6 addresses delivery of care where circumstances
lines can be helpful, many management decisions of ACHD expertise may improve patient outcomes.
for patients with ACHD must be based on insuf-
ficient data or care guidelines and require clinical
experience often involving multiple members of
3.4. Evaluation of Suspected
an ACHD team. Patients with complex anatomic and Known CHD
and physiological forms of ACHD may need Tools commonly used in the evaluation of adults with
approaches to evaluation and treatment that suspected or known acquired cardiovascular disease

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Stout et al 2018 ACHD Guideline

Table 6.  Delivery of Care: Circumstances Where ACHD Expertise May Improve Outcomes

CLINICAL STATEMENTS
Circumstance Possible Solution Rationale Example

AND GUIDELINES
Care of patients in 1. Face-to-face consultation with an 1. Patients in ACHD AP classification IA* are Patients with small VSDs are thought to
the lowest ACHD ACHD cardiologist. likely to be asymptomatic and not require have excellent long-term survival, although
AP classification frequent routine congenital cardiac care. complications (double-chamber RV, IE, aortic
(IA)* valve prolapse and aortic regurgitation)
2. Collaborative care planning 2. The very long-term outcomes of patients
may manifest in adulthood; consequently,
between an ACHD patient’s with ACHD AP classification IA* lesions have
patients with small VSDs warrant lifelong
general cardiologist or primary not been well described, although available
follow-up.S3.3-12
care provider and an ACHD data suggest that patients with simple CHD
cardiologist. have higher cardiac mortality in long-term
follow-up than age-matched controls.S3.3-11
3. Consultation with an ACHD cardiologist
should help to accurately assess the patient’s
ACHD AP class, provide information
regarding potential long-term outcomes, and
reinforce signs and symptoms that should
prompt further evaluation.
Cardiac imaging of Imaging studies should be performed 1. The complexity and variability of lesions, Although imaging of a patient with
patients with ACHD and interpreted by individuals with repairs, and sequelae in CHD constrain the TOF may seem straightforward because
expertise in CHD imaging. use of standard protocols and sequences many have familiar chamber and great
and often require modification of plans vessel relationships, there are nuances
during acquisition of images, as well as to echocardiographic imaging of RV
specialized skills in interpretation. Thus, CHD size and function, PR severity, and/or
expertise is helpful for optimal quality and location of right ventricular outflow tract
interpretation of cardiac imaging studies. obstruction that affect clinical care and
are thus best carried out by sonographers
2. Use of a multimodality cardiac imaging
and echocardiographers with appropriate
approach can be used for patients with
expertise. Similarly, expertise in congenital
ACHD, accounting for patient-specific
CMR is important in evaluating patients
considerations, strengths and weaknesses
with TOF, as RV volumes and function are
of each modality, institutional resources,
key components in evaluation for timing of
and expertise.
pulmonary valve replacement.S3.3-15,S3.3-16
3. ACHD programs need a dedicated CMR
service, and CMR expertise is integral to
an ACHD program, as is expertise in ACHD
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CCT.S3.3-13,S3.3-14
Electrophysiological Perform procedures in Examples of diagnostic questions best Bradyarrhythmia and tachyarrhythmias are
care of patients electrophysiology laboratories answered by electrophysiological study: common in TGA with atrial switch patients
with ACHD equipped for 3D mapping and a) evaluation of the conduction system in and may seem “straightforward,” but
ablation and involve specialists cases of suspected postsurgical conduction the altered anatomy adds complexity to
experienced in the management of abnormalities the procedures and emphasizes the need
arrhythmias in patients with ACHD. b) evaluation of syncope for specialized equipment and expertise
c) diagnosis of the mechanism of to ensure the best chance for procedural
supraventricular tachycardia or wide success. For example: 1) pacemaker
complex tachycardia placement in a patient with TGA with
d) programmed ventricular stimulation atrial switch can be challenging because of
particularly in patients following repair of the altered atrial anatomy and interatrial
TOF and its variants (Section 4.4.1.) as well baffle that will necessitate placement of
as preoperative assessment of arrhythmia an atrial lead in the anatomic left atrium,
substrates that may be amenable to often scarred such that tissue amenable
operative intervention, such as an atrial to pacing is difficult to find; and 2) atrial
maze procedure for atrial arrhythmias. flutter is a common arrhythmia in TGA with
The latter procedure is commonly used at atrial switch, but the flutter circuit may be
the time of conversion of atriopulmonary on the systemic side of the interatrial baffle
connection Fontan, and may also be and thus may require baffle puncture or
useful in other forms of repaired CHD with retrograde approach to effectively ablate
postoperative atrial arrhythmias such as TOF. the circuit.
Diagnostic and 1. Perform procedure in a 1. Patients with ACHD often have complex In patients with CHD, the presence of
interventional hospital with cardiologists, underlying cardiac anatomy and physiology. anatomic and physiological complexity from
cardiac procedures, anesthesiologists, surgeons, and the specific defect or surgical palliation, may
2. The data obtained and the interventions
including other providers with expertise in change the overall care plan and procedural
performed during ACHD cardiac
electrophysiology the management of patients with decision-making. Procedures that may
procedures are difficult to sort out without
procedures ACHD. seem straightforward, such as pacemaker
specialized knowledge of the CHD.
implantation or ASD closure, may be more
2. Consultation with providers with 3. An ACHD program has additional resources complex when accounting for the nuances
ACHD expertise may be substituted such as cardiac anesthesia, congenital imparted by CHD.
if the procedure is urgent such that cardiac surgery, and specialty cardiac
timely transfer is not feasible. imaging, should the need for those services
arise during or after the procedure.

(Continued )

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Stout et al 2018 ACHD Guideline

Table 6. Continued
CLINICAL STATEMENTS

Circumstance Possible Solution Rationale Example


AND GUIDELINES

Administration 1. Performed by, or in collaboration 1. ACHD-specific issues need to be The application of anesthesia for laparoscopic
of anesthesia for with, an anesthesiologist with addressed when considering anesthesia, procedures can be especially challenging in
invasive procedures expertise in the management of including underlying cardiac physiology Fontan patients. Significant cardiovascular
in patients patients with ACHD. and hemodynamics, and the effects of and respiratory alterations may occur as a
with ACHD AP anesthetic medications and ventilation result of increased intra-abdominal pressure
classification IB-D, strategies. and decreased venous return. Abdominal
IIA-D, and IIIA-D* insufflation may lead to lower preload and
2. If clinical urgency precludes 2. Many patients with ACHD have had
hypotension, while at the same time elevating
transfer, consultation with an surgeries in the past, which may have
systemic vascular resistance and compromising
anesthesiologist with ACHD created or identified airway or vascular
cardiac output. Elevations in pulmonary
expertise would be of benefit to access concerns. Patients with ACHD can
vascular resistance attributable to hypercarbia
on-site providers who do not have also have underlying restrictive and/or
can be caused by either direct carbon dioxide
ACHD expertise. obstructive lung disease that should be
absorption or hypoventilation.S3.3-19
considered.S3.3-17,S3.3-18
Patients with ACHD 1. Consultation with experts 1. PAH imparts a poor prognosis Management of PAH in patients with shunts
and pulmonary in pulmonary hypertension compared with CHD without PAH. can be difficult. For example, in patients for
hypertension and ACHD to assist in the Because of the complexity of PAH in the whom PAH treatment is expected to allow
interpretation of diagnostic and setting of CHD, patients with ACHD subsequent closure of a shunt, cohort series
invasive studies and determine benefit from the expertise of both ACHD demonstrate progression of pulmonary
the best course of management. providers and pulmonary hypertension vascular resistance or late mortality if defects
providers.S3.3-20–S3.3-28 with associated pulmonary vascular resistance
elevation beyond 2.5 Wood units (>4 Wood
units×m2) or Qp:Qs >3 were closed.S3.3-
29,S3.3-30
The utility of acute administration of
pulmonary vasodilator therapy as a marker of
reversibility of pulmonary vascular resistance
remains uncertain. “Treat-to-repair” strategies
involving use of PAH therapies to bring
pulmonary vascular resistance into a range
where repair can be considered have been
applied, but the utility of such strategies also
remains uncertain.

*See Tables 3 and 4 for details on the ACHD AP classification system.


3D indicates 3-dimensional; ACHD, adult congenital heart disease; AP, anatomic and physiological; ASD, atrial septal defect; CCT, cardiac computed
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tomography; CHD, congenital heart disease; CMR, cardiovascular magnetic resonance; IE, infective endocarditis; PAH, pulmonary arterial hypertension; PR,
pulmonary regurgitation; Qp:Qs, pulmonary–systemic blood flow ratio; RV, right ventricle; TGA, transposition of the great arteries; TOF, tetralogy of Fallot; and
VSD, ventricular septal defect.

are also valuable in the evaluation of patients with have more utility in the evaluation and management
ACHD. Some tools (eg, echocardiography) are reg- of patients with ACHD than in patients with acquired
ularly used in the serial evaluation of patients with cardiovascular disease (Tables 7 and 8). Cost and risk
ACHD, whereas other tools (eg, CMR and CCT) may to patients can be minimized by ensuring studies are
acquired and interpreted by centers and providers
Table 7.  Use of ECGs in ACHD Evaluation with CHD expertise.
Identification of sinus bradycardia or junctional rhythm in patients at risk
of sinus node dysfunction (especially after the Mustard, Senning, Glenn, or Table 8.  Circumstances Where CMR, CCT, TEE, and/or Cardiac
Fontan procedure) Catheterization May be Superior to TTE
Identification of clinically inapparent intra-atrial re-entry tachycardia in
Assessment of RV size and function in repaired TOF, systemic right
patients who have had atriotomy
ventricles, and other conditions associated with RV volume and pressure
Identification of atrioventricular block in patients at risk for progression of overloadS3.4.4-1,S3.4.4-3
atrioventricular conduction system disease (especially CCTGA)
Identification of anomalous pulmonary venous connectionsS3.4.4-16
Evaluation of rhythm in patients with pacemakers
Serial assessment of thoracic aortic aneurysms, especially when the dilation
Measurement of QRS duration in patients after repair of TOF and as part might extend beyond the echocardiographic windowsS3.4.4-7
of CRT evaluation
Accurate assessment of PA pressure and pulmonary vascular resistance
Preoperatively to compare with postoperative ECGs in patients undergoing
Assessment for recoarctation of the aorta
heart surgery and noncardiac surgery
Sinus venosus defects
Postoperatively to identify arrhythmias (eg, atrial ectopic tachycardia, atrial
flutter, AF, junctional ectopic tachycardia, atrioventricular block) Vascular rings
Diagnosis of Wolff-Parkinson-White Syndrome in patients with Ebstein anomaly Evaluation of coronary anomalies
Initial evaluation of suspected acute coronary syndromes Quantification of valvular regurgitation

ACHD indicates adult congenital heart disease; AF, atrial fibrillation; CCT indicates cardiac computed tomography; CMR, cardiovascular
CCTGA, congenitally corrected transposition of the great arteries; CRT, cardiac magnetic resonance; PA, pulmonary artery; RV, right ventricular; TEE,
resynchronization therapy; ECG, electrocardiogram; and TOF, tetralogy of Fallot. transesophageal echocardiography; and TOF, tetralogy of Fallot.

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Stout et al 2018 ACHD Guideline

3.4.1. Electrocardiogram periods of time. Any symptoms of arrhythmia

CLINICAL STATEMENTS
should prompt investigation to establish an accu-

AND GUIDELINES
Recommendations for Electrocardiogram
rate diagnosis and direct subsequent therapy.
COR LOE Recommendations
1. A standard 12-lead electrocardiogram (ECG)
3.4.2. Ionizing Radiation Principles
is recommended in adults with CHD with
I C-EO serial assessment depending on the specific Recommendation for Ionizing Radiation Principles
ACHD AP classification or when symptoms
Referenced studies that support the recommendation are
develop or worsen.
summarized in Online Data Supplement 6.
2. Ambulatory electrocardiographic monitoring
COR LOE Recommendation
should be performed in patients with
CHD who are at risk of tachyarrhythmia, 1. Strategies to limit and monitor radiation
I C-EO
bradyarrhythmia or heart block, or when exposure are recommended during imaging
symptoms possibly of arrhythmic origin I B-NR of patients with ACHD, with studies not
develop. involving ionizing radiation chosen whenever
appropriate.S3.4.2-1–S3.4.2-4

Recommendation-Specific
Supportive Text Recommendation-Specific
Supportive Text
1. The ECG is an essential part of a complete car-
diovascular evaluation of a patient with ACHD, 1. Low-dose ionizing radiation is a known carcin-
similar to elements of the physical examination. ogen, and certain levels of exposure similar to
Regardless of anatomic diagnosis, it is important medical exposure have been associated with later
to obtain an ECG at baseline for comparison to malignancy.S3.4.2-5,S3.4.2-6 Patients with ACHD have
any subsequently obtained ECG, because an ab- multiple potential exposures to low-dose ionizing
normal baseline ECG is expected in many forms radiation throughout their lifetimes from cardiac
of CHD, particularly those who have undergone catheterizations, computed tomographic (CT)
surgical repair. A follow-up ECG is recommended scans, nuclear perfusion scans, stress tests, and
in specific lesions and in the setting of new or chest x-rays. It remains unclear whether there is an
worsening congestion or low cardiac output syn- increased risk of malignancy among patients with
drome (Table 7). ACHD, but the exposure levels from multiple pro-
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2. Asymptomatic arrhythmias seen in patients with cedures are in the range of concern. Every effort
ACHD may be associated with development of should be made to use tests without radiation
symptoms and increased risk of death, and are whenever possible or to select protocols with the
more common in particular lesions or repairs. lowest possible doses of radiation compatible with
Bradyarrhythmias or tachyarrhythmias may occur, securing the needed clinical information.
with some requiring treatment even when asymp-
tomatic. For example, sinus node dysfunction is 3.4.3. Echocardiography
common in patients with atrial switch repairs of Recommendations for Echocardiography
transposition of the great arteries (TGA), whereas Referenced studies that support recommendations are summarized
in Online Data Supplement 7.
complete heart block is seen in patients with con-
genitally corrected transposition of the great arter- COR LOE Recommendations

ies (CCTGA) or late after atrioventricular septal I B-NR


1. Intraoperative TEE is recommended to guide
surgical repair of CHD in adults.S3.4.3-1
defect (AVSD) repair, especially in those patients
with transient postoperative heart block.S3.4.1-1–S3.4.1-3 2. Patients with ACHD should undergo
transthoracic echocardiography (TTE) for
Some of these events have occurred as late as I C-EO initial assessment, with timing of serial
15 years after surgery. The atrioventricular node assessment based on anatomic and
is typically displaced inferiorly in AVSD, which physiological severity and clinical status.

is associated with relative hypoplasia of the left


anterior fascicle.S3.4.1-4 Atrial tachyarrhythmias
Recommendation-Specific
are common in atrial switch repairs of TGA,
Fontan repairs, and Ebstein anomaly.S3.4.1-5–S3.4.1-7 Supportive Text
Thus, baseline and periodic screening for asymp- 1. A large retrospective study has shown that the
tomatic arrhythmias with ambulatory electrocar- routine use of intraoperative TEE has a substantial
diographic monitoring is advised to ensure that impact on patient care, leading to alteration of
asymptomatic arrhythmias that would warrant a planned procedure or revision of the initial repair
change in therapy are not present,S3.4.1-8 acknowl- in 14% of cases and was also determined to be
edging the limitations of monitoring over short cost-effective.S3.4.3-1

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Stout et al 2018 ACHD Guideline

2. For patients with ACHD in whom abnormalities require modification of plans during acquisi-
CLINICAL STATEMENTS

and changes that may be identified on echocar- tion of images, as well as specialized skills in
AND GUIDELINES

diography (eg, valvular or ventricular function or interpretation.S3.4.4-12,S3.4.4-13 Thus, a dedicated CMR


pulmonary pressures) commonly influence man- service is integral to an ACHD program.S3.4.4-4,S3.4.4-5
agement decisions; echocardiography is an indis- CMR can provide exquisite anatomic detail and
pensable tool in the initial and serial follow-up unique physiological information in many forms
evaluation. TTE is also valuable in the initial and of CHD. It has a particularly important role in
serial evaluation of patients without symptoms or the assessment of extracardiac cardiovascular
changes in examination (Table 8). defects (eg, CoA, aortic aneurysm, and abnor-
malities of the thoracic arterial and venous
3.4.4. CMR Imaging anatomy and connections).S3.4.4-6,S3.4.4-7 The eluci-
dation of uncommon, complex forms and vari-
Recommendations for CMR Imaging
Referenced studies that support recommendations are summarized
ations of CHD is routinely facilitated by a CMR
in Online Data Supplement 8. study.S3.4.4-5 Contraindications to CMR are com-
COR LOE Recommendations mon in patients with ACHD, so they should be
1. In patients with ACHD who have or who are
sought and confirmed. However, the high value
at risk of developing RV enlargement and of serial CMR has encouraged modification of
I B-NR dysfunction, serial CMR is recommended newer pacemakers, leads, and other devices
for quantitative assessment of RV size and
function.S3.4.4-1–S3.4.4-3
and imaging protocols to facilitate imaging in
an expanding subset of patients with ACHD
2. CMR can be useful in the initial evaluation
and serial assessment of selected patients who have had previous instrumentation. If a
IIa C-LD
with CHD based on anatomic complexity contraindication is confirmed, alternative forms
and clinical status.S3.4.4-1,S3.4.4-2,S3.4.4-4–S3.4.4-10 of imaging, especially CCT, can obtain much of
the information otherwise obtained from CMR
and some unique information not provided by
Recommendation-Specific
CMR.S3.4.4-14 However, CCT has the disadvan-
Supportive Text tage of substantial patient exposure to ionizing
1. CMR plays a valuable role in assessment of RV size radiation, especially when serial studies are con-
and function, because it provides data that are re- templated over a lifetime.S3.4.4-9 Real-time 3D ech-
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producible and more reliable than data obtained ocardiography shows promise for replacing CCT
with alternative imaging techniques.S3.4.4-1–S3.4.4-4 and even CMR for serial studies, especially when
Real-time 3-dimensional (3D) echocardiography is focusing on ventricular volumes and intracardiac
an emerging technique that shows some promise structures only, and if reasonably complete data
for replacing CCT and even CMR for serial studies, sets can be obtained (Tables 8 and 9).S3.4.4-11,S3.4.4-15
especially when focusing on ventricular volumes
3.4.5. Cardiac Computed Tomography
and intracardiac structures only, and if reasonably
complete data sets can be obtained.S3.4.4-11 Recommendation for Cardiac Computed Tomography
Referenced studies that support the recommendation are
2. CMR has unique value in the assessment and
summarized in Online Data Supplement 9.
serial follow-up of patients with ACHD, because
COR LOE Recommendation
it offers unrestricted access to the heart and great
1. CCT imaging can be useful in patients with
vessels noninvasively and without ionizing radi- ACHD when information that cannot be
ation. The complexity and variability of lesions, IIa C-LD obtained by other diagnostic modalities is
repairs, and sequelae in CHD constrain the use important enough to justify the exposure to
ionizing radiation.S3.4.5-1,S3.4.5-2
of standard protocols and sequences, and often
Table 9.  Comparison of Imaging Modalities Useful in ACHD Evaluation

Ventricular Valvular Coronary Extracardiac


Radiation Volumes/ Structure/ Anatomy and Vascular
Exposure Relative Cost Function Function Course Anatomy
Echocardiography No $ ++ +++ +/- +/-
CMR No $$ +++ ++ ++* +++
CCT Yes $$ +* + +++ +++
Cardiac catheterization Yes $$ + ++ +++ ++

$ indicates less expensive; $$, more expensive; +/-, possible value; +, good; ++, very good; and +++, excellent.
*In specific gated imaging protocols.
ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; and CMR, cardiovascular magnetic resonance.

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Stout et al 2018 ACHD Guideline

Recommendation-Specific optimal imaging of vessels in which flow is com-

CLINICAL STATEMENTS
Supportive Text promised). Procedures should be planned with ap-

AND GUIDELINES
preciation of the anatomy and physiology likely to
1. The most important disadvantage of CCT (in- be encountered, including sequelae and residua of
cluding CT angiography) as an imaging technique prior surgery and interventions.
is the associated exposure to ionizing radiation. The expansion of interventional catheter tech-
This is especially problematic in patients with niques has dramatically expanded possibilities for
ACHD in whom serial assessments are contem- interventional treatment for an increasing number
plated over a lifetime.S3.4.5-1 Gating CCT to the ECG of conditions. Operators require specialized train-
allows image acquisition during multiple phases ing and expertise in ACHD. In addition, catheteri-
of the cardiac cycle, thereby providing cine im- zation laboratories specially equipped with devices
aging and the ability to select phases of the cycle and tools used in ACHD intervention are needed
of specific interest (usually end-systole and end- and personnel trained in their use. Such equipment
diastole), at the cost of increased radiation dose. and expertise differ from those found in catheteri-
Electrocardiographic gating is generally unneces- zation laboratories devoted primarily to diagnostic
sary when the focus is assessment of extracardiac catheterization and coronary interventions.
vascular structures, which can consequently be 2. For patients at low or intermediate risk of obstruc-
imaged using substantially lower doses of ionizing tive coronary disease, CT coronary angiography
radiation. Ongoing development of protocols and can be an alternative to cardiac catheterization
equipment that reduce radiation exposure are for assessing coronary artery course and patency.
welcome advances.S3.4.5-2
3.4.7. Exercise Testing
3.4.6. Cardiac Catheterization
Recommendations for Exercise Testing
Recommendations for Cardiac Catheterization Referenced studies that support recommendations are summarized
Referenced studies that support recommendations are summarized in Online Data Supplement 11.
in Online Data Supplement 10.
COR LOE Recommendations
COR LOE Recommendations
1. In patients with ACHD, cardiopulmonary
1. Cardiac catheterization (hemodynamic exercise testing (CPET) can be useful for
IIa B-NR
and/or angiographic) in patients with baseline functional assessment and serial
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ACHD AP classification II and III, or testing.S3.4.7-1,S3.4.7-2


interventional cardiac catheterization
I C-LD 2. In symptomatic patients with ACHD, a
in patients with ACHD AP classification
6-minute walk test can be useful to objectively
I to III should be performed by, or in IIa C-LD
assess symptom severity, functional capacity,
collaboration with, cardiologists with
and response to therapy.S3.4.7-3,S3.4.7-4
expertise in ACHD.S3.4.6-1–S3.4.6-4
2. In patients with a low or intermediate
pretest probability of coronary artery disease
(CAD), use of CT coronary angiography is
Recommendation-Specific
IIa B-NR reasonable to exclude significant obstructive Supportive Text
CAD when cardiac catheterization has
significant risk or because of patient 1. Patients with ACHD often overestimate their
preference.S3.4.6-5–S3.4.6-9 physical capabilities and underreport limitations.
In contrast to patients with acquired heart di-
sease, patients with ACHD may never have ex-
Recommendation-Specific
perienced “normal” function. Decline in physical
Supportive Text capacity may occur imperceptibly over many
1. Cardiac catheterization remains a standard tool years.S3.4.7-1,S3.4.7-2 Consequently, tools more precise
when diagnosis, prognosis, or management re- than patient history are necessary for evaluation
quire a) more precise definition of anatomy than is and serial follow-up of functional capacity. CPET
achievable via advanced noninvasive imaging (eg, provides objective, reproducible, and repeatable
structures with low flow or those shielded from assessment of the cardiovascular, respiratory, and
other techniques), b) calculation of pressures and muscular systems and has been shown to have
resistances, or c) physiological or anatomic simu- prognostic value in patients with a wide variety of
lation to allow additional calculation or anatomic ACHD conditions.S3.4.7-1
visualization. Cardiac catheterization can provide 2. In severely impaired patients with ACHD, or those
unique information not reliably available from other who cannot complete CPET for other reasons, the
diagnostic modalities (eg, direct pressure measure- 6-minute walk test provides a more limited set of
ment in a vessel or chamber, determination of pul- data, which nevertheless has prognostic value be-
monary artery (PA) pressures and resistance, and yond history alone.S3.4.7-3,S3.4.7-4

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Stout et al 2018 ACHD Guideline

3.5. Transition Education ommendations derived from those that apply to com-
CLINICAL STATEMENTS

petitive sportsS3.6-16 have been applied to recreational


AND GUIDELINES

Recommendation for Transition Education


activities despite the absence of evidence on the risk
Referenced studies that support the recommendation are
summarized in Online Data Supplement 12.
or safety of moderate activity. The 2015 “Eligibility and
Disqualification Recommendations for Competitive
COR LOE Recommendation
Athletes With Cardiovascular Abnormalities: Task Force
1. Clinicians caring for patients with CHD
should deliver developmentally appropriate
4: Congenital Heart Disease”S3.6-14 does work toward
I B-NR transition education to adolescent and encouraging participation and shared decision-mak-
young patients with CHD, and to their ing with patients regarding competitive sports partic-
families/support network.S3.5-1,S3.5-2
ipation. Most patients with ACHD can safely engage
in regular, moderate physical activity. A few conditions,
Recommendation-Specific such as systemic ventricular systolic dysfunction, sys-
Supportive Text temic ventricular outflow tract obstruction, hemody-
namically significant arrhythmias, or aortic dilation,
1. Preparing a patient for independent cardiac care is warrant more cautious recommendations.S3.6-17
an ongoing process that should start in early ado-
lescence if not soonerS3.5-3 and may extend beyond
18 years of age in many patients. The recommen- Recommendation-Specific
dation and goals for transition and transition ed- Supportive Text
ucation have been described and include verbal, 1. Physical activity is widely recognized as being ben-
written, and experiential efforts to teach patients eficial to the physical and mental health of those
and families about their specific heart disease, ex- who participate.S3.6-2–S3.6-4 There is conflicting evi-
pectations, and concerns regarding CHD, as well dence regarding physical activity levels in patients
as skills to navigate the healthcare system as an with CHD, with some suggesting the tendency
adult.S3.5-4 Lack of education about the need for for less activityS3.6-5,S3.6-9 and a greater prevalence
transition and lifelong cardiac care leads to gaps of obesityS3.6-1 than in the general population.
in care that can result in increased hospitaliza- Studies describe the beneficial effects and safety
tions, need for urgent intervention, and increased of exercise programs for patients across the spec-
morbidity.S3.5-5,S3.5-6 A structured approach to transi-
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trum of CHD.S3.6-18,S3.6-19 Activity recommendations


tion education improves health related knowledge should be individualized based on the patient’s
and self-management.S3.5-1,S3.5-2 This education is a clinical status and their interests.S3.6-20
continual process that includes after transfer to an 2. There is evidence that exercise capacity varies
ACHD care provider.S3.5-4 among congenital heart defects, with declining
capacity (generally) as complexity increases.S3.6-10,S3.6-11
3.6. Exercise and Sports Knowledge of the typical exercise capacity
for patients with a specific lesion is im-
Recommendations for Exercise and Sports portant when making appropriate activity
Referenced studies that support recommendations are summarized recommendations.S3.6-10 Self-directed activity is
in Online Data Supplement 13.
usually at 40% to 60% of maximal exercise ca-
COR LOE Recommendations
pacity, whereas fitness training occurs at 60% to
1. Clinicians should assess activity levels at 80% of maximal capacity.S3.6-20 Exercise capacity
regular intervals and counsel patients
I C-LD with ACHD about the types and intensity is defined in relation to maximal oxygen con-
of exercise appropriate to their clinical sumption. The writing committee recognizes that
status.S3.6-1–S3.6-9 not all ACHD centers will have the resources to
2. CPET can be useful to guide activity conduct CPET, which is the preferred method of
IIa C-LD recommendations for patients with
evaluation. If CPET cannot be performed, other
ACHD.S3.6-10,S3.6-11
exercise tests using an established treadmill or
3. Cardiac rehabilitation can be useful to
IIa B-NR increase exercise capacity in patients with
bicycle ergometer protocol are an acceptable al-
ACHD.S3.6-12,S3.6-13 ternative for assessing exercise capacity, recogniz-
ing that valuable information may be unavailable
compared with CPET.
Synopsis 3. As with other populations of cardiac patients, in-
Historically, guidelines for physical activity among pa- activity leads to reduced exercise performance.
tients with CHD have focused on restriction, rather Regular exercise and cardiac rehabilitation may
than promotion of activity.S3.6-14,S3.6-15 Because of fears improve exercise capacity and HF symptoms, and
of adverse events such as SCD or aortic dissection, rec- ought to be encouraged.S3.6-6,S3.6-7,S3.6-21,S3.6-22

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Stout et al 2018 ACHD Guideline

3.7. Mental Health and and surgery in childhood.S3.7-6,S3.7-8,S3.7-9 It is likely

CLINICAL STATEMENTS
Neurodevelopmental Issues that this impact will persist into adulthood and

AND GUIDELINES
may manifest in lower educational and occupa-
Recommendations for Mental Health and Neurodevelopmental tional achievement. This is particularly evident in
Issues patients with genetic conditions such as 22q11
Referenced studies that support recommendations are summarized
in Online Data Supplement 14.
deletion and trisomy 21.
COR LOE Recommendations

I B-NR
1. Patients with ACHD should be evaluated for 3.8. Endocarditis Prevention
depression and anxiety.S3.7-1–S3.7-3
Patients with ACHD have an increased risk of develop-
2. Referral for mental health evaluation and
IIa B-NR treatment is reasonable in patients with
ing infective endocarditis (IE).S3.8-1,S3.8-2 The most com-
ACHD.S3.7-1–S3.7-4 mon pathogens responsible for IE include Streptococ-
3. Neurodevelopmental or neuropsychological
cus viridans, Staphylococcus species, and Enterococcus
testing may be considered in some patients species. Despite advances in antimicrobial therapy and
IIb B-NR with ACHD to guide therapies that enhance surgical techniques, IE remains a condition associated
academic, behavioral, psychosocial, and
adaptive functioning.S3.7-5–S3.7-9
with significant morbidity and mortality. Numerous
guidelines are available with recommendations on the
prevention and diagnosis of IE.S3.8-3–S3.8-5 These guidelines
Synopsis include consistent descriptions of the patients at high-
Mental health and neurodevelopmental issues are com- est risk of adverse effects from endocarditis. Antibiotic
mon in patients with ACHD and may significantly affect prophylaxis continues to be recommended for patients
QoL. Neurodevelopmental abnormalities are more fre- with high-risk characteristics, which are often found in
quently seen in children who have complex disease, com- patients with ACHD.S3.8-2 These patients include:
plex surgical repairs, and other characteristics.S3.7-10–S3.7-12 • Those with previous IE;
There is extensive literature in the pediatric population • Patients with prosthetic valves (biological and me-
on the frequency and importance of neurodevelopmen- chanical, surgical and transcatheter);
tal abnormalities, However, many adults may not have • Patients within 6 months of placement of pros-
been evaluated as children in accordance with current thetic material;
• Patients with residual intracardiac shunts at the
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diagnostic and treatment strategies.S3.7-13,S3.7-14 Neurode-


velopmental disorders, such as impairment of cognition, site of or adjacent to previous repair with pros-
social skills and communication, and attention disorders, thetic material or devices; or
are often underrecognized even though appropriate di- • Patients with uncorrected cyanotic heart disease.
agnosis, treatment, and rehabilitation may be beneficial See Online Data Supplement 15 for referenced
in optimizing function and QoL. An AHA scientific state- studies.
ment describes the common neurodevelopmental disor-
ders affecting children with CHD and may inform neu- 3.9. Concomitant Syndromes
rodevelopmental issues related to adults with CHD.S3.7-13
Recommendation for Concomitant Syndromes
Referenced studies that support the recommendation are
Recommendation-Specific summarized in Online Data Supplement 16.

Supportive Text COR LOE Recommendation


1. Genetic testing for 22q11 deletions is
1. Anxiety and depression are underrecognized in IIa B-NR reasonable for patients with conotruncal
the ACHD population. Point-of-care assessment cardiac defects.S3.9-1,S3.9-2
with simple questions about anxiety and depres-
sion should be included in the symptom review.
2. Anxiety and depression are prevalent among Synopsis
patients with ACHD. Self-reported symptoms Patients with genetic syndromes may have phenotypic
are incomplete to identify the existence of mood manifestations and associated CHD as clinical features
disorders. Structured professional psychological of the genetic abnormality. An underlying chromoso-
evaluation can identify up to 50% more patients mal abnormality exists in at least 10% of infants with
with mood disorders.S3.7-1 CHD and may not have been previously tested in pa-
3. Although there is limited evidence on neuro- tients with ACHD.S3.9-3 Clinicians caring for patients with
developmental and neuropsychological issues ACHD should recognize the potential for undiagnosed
in patients with ACHD, there is increasing evi- genetic abnormalities that may affect overall health
dence of the neurodevelopmental impact of CHD (Table 10) and pursue appropriate evaluation.

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Stout et al 2018 ACHD Guideline

Table 10.  Underlying Genetic Syndromes Commonly Associated With CHDS3.9-4,S3.9-6


CLINICAL STATEMENTS

Syndrome Genetic Abnormality Clinical Features Common Cardiac Findings


AND GUIDELINES

DiGeorge syndrome (velocardiofacial 22q11.2 deletion Thymic and parathyroid hypoplasia, immunodeficiency, IAA type B, aortic arch
syndrome) low-set ears, hypocalcemia, speech and learning disorders, anomalies, truncus arteriosus,
renal anomalies, psychiatric disease TOF
25%–75% have CHD, depending on age studiedS3.9-7,S3.9-8
Down syndrome Trisomy 21 Developmental disability, characteristic facial features, ASD, VSD, AVSD, TOF
hypotonia, palmar crease
40%–50% have CHD
Holt–Oram syndrome S3.9-9
TBX5 Upper limb skeletal abnormalities ASD, VSD, MV disease
75% have CHD
Klinefelter syndrome 47 XXY Tall stature, hypoplastic testes, delayed puberty, PDA, ASD, MV prolapse
developmental disability
50% have CHD
Noonan syndromeS3.9-10 PTPN11, KRAS, SOS1 Facial anomalies, webbed neck, chest deformity, short PS, ASD, HCM
RAF1, NRAS, BRAF, stature, lymphatic abnormalities, bleeding abnormalities
MAP2K1
80% have CHD
Turner syndrome 45X Short stature, webbed neck, lymphedema, primary Coarctation, BAV, aortic
amenorrhea stenosis, hypoplastic left
heart, ascending aortopathy
30% have CHD
Risk of aortic dissection
Williams syndrome 7q11.23 deletion Elfin face, social personality, hearing loss, developmental Supravalvar aortic stenosis,
delay, infantile hypercalcemia peripheral PS
50%–80% have CHD

ASD indicates atrial septal defect; AVSD, atrioventricular septal defect; BAV, bicuspid aortic valve; CHD, congenital heart disease; HCM, hypertrophic cardiomyopathy;
IAA, interrupted aortic arch; MV, mitral valve; PDA, patent ductus arteriosus; PS, pulmonary stenosis; TOF, tetralogy of Fallot; and VSD, ventricular septal defect.

Recommendation-Specific The impact of acquired heart disease is increasing as


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Supportive Text the lifespan of patients with ACHD extends. Myocardial


infarction is one of the leading contributing causes of
1. Several forms of CHD may be associated with un- death for late surviving adults with acyanotic CHD.S3.10-4
derlying genetic syndromes (Table 10). Some ge- Major adverse cardiac events, such as HF, percutaneous
netic syndromes may not be phenotypically appar- coronary intervention, coronary artery bypass graft sur-
ent in adults, and prior childhood genetic workup gery, malignant arrhythmia, cardiac shock, and place-
may not be readily available; therefore, genetic ment of an implantable cardioverter-defibrillator (ICD),
syndromes may be missed in patients with ACHD. are also quite prevalent.S3.10-5,S3.10-6 Overall, cardiovascular
Many of these syndromes may have important reasons account for approximately 77% of all deaths in
clinical comorbidities, including but not limited to patients with ACHD, with approximately half attributable
learning disabilities, psychiatric conditions, and re- to chronic HF.S3.10-7 Evaluation for acquired cardiac condi-
productive disorders. Up to 5% of children born tions is warranted in patients with risk factors, although
with CHD have DiGeorge syndrome (22q11.2 dele- results of testing (eg, stress perfusion studies) should
tion), the congenital heart defects most commonly account for preexisting abnormalities caused by CHD,
associated being those of conotruncal origin. Di- recognizing prior interventions can mimic abnormalities
George syndrome is an autosomal dominant con- otherwise suggestive of acquired heart disease.S3.10-8
dition. Therefore, genetic testing is reasonable for In patients with ACHD, prevention and treatment of
patients with ACHD with conotruncal defects for conditions predisposing to acquired cardiovascular di-
recognition and management of comorbidities and sease such as diabetes mellitus, obesity, hypertension,
for counseling on the potential risk of recurrence in dyslipidemia, and/or similar comorbidities are impor-
offspring.S3.9-4,S3.9-5 tant. Given the increased risk of acquired cardiovas-
cular disease with age, promoting a healthy lifestyle
is important in all patients with ACHD, although there
3.10. Acquired Cardiovascular Disease are not data demonstrating the effects of risk reduction
Patients with ACHD can acquire other cardiovascular on clinical outcomes specific to the ACHD population.
diseases such as hypertension, atherosclerotic coronary Emphasizing the importance of daily physical activity
artery disease, vascular disease, stroke, and HF.S3.10-1–S3.10-3 according to functional capacity, and decreasing sed-

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Stout et al 2018 ACHD Guideline

entary behavior as appropriate for the patient’s clinical and Management of Patients Undergoing Noncardiac

CLINICAL STATEMENTS
status is essential when counseling patients with con- Surgery”S3.12-10 may be applied; however, those guide-

AND GUIDELINES
genital heart defects.S3.10-9 Interestingly, most patients lines may not apply directly. One must remain cognizant
with ACHD lead healthier lifestyles compared with con- that there are differences in cardiac issues commonly
trol patients,S3.10-10 suggesting that this patient popula- present in patients with ACHD, such as mechanisms
tion may be receptive to advice and may continue to for ventricular dysfunction, type and mechanisms of
benefit from recommendations about diet, activity, and arrhythmia, and the probability of coronary artery di-
modifiable risk factors. sease. The 2014 guidelineS3.12-10 was developed prima-
See Online Data Supplement 17 for referenced rily with evidence and experience derived from, and re-
studies. lated to, patients with acquired heart disease. Thus, the
evidence supporting recommendations regarding risk
indices and management strategies may not apply to
3.11. Noncardiac Medical Issues many patients with ACHD.
Recommendation for Noncardiac Medical Issues
Referenced studies that support the recommendation are Recommendation-Specific
summarized in Online Data Supplement 18.
Supportive Text
COR LOE Recommendation
1. Patients with ACHD at risk for hepatitis C
1. A checklist of issues to consider in the assess-
I C-LD should be screened and vaccinated for viral ment and management of patients with ACHD
hepatitis and treated as appropriate.S3.11-1 undergoing noncardiac surgery is presented
in Table 11. Patients with ACHD may present
with nonroutine and unusual physiological
Recommendation-Specific
challenges (eg, those related to fluid balance
Supportive Text in the setting of single ventricle or the impact
1. Patients with ACHD are at risk of hepatitis C be- of vascular resistances on shunts in cyanotic
cause of blood exposure during cardiac surgery. patients).S3.12-2–S3.12-4 Heightened surveillance may
Hepatitis screening is warranted especially in those mandate extended postoperative intensive or
with exposure to blood products before universal other high-acuity care.S3.12-2
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screening for hepatitis C, which began in 1992. 2. Case series and analysis of administrative databases
Hepatitis vaccination and/or consultation with confirm that surgical procedures in patients with
a hepatologist should also be offered where ap- ACHD carry greater risk than in patients without
propriate, particularly in patients with ACHD with ACHD.S3.12-1–S3.12-3,S3.12-6,S3.12-8,S3.12-11–S3.12-13 Risk relates
concomitant liver disease (eg, Fontan patients). to the specific type of ACHD, surgical procedure,
urgency of intervention, and availability of specialized
resources.S3.12-1,S3.12-3–S3.12-6,S3.12-8,S3.12-14 Noncardiac
3.12. Noncardiac Surgery surgery is usually accomplished without substan-
Recommendations for Noncardiac Surgery tial morbidity or mortality, but even minor sur-
Referenced studies that support recommendations are summarized gery can be complicated in patients with ACHD.
in Online Data Supplement 18. Surgery that is low risk in the general population
COR LOE Recommendations may be associated with higher risk in the ACHD
1. Optimization before and close surveillance population.S3.12-1,S3.12-6 Patients with ACHD may
after invasive procedures, regardless of the present with nonroutine and unusual physiolog-
I C-LD complexity of the anatomic defect or type
of procedure is beneficial for patients with
ical challenges (eg, those related to fluid balance
ACHD.S3.12-1–S3.12-4 in the setting of single ventricle or the impact
2. In patients with ACHD AP classification
of vascular resistances on shunts in cyanotic
IB-D, IIA-D, and IIIA-D* noncardiac surgical patients).S3.12-2,S3.12-4
I B-NR
and interventional procedures should When possible, patients with ACHD, especially
be performed in a hospital with or in
consultation with experts in ACHD when
those with complex disease (ACHD AP classifica-
possible.S3.12-1,S3.12-3,S3.12-5–S3.12-9 tion II and III) and/or whose disease has progressed
*See Tables 3 and 4 for details on the ACHD AP classification system.
(stages B, C, D) (Tables 3 and 4), should receive
preoperative evaluation and surgery or other non-
surgical intervention within an ACHD program.
Synopsis Because the inability to access resources or urgent
Patients with ACHD may have greater operative risk conditions may preclude transfer or timely consul-
than patients without ACHD. The “2014 ACC/AHA tation, collaboration with members of the mul-
Guideline on Perioperative Cardiovascular Evaluation tidisciplinary ACHD team may be helpful. Clear

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Stout et al 2018 ACHD Guideline

Table 11.  ACHD Management Issues for Noncardiac Surgery


3.13. Pregnancy, Reproduction,
CLINICAL STATEMENTS

Clarify CHD diagnosis and Sexual Health


AND GUIDELINES

 Clarify prior procedures, residua, sequelae, and current status, including


ACHD AP classification
3.13.1. Pregnancy
 Be aware that history obtained from only the patient and family may be Recommendations for Pregnancy
faulty or incomplete Referenced studies that support recommendations are summarized
in Online Data Supplement 19.
 Obtain and review old records to ensure accurate understanding of past
procedures and clinical course COR LOE Recommendations

 Complete additional investigations required to define ACHD AP 1. Women with CHD should receive
classification prepregnancy counseling with input
from an ACHD cardiologist to determine
 Develop management strategies to minimize risk and optimize outcome I C-LD
maternal cardiac, obstetrical and fetal
Factors associated with increased risk of perioperative morbidity and risks, and potential long-term risks to the
mortalityS3.12-12: mother.S3.13.1-1–S3.13.1-4

 Cyanosis 2. An individualized plan of care that addresses


expectations and contingencies should be
  Congestive HF developed for and with women with CHD
I C-LD
  Poor general health who are pregnant or who may become
pregnant and shared with the patient and all
  Younger age caregivers.S3.13.1-2,S3.13.1-3
  Pulmonary hypertension 3. Women with CHD receiving chronic
  Operations on the respiratory and nervous systems anticoagulation should be counseled,
I B-NR ideally before conception, on the risks and
  Complex CHD benefits of specific anticoagulants during
  Urgent/emergency procedures pregnancy.S3.13.1-5,S3.13.1-6

Issues to consider: 4. Women with ACHD AP classification IB-


D, IIA-D, and IIIA-D* should be managed
  Endocarditis prophylaxis collaboratively during pregnancy by
I B-NR
ACHD cardiologists, obstetricians, and
  Complications related to underlying hemodynamics
anesthesiologists experienced in
 Abnormal venous and/or arterial anatomy affecting venous and arterial ACHD.S3.13.1-2,S3.13.1-7,S3.13.1-8
access
5. In collaboration with an ACHD cardiologist
  Persistent shunts to ensure accurate assessment of pregnancy
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risk, patients at high risk of maternal


  Valvular disease
morbidity or mortality, including women
  Arrhythmias, including bradyarrhythmias with pulmonary arterial hypertension
I C-EO (PAH), Eisenmenger syndrome, severe
 Erythrocytosis
systemic ventricular dysfunction, severe
  Pulmonary vascular disease left-sided obstructive lesions, and/or ACHD
AP classification ID, IID, IIID* should be
 Meticulous line care (also consider air filters for intravenous lines) to counseled against becoming pregnant or be
reduce risk of paradoxic embolus in patients who are cyanotic because given the option of terminating pregnancy.
of right-to-left shunts
6. Men and women of childbearing age with
 Adjustment of anticoagulant volume in tubes for some blood work in I B-NR CHD should be counseled on the risk of
cyanotic patients CHD recurrence in offspring.S3.13.1-9
  Prevention of venous thrombosis 7. Exercise testing can be useful for risk
  Monitoring of renal and liver function assessment in women with ACHD AP
IIa B-NR
classification IC-D, IIA-D, and IIIA-D* who
  Periprocedure anticoagulation are considering pregnancy.S3.13.1-10,S3.13.1-11
  Possible need for nonconventional drug dosing 8. When either parent has CHD, it is
 Increased prevalence of hepatitis C infection because of prior procedures IIa B-NR reasonable to perform fetal
and remote blood transfusions echocardiography.S3.13.1-12,S3.13.1-13

  Developmental disability *See Tables 3 and 4 for the ACHD AP classification system.

ACHD indicates adult congenital heart disease; AP, anatomic and


physiological; CHD, congenital heart disease; and HF, heart failure. Synopsis
Most data regarding cardiac and obstetric risk to
processes for timely consultation and support are women with CHD during pregnancy derive from ret-
needed to manage the physiological challenges rospective case series.S3.13.1-2–S3.13.1-5,S3.13.1-8,S3.13.1-10,S3.13.1-12,
presented by patients with ACHD related to fluid S3.13.1-14–S3.13.1-20
Many women with CHD considering
balance, vascular resistance, and shunts.S3.12-3,S3.12-4 pregnancy may have received inconsistent guidance
A checklist of issues to consider in assessment and regarding pregnancy risks.S3.13.1-21 Several risk scores
management of patients with ACHD undergoing have been developed to risk-stratify women with heart
noncardiac surgery is presented in Table 11. disease desiring pregnancy,S3.13.1-2,S3.13.1-7 and a prospective

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Stout et al 2018 ACHD Guideline

validation study suggests that the World Health Orga- 3. Chronic anticoagulation during pregnancy is as-

CLINICAL STATEMENTS
nization classification is the most accurate prediction sociated with increased risk of maternal bleed-

AND GUIDELINES
model.S3.13.1-11 Although many women with CHD tol- ing and thrombotic events as well as a higher
erate the hemodynamic changes of pregnancy, others risk of fetal loss, and in the case of warfarin, the
may face significant immediate or late risks of preg- risk of teratogenicity.S3.13.1-5,S3.13.1-14 The choice of
nancy including volume overload, arrhythmias, pro- specific anticoagulant must balance maternal
gressive cardiac dysfunction, and death. Cardiac medi- well-being and risks for mother and fetus, and
cations may need to be adjusted during pregnancy should be individualized. Patients with me-
and counseling provided to discuss the options for and chanical valves should be treated according to
potential impact of those changes. Some specific com- GDMT.S3.13.1-25
plications may be more common in women with cer- 4. The hemodynamic changes of pregnancy, labor,
tain types of CHD, such as hypertension, which is more and delivery can result in hemodynamic decom-
common in women with coarctation.S3.13.1-22,S3.13.1-23 The pensation for some women with CHD.S3.13.1-1,
offspring of patients with ACHD have an increased risk S3.13.1-7,S3.13.1-15,S3.13.1-24
Management involving the
of CHD and other events such as prematurity.S3.13.1-24 All expertise of ACHD, maternal-fetal medicine, and
women with CHD should receive appropriate counsel- anesthesiology should help anticipate and miti-
ing regarding contraception choices. A multidisciplinary gate some of the potentially detrimental maternal
team that includes ACHD specialists and maternal-fe- or fetal outcomes.
tal medicine obstetricians with expertise in caring for 5. Women at high risk include, but are not limited
women with heart disease is appropriate for achieving to, those diagnosed with cardiac conditions that
optimal outcomes. meet World Health Organization maternal cardiac
risk classification IV.S3.13.1-26
a. PAH of any cause
Recommendation-Specific b. Severe systemic ventricular dysfunction: LV
Supportive Text ejection fraction <30% and/or NYHA III–IV
1. Prepregnancy counseling allows for an individu- symptoms
alized risk assessment. This will include discuss- c. Severe left heart obstruction
ing maternal risks for pregnancy, delivery, and d. Severe native coarctationS3.13.1-16,S3.13.1-27,S3.13.1-28
postpartum period, and medications that may These patients have an extremely high risk of
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be teratogenic and require alternative therapies maternal mortality or severe morbidity, and if
(eg, angiotensin-converting enzyme inhibitors/ pregnant, the option of pregnancy termina-
angiotensin-receptor blockers). Additionally, tion should be discussed
counseling should include a discussion related 6. Prepregnancy counseling regarding the risk of
to fetal risk in regard to CHD transmission and CHD recurrence in offspring provides helpful in-
overall risk to the health of the fetus. ACHD car- formation to parents to inform decision-making
diologists are valuable in accurately assessing regarding family planning and delivery options,
pregnancy risks. Risk may be overestimated or and should allow adequate time dedicated to
underestimated by providers without expertise answering important questions from the parents.
in CHD and pregnancy, leading to patients’ re- 7. CPET performed before conception can predict
ceiving inaccurate recommendations on risks of maternal and neonatal outcomes in pregnant
pregnancy, risks of delivery, and the type of de- women with CHD. A blunted heart rate response
livery (eg, the incorrect notion that most women to exercise in women with CHD is associated with
with CHD require cesarean delivery for cardiac a higher risk of maternal cardiac and neonatal
reasons). adverse events.S3.13.1-11
2. This care plan should address maternal cardiac 8. If the patient with CHD or their partner is preg-
risks on the basis of the individual patient’s nant, there is an increased risk of CHD in the off-
anatomy and physiology. Clear documenta- spring and fetal echocardiography can be useful
tion is important so that all providers are well in defining whether CHD is present, and if so,
aware of the risks and expected outcomes, in- help to determine the course of action at the time
cluding risk of maternal volume shifts, arrhyth- of delivery. There are data to suggest a prenatal
mias, labor and delivery plan, and need for diagnosis improves neonatal survival, although
maternal cardiac monitoring when indicated. selection bias (eg, preoperative deaths, family
Contingency plans for anticipated complica- preference) is a limitation for many studies, so
tions related to the presence of CHD should benefit has been more difficult than expected to
also be developed. prove.S3.13.1-13,S3.13.1-29,S3.13.1-30

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Stout et al 2018 ACHD Guideline

3.13.2. Contraception women, but acute fluid retention is a risk to be


CLINICAL STATEMENTS

considered.
AND GUIDELINES

Recommendations for Contraception


Referenced studies that support recommendations are summarized 2. Women with CHD who are at high risk of throm-
in Online Data Supplement 20. bosis include those with cyanosis, Fontan physi-
COR LOE Recommendations ology, mechanical valves, prior thrombotic events,
1. Women of childbearing potential with
and PAH. In women who are at high risk of throm-
CHD should be counseled about the risks bosis and who receive warfarin, there are no data
I C-LD
associated with pregnancy and appropriate on which to base a recommendation or coun-
contraceptive options.S3.13.2-1–S3.13.2-3
seling as to whether it is safe to use estrogen-
2. Estrogen-containing contraceptives are
containing contraception. It is unclear whether
potentially harmful for women with CHD
who are at high risk of thromboembolic the use of warfarin offsets adequately the addi-
III: Harm B-NR
events (eg, cyanosis, Fontan physiology, tional risk of thrombosis related to pregnancy in
mechanical valves, prior thrombotic events,
high-risk patients.
PAH).S3.13.2-4,S3.13.2-5
3.13.3. Infertility Treatment
Synopsis Menstrual cycle disorders are not uncommon in women
with CHD. In small case series of women with CHD, var-
The use of contraceptive agents should be balanced a- ious causes for infertility were documented including
gainst the risks of pregnancy in every woman with CHD primary and secondary amenorrhea, oligomenorrhea,
after menarche.S3.13.2-6 There are no data on the safety and uterine anomalies.S3.13.3-1,S3.13.3-2 In more complex
of various contraceptive techniques in patients with forms of CHD (eg, the population with Fontan pallia-
ACHD. tion), the prevalence of primary amenorrhea may be as
high as 40%.S3.13.3-2 Menarche occurs at an older age
Recommendation-Specific in these women than in the general population.S3.13.3-2
Supportive Text Women with CHD also have higher rates of spontane-
ous abortion and miscarriage.S3.13.3-3–S3.13.3-5 The preva-
1. The individualized benefits and risks of each con-
lence of infertility in men with CHD is unknown. Each
traceptive therapy must be determined based on
patient with ACHD should be counseled regarding the
the patient’s anatomy and physiology in consulta-
potential for infertility and referral to a specialized re-
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tion with a gynecologist. This counseling should


productive endocrinologist when appropriate, although
include the expected failure rates of contraceptive
there is little specific guidance for women based on
options and the anticipated maternal and fetal
types of CHD. Alternative options for family planning
risks of unplanned pregnancy, with these issues
including assisted reproductive technologies and adop-
revisited on a regular basis.
tion is appropriate, and risks versus benefits of all op-
Contraceptive choices include combined hor-
tions are addressed during counseling.
monal (estrogen/progesterone) contraception,
progesterone-only agents, intrauterine devices, 3.13.4. Sexual Function
barrier methods, and permanent sterilization. Low- Sexuality is an important element of QoL. Although
dose combination oral contraceptive (≤20 mcg of there are data that sexual function is a concern in both
ethinyl estradiol) is an option except in women women and men, there is minimal evidence on the
who are at increased risk of thrombosis.S3.13.2-4 prevalence of sexual concerns among adults with CHD
Medroxyprogesterone acetate is a less effective and far less to guide interventions.S3.13.4-1
method of contraception, and the potential for Concerns with sexual health are present in 20% to
fluid retention must be considered.S3.13.2-5 Intra- 40% of men with CHD.S3.13.4-2–S3.13.4-4 Erectile dysfunction
uterine devices are highly effective methods of is reported by up to 42% of men with CHD.S3.13.4-1,S3.13.4-3
contraception; however, women may experience Men with CHD report being in sexual relationships sig-
vasovagal reactions at the time of implant. Tubal nificantly less often than the general population.S3.13.4-1,
ligation is generally safe with recognized risks S3.13.4-4
Among men with CHD who report sexual health
associated with anesthesia and abdominal insuf- concerns, there is a high level of psychological dis-
flation. An efficacious option is a vasectomy for tress and diminished QoL.S3.13.4-1,S3.13.4-2,S3.13.4-4,S3.13.4-5 The
the male partner; however, the long-term prog- ACHD provider should be mindful of this often-unspoken
nosis of the female patient with CHD must be concern and create an environment in which the patient
considered and discussed openly. In the case of feels comfortable addressing concerns about their
unplanned pregnancy with desire for termination, sexuality.
the morning-after pill (levonorgestrel) is safe for See Online Data Supplement 21 for referenced studies.

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Stout et al 2018 ACHD Guideline

3.14. Heart Failure and Transplant of transplantation are limited, particularly for individual

CLINICAL STATEMENTS
lesions. Larger studies based on transplant databases do
3.14.1. Heart Failure

AND GUIDELINES
not allow for analysis based on the type of CHD.S3.14.2-1–
Recommendation for Heart Failure S3.14.2-4
Currently, patients with ACHD may have fewer
Referenced studies that support the recommendation are mechanical circulatory devices (eg, ventricular-assist
summarized in Online Data Supplement 22.
devices), which may lower their listing status and hence
COR LOE Recommendation
potential for organ receipt.S3.14.2-1,S3.14.2-2,S3.14.2-4–S3.14.2-7
1. Consultation with ACHD and HF Although specific criteria for timing of referral for
specialists is recommended for patients
I C-LD
with ACHD and HF or severe ventricular transplantation are desirable, universal recommendations
dysfunction.S3.14.1-1–S3.14.1-4 cannot be made based on current data. Generally, pub-
lished data show that immediate and early posttransplan-
tation risk is higher in ACHD than in acquired heart di-
Synopsis
sease because of increased perioperative mortality.S3.14.2-2
HF is a significant issue in patients with ACHD. It is com- However, once beyond the perioperative period, patients
mon, associated with morbidity and mortality, and is with ACHD do as well as or better than those with ac-
anticipated to increase in prevalence. However, despite quired heart disease, with expected 10-year survival e-
the clinical importance of HF in patients with ACHD and quivalent to or better than that of patients without
efforts to study the effects of medication and device ACHD.S3.14.2-2–S3.14.2-4,S3.14.2-6,S3.14.2-7 Risks for poor outcomes
therapy in these patients, there are no data to support include single ventricle anatomy, anatomic complexity,
treatment recommendations. For patients with biven- protein-losing enteropathy, or high titers of panel reac-
tricular physiology, systemic left ventricular (LV) dys- tive antibodies.S3.14.2-8,S3.14.2-9 The current allocation system
function, no repairable residual hemodynamic abnor- puts patients with ACHD at a disadvantage. Rather than
malities, and persistent HF symptoms, standard GDMT priority dictated by the usual accepted risk markers, pa-
is ostensibly preferable to no treatment. However, ex- tients with ACHD are often listed by “exception,” a pro-
pectations of its benefit should be tempered, and risk cess that requires the clinician to argue that the patient
may be different in patients with acquired CVD, be- warrants higher priority than would be evident by apply-
cause CHD patients have not been included in the trials ing the used risk markers. There is also significant mortal-
by which those guidelines were developed. ity for patients with ACHD while on the waitlist.S3.14.2-10,
S3.14.2-11
Surgical alternatives to transplantation exist for
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some patients with CHD (eg, valve replacement, shunt


Recommendation-Specific
closure), but these patients are at high risk of periopera-
Supportive Text tive mortality.S3.14.2-12 Ideally, providers will consider early
1. HF is common in patients with ACHD and is associ- referral to a transplant center with expertise in ACHD
ated with increased morbidity and mortality.S3.14.1-1– transplantation when transplantation becomes a relevant
S3.14.1-4
There are many causes of HF symptoms clinical consideration. Additionally, it is advisable to con-
that may be reversible, including valve dysfunc- sider options for transplantation or ventricular assist de-
tion, shunts, arrhythmias, venous obstruction, and vice as a backup before other high-risk surgery is pursued.
systolic and/or diastolic ventricular dysfunction, See Online Data Supplement 23 for referenced studies.
which require evaluation and treatment when
3.14.3. Multiorgan Transplant
possible. Unlike acquired HF, and despite the clin-
Recognizing the vulnerability of many organ systems in
ical importance of HF in ACHD, data to support
patients with CHD, multiorgan transplantation is often
a treatment recommendations including typical
considered, although infrequently performed. Multi-
HF medical therapy (eg, angiotensin-converting
organ transplantation requires a multidisciplinary and
enzyme inhibitors, angiotensin-receptor blockers,
comprehensive approach with thoughtful planning and
beta blockers, and aldosterone antagonists)S3.14.1-5
communication among practitioners.
are limited in patients with ACHD.S3.14.1-6–S3.14.1-22 HF
Multiorgan transplantation may be performed as se-
in patients with ACHD is multifactorial and may
quential operations or as a single operation. Typically,
manifest as variable response to pharmacotherapy.
simultaneous multiorgan procedure in patients with
Advanced HF therapies may be technically difficult
CHD will be heart-lung transplantation for conditions
or considered too late in the course. Thus, timely
that result in irreversible pulmonary hypertension such
evaluation by ACHD and HF specialists is crucial to
as Eisenmenger syndrome.S3.14.3-1,S3.14.3-2 Fewer than 100
optimal care of such patients.
heart-lung transplants are performed internationally
3.14.2. Heart Transplant each year, with a median survival of 3.3 years and 10-year
Because of the prevalence of HF among patients with survival of 32%.S3.14.3-3 Survival is worse for heart-lung
CHD, heart transplantation is increasingly being con- recipients than single-organ heart or lung recipients pos-
sidered as a therapeutic option. Data on proper timing sibly, in part, because of longer wait times.S3.14.3-4

Circulation. 2019;139:e698–e800. DOI: 10.1161/CIR.0000000000000603 April 2, 2019 e723


Stout et al 2018 ACHD Guideline

The occurrence of simultaneous heart-liver trans- appropriate. Similarly, although the goal is not to
CLINICAL STATEMENTS

plantation is an option in patients with severe right-sid- wait to discuss end-of-life until death is imminent,
AND GUIDELINES

ed HF and in single ventricle patients after Fontan palli- such discussion may not have the same benefit for
ation. Given the recognized vulnerability of the liver to young patients who are clinically well with low-risk
injury in Fontan patients and the fact that heart alone disease. Thus, it is important to always have and en-
transplantation outcomes have been poor in patients courage the option to discuss end-of-life issues, but
with concomitant liver dysfunction, transplant centers timing of conversation is individualized.
may favor heart-liver transplantation in those with cir-
rhosis, but this policy is not universal. Fewer than 15
such procedures are performed annually in the United
3.16. Cyanosis
States, and approximately 20% of patients are referred The definition of cyanosis is “blueish discoloration of the
because of underlying CHD.S3.14.3-5,S3.14.3-6 Consequently, skin and/or mucous membranes resulting from inade-
experience with these procedures is limited,S3.14.3-5,S3.14.3-7 quate oxygenation of the blood.” Generally, for cyanosis
and heterogeneity makes generalizability difficult. Data to be visible, at least 5 g/L of unsaturated hemoglobin
are insufficient to support recommendations. For all in tissue is needed.S3.16-1 Anemia may result in hypoxe-
patients, survival mimics that for liver transplantation mia that is not manifest as cyanosis. In this guideline,
alone with 1-, 2-, and 5-year survival at 84%, 74%, and “cyanosis” is used as a generic term to identify hypox-
72%, respectively.S3.14.3-6 Outcomes in Fontan patients emia caused by right-to-left shunting of blood, but not
with or without cirrhosis are not necessarily different all hypoxemic patients will be visibly cyanotic at all times.
in those who receive heart transplantation alone.S3.14.3-5, Cyanotic heart disease encompasses a widely hetero-
S3.14.3-8
Multicenter data gathering on patients con- geneous group; therefore, an individualized approach is
sidered for multiorgan transplantation are needed to needed for each patient according to the clinical details.
inform future recommendations for these therapies. Secondary erythrocytosis (a physiological increase in red
blood cell mass in response to hypoxemia) and polycythe-
mia (a neoplastic proliferation of hematopoietic cells in-
3.15. Palliative Care cluding the red blood cell line) are fundamentally different
conditions that require different treatments. In secondary
Recommendation for Palliative Care
Referenced studies that support the recommendation are
erythrocytosis, the patient’s own homeostatic processes
generally direct achievement of an optimal level of red cell
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summarized in Online Data Supplement 24.


COR LOE Recommendation mass, estimated by hemoglobin and hematocrit.S3.16-2
1. Discussion of end-of-life issues and advance
Iron deficiency is frequently encountered in cyanotic
IIa B-NR directives can be beneficial for patients with individuals.S3.16-3 In addition to contributing to symp-
ACHD or their surrogates.S3.15-1–S3.15-3 toms, iron deficiency causes a reduction of hemoglobin
without a proportional change in hematocrit and thus
compromises systemic oxygen transport without lower-
Recommendation-Specific
ing viscosity.S3.16-3 Symptoms mimic those of hyperviscos-
Supportive Text ity. Consequences of iron deficiency may include stroke
1. Patients with ACHD sometimes have significant and myocardial ischemia,S3.16-4–S3.16-6 although published
morbidities not amenable to effective medical or findings are inconsistent. Iron deficiency requires assess-
surgical treatment and may be best managed using ment of serum iron, ferritin, and transferrin levels, be-
the consultative expertise of palliative care special- cause mean corpuscular volume is not a reliable screen-
ists. Accurate predictions of prognosis in ACHD are ing test.S3.16-7 Limited data suggest that treatment of
difficult, and patients commonly receive aggressive transferrin saturation <20% with iron supplementation
treatments during their terminal admission.S3.15-4 until iron stores are replete can be done safely.S3.16-8
There is a discrepancy between patient-reported in- Although there is an exponential relationship be-
terest in discussing advance directives and physician- tween viscosity and hematocrit, available data do not
reported discussions, with more patients interested in justify a cut point for a ”safe” hematocrit.S3.16-3 There is
such discussions than recognized by providers.S3.15-1, no clear correlation between viscosity, iron deficiency,
S3.15-2
Early discussion of advance planning is favored and a patient’s symptoms or clinical condition.S3.16-3 The
by nearly twice as many patients as physicians.S3.15-3 nature and cause of hyperviscosity symptoms are not
Early discussion of end-of-life issues is consistent well understood. The severity and frequency of symp-
with patient-centered care and patient satisfaction toms of hyperviscosity do not correlate with measured
and can facilitate palliative care. Although discuss- hematocrit. Phlebotomy is, therefore, rarely necessary
ing end-of-life options would seem appropriate for in patients with secondary erythrocytosis, and routine
all patients, there are circumstances (eg, cultural or phlebotomy is not supported by data. Patients with
cognitive) when those conversations may not be suspected hyperviscosity need to be rehydrated either

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Stout et al 2018 ACHD Guideline

with oral fluids or intravenous normal saline solution Table 12.  Specific Management Practices for Cyanotic CHD

CLINICAL STATEMENTS
as a first-line therapy, evaluated for iron deficiency, and Recording clinical oxygen saturation at rest (>5 min) rather than

AND GUIDELINES
treated if appropriate. Phlebotomy (with equal volume immediately after effort (eg, walking into a clinic examination room).
fluid replacement) is sometimes performed in special Meticulous intravenous care to avoid air or particulate matter, which may
cases wherein, after adequate hydration, hematocrit include use of air/particulate filters on all intravenous access lines, when
feasible, and careful de-airing of all lines.
remains higher than the patient’s baseline and symp-
Cerebral imaging for any new headache or neurologic sign to assess for
toms persist, or there is evidence of end-organ damage
possible cerebral abscess, hemorrhage, or stroke.
attributable to hyperviscosity (eg, myocardial ischemia,
Measurement of serum uric acid and treatment with allopurinol in a
transient ischemic attack/stroke).S3.16-9,S3.16-10 patient with a history of gout.
Observational studies in cyanotic individuals have
Supplemental oxygen as needed for symptom relief but not to a target
shown evidence of altered synthesis and function of oxygen saturation level and not if there is no demonstrable symptomatic
clotting factors that may contribute to both hypo- and benefit.
hypercoagulability,S3.16-11,S3.16-12 and thrombosis and Avoidance of or cautious use of therapies that may reduce the patient’s
bleeding (particularly epistaxis or hemoptysis) have hypoxia-mediated drive to ventilation, such as narcotics or, in rare
circumstances, excess supplemental oxygen.S3.16-22
been described in patients with Eisenmenger syndrome,
which may be life-threatening.S3.16-13–S3.16-15 These dispa- Anesthesia by providers with expertise in anesthesia for patients with
ACHD for any noncardiac surgery.
rate trends preclude developing universally applicable
Non-estrogen–containing birth control for women of child-bearing
recommendations, including use of antiplatelet or an-
potential (intrauterine device may be a preferred option). Avoidance of
ticoagulant therapy in these patients.S3.16-16 Similarly, birth control entirely is not a safe, acceptable option.
there is not a clear role for preoperative phlebotomy to Patients can travel safely on commercial airlines without undue risk.S3.16-23
improve coagulation properties. Preflight simulation testing or mandated supplemental oxygen are not
Cyanotic heart disease is a multisystem disorder. usually indicated, although adequate hydration and movement during the
flight are appropriate.
Manifestations, in addition to those already discussed,
include renal dysfunction, gout, infections, and osteoar- Measurement of coagulation parameters (eg, activated partial
thromboplastin time, international normalized ratio, thrombin time) in
thropathy. Alterations can be found of myocardial,S3.16-17, a patient with an elevated hematocrit >55% requires adjustment of
S3.16-18
cerebral,S3.16-19 and retinal blood flow,S3.16-20 and anticoagulant volume in the blood collection vials to account for reduced
plasma volume in the draw.S3.16-24
kidney function.S3.16-21 Providers should recognize mul-
tiorgan susceptibility and avoid treatments that may ACHD indicates adult congenital heart disease and CHD, congenital heart
disease.
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have adverse noncardiac effects. Additional practices


that may contribute to effective management of cya-
notic patients are listed in Table 12. ered. However, studies in patients with ACHD do exist
See Online Data Supplement 25 for referenced studies. and evaluate conventional pharmacological therapy, es-
pecially for HF and for arrhythmia, including beta block-
ers, angiotensin-converting enzyme inhibitors, angio-
3.17. Pharmacological Therapy for ACHD tensin-receptor blockers, and aldosterone antagonists,
Patients with ACHD are commonly excluded from clin- although results vary.S3.17-2–S3.17-9
ical trials, and there are few data to guide pharma- Pharmacological therapies in patients with ACHD
cological therapies. Although it may be tempting to are often directed to specific conditions (ie, beta block-
extrapolate from management guidelines developed ers for arrhythmia treatment). However, there are lim-
for patients without CHD (eg, HF guidelines),S3.17-1 ited data examining the benefits of beta blockers in
treatments may not have the same benefit in the het- specific ACHD populations. Results from a small study
erogeneous population of patients with ACHD and in indicate that beta-blocker therapy may have potential
some cases may cause harm. The evaluation of new to improve functional class in patients with a systemic
symptoms in a patient with ACHD must be tailored right ventricle and a pacemaker.S3.17-2 Angiotensin-
to the patient’s anatomy, surgical repair, and physiol- converting enzyme inhibitors and angiotensin-recep-
ogy. Before considering pharmacological therapies, e- tor blockers have also been assessed in small studies
valuation for residual shunts, baffle stenosis, valvular in specific ACHD populations in which no significant
or conduit dysfunction, and collateral vessels, any of benefit on ventricular function or exercise capacity has
which may be amenable to interventions, is an impor- been proven.S3.17-6–S3.17-8 Data from 1 small trial with
tant consideration. a short follow-up interval in patients with a systemic
The literature documenting pharmacological thera- right ventricle suggest that eplerenone may be associ-
pies for patients with ACHD is limited to small studies ated with reduced myocardial fibrosis, as assessed by
with limited duration of drug administration and fol- imaging.S3.17-3
low-up. Additionally, the endpoints used are often sur- Some pharmacological therapies affecting the pul-
rogate markers that have not been validated for clinical monary vasculature (eg, endothelin-receptor antago-
decision-making, and studies are also often underpow- nists and phosphodiesterase type-5 [PDE-5] inhibitors)

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Stout et al 2018 ACHD Guideline

have a beneficial effect on long-term outcomes in pa- Recommendations for Atrial Septal Defect (Continued)
CLINICAL STATEMENTS

tients with Eisenmenger syndrome.S3.17-10 Similarly, there


AND GUIDELINES

COR LOE Recommendations


are limited data on the use of pulmonary vasodilator
Therapeutic (Continued)
therapy in Fontan patients, in whom the pulmonary vas-
6. In asymptomatic adults with isolated
cular resistance may be abnormal.S3.17-11–S3.17-13 Because secundum ASD, right atrial and RV
of the lack of data, clinical recommendations regarding enlargement, and net left-to-right shunt
pharmacological therapy for patients with ACHD are sufficiently large to cause physiological
sequelae (eg, Qp:Qs 1.5:1 or greater),
unsupported. Individualized care is needed, recognizing without cyanosis at rest or during exercise,
the potential benefits and risks of the therapy relative IIa C-LDSR
transcatheter or surgical closure is reasonable
to patient-specific anatomic and physiological issues. to reduce RV volume and/or improve
functional capacity, provided that systolic PA
See Online Data Supplement 22 for referenced pressure is less than 50% of systemic pressure
studies. and pulmonary vascular resistance is less than
one third systemic resistance.S4.1.1-7–S4.1.1-10,S4.1.1-12
7. Surgical closure of a secundum ASD in
4. SPECIFIC LESIONS adults is reasonable when a concomitant
surgical procedure is being performed and
4.1. Shunt Lesions IIa C-LD
there is a net left-to-right shunt sufficiently
large to cause physiological sequelae (eg,
4.1.1. Atrial Septal Defect Qp:Qs 1.5:1 or greater) and right atrial and
RV enlargement without cyanosis at rest or
Recommendations for Atrial Septal Defect
during exercise.S4.1.1-15–S4.1.1-18
Referenced studies that support recommendations are summarized
in Online Data Supplement 26 and the systematic review 8. Percutaneous or surgical closure may be
report.S4.1.1-1 considered for adults with ASD when net
left-to-right shunt (Qp:Qs) is 1.5:1 or
COR LOE Recommendations greater, PA systolic pressure is 50% or
IIb B-NR
Diagnostic more of systemic arterial systolic pressure,
and/or pulmonary vascular resistance is
1. Pulse oximetry at rest and during exercise is greater than one third of the systemic
recommended for evaluation of adults with resistance.S4.1.1-19,S4.1.1-20
I C-EO unrepaired or repaired ASD with residual
shunt to determine the direction and 9. ASD closure should not be performed in
magnitude of the shunt. adults with PA systolic pressure greater than
III: Harm C-LD two thirds systemic, pulmonary vascular
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2. CMR, CCT, and/or TEE are useful to evaluate resistance greater than two thirds systemic,
I B-NR pulmonary venous connections in adults and/or a net right-to-left shunt.S4.1.1-21,S4.1.1-22
with ASD.S4.1.1-2–S4.1.1-4
3. Echocardiographic imaging is
I B-NR recommended to guide percutaneous Synopsis
ASD closure.S4.1.1-5,S4.1.1-6
Therapeutic
ASDs are common and may occur as a consequence of
different anatomic defects, including secundum ASD,
4. In adults with isolated secundum ASD
causing impaired functional capacity, right primum ASD, sinus venosus defect (not properly a de-
atrial and/or RV enlargement, and net left- fect in the atrial septum but considered in this section),
to-right shunt sufficiently large to cause and coronary sinus septal defect. Left-to-right shunting
physiological sequelae (eg, pulmonary–
systemic blood flow ratio [Qp:Qs] ≥1.5:1) may result in right heart enlargement and RV dysfunc-
I B-NRSR
without cyanosis at rest or during exercise, tion and, in a minority of patients, PAH. Some patients
transcatheter or surgical closure to reduce may have right-to-left shunting or paradoxical embo-
RV volume and improve exercise tolerance
is recommended, provided that systolic PA lism, and some may develop arrhythmias. Percutaneous
pressure is less than 50% of systolic systemic device or surgical closure are the mainstays of therapy
pressure and pulmonary vascular resistance in those with hemodynamic or clinical consequences of
is less than one third of the systemic vascular
resistance.S4.1.1-7–S4.1.1-12 the defect. Severe PAH is a contraindication to closure,
and its presence must be accurately excluded before
5. Adults with primum ASD, sinus venosus
defect or coronary sinus defect causing closure.S4.1.1-21–S4.1.1-23
impaired functional capacity, right atrial and/ ASD may occur with other congenital cardiac ab-
or RV enlargement and net left-to-right
normalities. In some circumstances, such as in patients
shunt sufficiently large to cause physiological
sequelae (eg, Qp:Qs ≥1.5:1) without cyanosis with Ebstein anomaly and pulmonary stenosis (PS) or
I B-NR
at rest or during exercise, should be surgically right HF, the physiology related to the ASD is substan-
repaired unless precluded by comorbidities,
tially more complex, and ASD closure could result in
provided that systolic PA pressure is less than
50% of systemic pressure and pulmonary clinical deterioration. Therefore, these recommenda-
vascular resistance is less than one third of the tions regarding ASD address only isolated ASDs and not
systemic vascular resistance.S4.1.1-13,S4.1.1-14
ASD associated with complex CHD.

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Stout et al 2018 ACHD Guideline

The “Interventional Therapy Versus Medical Therapy 3. It is considered standard of care to use echocar-

CLINICAL STATEMENTS
for Secundum Atrial Septal Defect: A Systematic Review diographic imaging to guide closure of interatrial

AND GUIDELINES
(Part 2) for the 2018 AHA/ACC Guideline for the Man- communications. TEE and intracardiac echocar-
agement of Adults With Congenital Heart Disease”S4.1.1-1 diography are the most widely studied and used
has additional data and analyses. The results from the modalities for guidance of ASD closure. Defect
question “Are outcomes in asymptomatic patients with size, defect morphology, atrial rim adequacy, pul-
unoperated secundum ASD and RV dilatation improved monary venous anomalies, and left atrial append-
after percutaneous or surgical closure?” and the writing age thrombus can all be evaluated using TEE.
committee’s review of the totality of the literature were Echocardiography is also used to determine sizing
used to frame decision-making. Recommendations that either by balloon diameter producing complete
are based on a body of evidence that includes the sys- occlusion of the defect (”stop flow” diameter)
tematic review conducted by the ERC are denoted by or by direct visualization and measurement using
the superscript SR (eg, LOE B-RSR). intracardiac echocardiography. Echocardiography
See Section 3.3 for recommendations on who should can assess for pericardial effusion and for thrombi
perform surgeries, cardiac catheterization, and other on wires or devices. TTE has also been studied
procedures in these patients; Section 3.4 for recom- for guiding percutaneous ASD closure but is not
mendations on diagnostic evaluation; Section 4.4.6 for widely used for this purpose.
evaluation and management of severe PAH and Eisen- 4. Cardiac catheterization is performed at the time of
menger syndrome; and Figure 1 for a diagnostic and transcatheter ASD closure. Provided noninvasive
treatment algorithm for secundum ASD. See Table 13 imaging is of sufficiently high quality to estimate
for routine follow-up and testing intervals. pulmonary artery pressures and shunt magni-
tude, not every patient with an ASD requires a
diagnostic catheterization before surgical closure.
Recommendation-Specific However, a diagnostic catheterization may be
Supportive Text necessary to determine detailed hemodynamics
1. Pulse oximetry is useful in defining shunt direction for decision-making or to clarify discrepant or
at rest and with exercise, which will help guide deci- inconclusive noninvasive imaging data. Patients
sions regarding therapeutic options. Pulse oximetry with reduced functional capacity presumed
caused by hemodynamically important secun-
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at rest and with exercise may identify patients with


increased pulmonary arterial resistance and shunt dum ASD (moderate or large left-to-right shunt
reversal. In a subset of patients with resting sys- and evidence of right heart volume overload in
temic oxygen saturation >90%, a decrease in ox- the absence of significant PAH) benefit from sur-
ygen saturation with activity to <90% may occur, gical or transcatheter closure of the secundum
emphasizing the importance of performing resting ASD.S4.1.1-8,S4.1.1-10 Patients who do not undergo
and ambulatory pulse oximetry assessment. ASD closure have worse long-term outcomes,
2. TTE has limited use in assessment of anomalous including more atrial arrhythmias, reduced func-
pulmonary venous connections in adults with tional capacity, and eventually greater degrees
ASD. Moreover, the poor visualization of the su- of PAH. Older adults should be evaluated for
perior and posterior atrial septum by TTE in adults left atrial hypertension resulting from diastolic
may require testing with other imaging modalities dysfunction, which may cause similar symptoms
to clearly define septal anatomy. TEE is excellent but could result in clinical worsening after ASD
for visualization of the entire atrial septum as well closure because of further increase in left atrial
as pulmonary venous connections. Anomalous pressures when blood from the relatively restric-
right upper and middle lobe pulmonary venous tive and higher pressure left atrium can no longer
connections often occur in combination with su- decompress into the lower pressure right atrium.
perior sinus venosus defect; TEE is excellent for Cyanosis with exercise typically occurs in associ-
visualization of this combination but may not vis- ation with poor RV diastolic compliance and he-
ualize other anomalous pulmonary venous con- modynamics with exercise, and the ASD acts as a
nections. Cross-sectional imaging with CMR or “pop-off” to maintain cardiac output. However,
CCT is ideal for delineating pulmonary venous exercise-induced cyanosis is not an absolute con-
connections, particularly those that are associated traindication to ASD closure, because there are
with veins that may be difficult or impossible to rare cases of either streaming or directed tricuspid
image by echocardiography (eg, innominate vein regurgitation (TR) leading to right-to-left shunting
or vertical vein). CMR has the advantages of not with exercise not related to abnormal RV diastolic
involving ionizing radiation and ability to quantify pressures that may allow for closure after expert
degree of shunting. evaluation. Data are most compelling that closure

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Stout et al 2018 ACHD Guideline
CLINICAL STATEMENTS
AND GUIDELINES

Figure 1. Secundum ASD.


*Combination therapy with bosentan and PDE-5 inhibitor if symptomatic improvement does not occur with either alone. ACHD indicates adult congenital heart
disease; ASD, atrial septal defect; PAH, pulmonary artery hypertension; PASP, pulmonary artery systolic pressure; PDE-5, phosphodiesterase type-5 inhibitors; PH,
pulmonary hypertension; and Qp:Qs, pulmonary–systemic blood flow ratio.
Downloaded from http://ahajournals.org by on October 27, 2019

improves functional status, although some de- pulmonary venous connection and abnormalities
scriptive studies support improved long-term out- of the atrioventricular valves.S4.1.1-24,S4.1.1-25
comes after closure as well.S4.1.1-7–S4.1.1-12 6. Patients who do not undergo ASD closure have
5. Available percutaneously deployed ASD closure worse long-term outcomes, including more atrial
devices are approved for closure of secundum- arrhythmias, reduced functional capacity, and
type defects. Primum, sinus venosus, and coronary eventually greater degrees of PAH.S4.1.1-7–S4.1.1-10,
sinus ASDs should be closed surgically because S4.1.1-12
However, concomitant diseases may in-
of the absence of appropriate rims for percuta- fluence the anticipated benefit of ASD closure
neous device placement and the proximity of the in ameliorating symptoms and improving func-
atrioventricular valves and conduction system to tional capacity, and it has not been clearly dem-
the closure device. Congenital heart surgeons are onstrated that ASD closure in asymptomatic
trained in the nuances of repair of such defects, adults prevents long-term complications. Data
including common association with anomalous suggest that ASD closure improves functional

Table 13.  ASD: Routine Follow-Up and Testing Intervals

Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological


and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 36–60 24 6–12 3–6
ECG 36–60 24 12 12
TTE 36–60 24 12 12
Pulse oximetry As needed As needed Each visit Each visit
Exercise test† As needed As needed 12–24 6–12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†6-minute walk test or CPET, depending on the clinical indication.
ACHD indicates adult congenital heart disease; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; and TTE,
transthoracic echocardiogram.

e728 April 2, 2019 Circulation. 2019;139:e698–e800. DOI: 10.1161/CIR.0000000000000603


Stout et al 2018 ACHD Guideline

capacity but, in patients with normal functional Recommendations for Anomalous Pulmonary Venous Connections

CLINICAL STATEMENTS
capacity, the long-term benefit of ASD closure is (Continued)

AND GUIDELINES
less clear.S4.1.1-1,S4.1.1-9 Pending further study, it is COR LOE Recommendations
reasonable to close an ASD that is hemodynami- Diagnostic (Continued)
cally important in the absence of significant PAH. 2. Cardiac catheterization can be useful in
Older adults should be evaluated for left atrial adults with partial anomalous pulmonary
IIa B-NR
hypertension resulting from diastolic dysfunction venous connection to further define
hemodynamics.S4.1.2-5,S4.1.2-6
that may cause symptoms simulating those from
an ASD alone, in whom ASD closure could result Therapeutic

in clinical worsening because of further increase 3. Surgical repair is recommended for patients
with partial anomalous pulmonary venous
in left atrial pressure because the relatively restric- connection when functional capacity is
tive and higher pressure left atrium can no longer impaired and RV enlargement is present,
decompress into the lower pressure right atrium. I B-NR
there is a net left-to-right shunt sufficiently
large to cause physiological sequelae (eg,
Concomitant tricuspid annuloplasty can be of Qp:Qs ≥1.5:1), PA systolic pressure is less
benefit in patients with moderate or more TR, as than 50% systemic pressure, and pulmonary
the additional volume load may adversely affect vascular resistance is less than one third of
systemic resistance.S4.1.2-5
RV remodeling.
7. If surgical treatment is necessary for other con- 4. Repair of partial anomalous pulmonary
venous connection is recommended at the
genital or acquired cardiac conditions and the I B-NR
time of closure of a sinus venosus defect or
patient has a secundum ASD, it is reasonable to ASD.S4.1.2-7
perform ASD closure at the time of surgery. When 5. Repair of a scimitar vein is recommended in
there is moderate or greater TR, tricuspid valve adults when functional capacity is impaired,
evidence of RV volume overload is present,
repair may improve RV remodeling. there is a net left-to-right shunt sufficiently
8. To evaluate the patient with PAH and ASD, ensure I B-NR large to cause physiological sequelae (eg,
the shunt remains left to right despite elevated Qp:Qs ≥1.5:1), PA systolic pressure is less
than 50% systemic pressure and pulmonary
pulmonary vascular resistance and/or pulmonary vascular resistance is less than one third
pressure and that pulmonary pressure and PVR systemic.S4.1.2-5,S4.1.2-8,S4.1.2-9
are accurately measured. In this circumstance, 6. Surgery can be useful for right- or left-
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data derived from invasive hemodynamic assess- sided partial anomalous pulmonary venous
ment are important in clarifying the appropriate connection in asymptomatic adults with
RV volume overload, net left-to-right shunt
course of action. The exclusion of patients with IIa B-NR
sufficiently large to cause physiological sequelae
severe PAH from ASD closure may eventually (eg, Qp:Qs ≥1.5:1), pulmonary pressures less
be obviated by PA vasodilator and remodeling than 50% systemic and pulmonary vascular
resistance less than one third systemic.S4.1.2-5
therapy with prostaglandins, endothelin blockers,
7. Surgery can be useful for repair of a
and PDE-5 inhibitors. Because of the complexity scimitar vein in adults with evidence of
of the hemodynamics in such patients, collabo- IIa B-NR
RV volume overload, with Qp:Qs 1.5:1 or
ration between ACHD and pulmonary hyperten- greater.S4.1.2-5,S4.1.2-9
sion providers is important. Pretreatment with
PAH therapies and pulmonary arterial remodeling
Synopsis
agents, with a demonstrated reduction in pulmo-
nary arterial resistance of >20%, portends a fa- Abnormal connection between a pulmonary vein and
vorable prognosis after ASD closure.S4.1.1-26 systemic vein will result in volume overload of the right
9. Morbidity and mortality are prohibitively high heart, with a physiological effect similar to that of an
when surgical repair is attempted in patients with ASD. However, in the absence of an associated ASD, a-
open shunts, such as ASD when Eisenmenger nomalous pulmonary venous connection differs in that
syndrome is present.S4.1.1-21,S4.1.1-22 there is no potential for right-to-left shunting, and the
magnitude of the left-to-right shunt is not exacerbated
4.1.2. Anomalous Pulmonary Venous Connections by the development of acquired left heart disease. The
Recommendations for Anomalous Pulmonary Venous Connections most common anomalous pulmonary venous connec-
Referenced studies that support recommendations are summarized tion is of the right upper pulmonary vein to the superior
in Online Data Supplement 27.
vena cava,S4.1.2-10 which may be associated with a sinus
COR LOE Recommendations venosus defect. Other abnormal connections include
Diagnostic right pulmonary vein(s) to the inferior vena cava (often
1. CMR or CTA is recommended for evaluation via a so-called ”scimitar vein” and associated with se-
I B-NR of partial anomalous pulmonary venous questration of the right lower lobe), left upper pulmo-
connection.S4.1.2-1–S4.1.2-4
nary vein(s) to the left innominate vein, and right upper

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Stout et al 2018 ACHD Guideline

pulmonary vein(s) connecting high on the superior vena abnormalities.S4.1.2-10 Pulmonary hypertension is
CLINICAL STATEMENTS

cava. Long-term sequelae of anomalous pulmonary ve- associated with poor outcomes.
AND GUIDELINES

nous connections reflect the impact of right heart vol- 6. It is unusual for a single anomalous pulmonary
ume overload and are similar to the sequelae of ASDs. venous connection from only one pulmonary lobe
Surgical repair can be challenging as low-velocity ve- to result in a sufficient volume load to justify sur-
nous flow imparts risk of thrombosis of the surgically gical repair. However, if there is >1 anomalous
operated vein. vein and a moderate or large left-to-right shunt,
See Section 3.3 for recommendations on who then surgical repair is associated with a reduction
should perform surgeries, cardiac catheterization, and in RV size and PA pressure and can be useful.S4.1.2-5
other procedures in these patients; Section 3.4 for rec- 7. Surgical repair of a scimitar vein includes direct
ommendations on diagnostic evaluation; and Section reimplantation of the scimitar vein into the left
4.4.6 for evaluation and management of severe PAH atrium, side-to-side anastomosis of the scimitar
and Eisenmenger syndrome. vein to the left atrium and closure of its connec-
tion to the inferior vena cava or intracaval baff-
Recommendation-Specific ling. This surgery can be technically challenging
with a greater risk of postoperative vein throm-
Supportive Text
bosis than is associated with simpler anomalous
1. Cross-sectional imaging with CMR or CTA is ideal pulmonary vein abnormalities.S4.1.2-10
for delineating pulmonary venous connections.
CMR has the advantage of not using ionizing 4.1.3. Ventricular Septal Defect
radiation and may also quantify the degree of
Recommendations for Ventricular Septal Defect
shunting. Echocardiography is an important part Referenced studies that support recommendations are summarized
of the evaluation and may identify the anomalous in Online Data Supplement 28.
veins,S4.1.2-11 particularly in patients with excel- COR LOE Recommendations
lent acoustic windows; however, CMR and CTA
Therapeutic
are superior for evaluating extracardiac vascular
1. Adults with a VSD and evidence of
anatomy. left ventricular volume overload and
2. In higher-risk patients, invasive hemodynamic hemodynamically significant shunts (Qp:Qs
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assessment can be useful for direct measurement I B-NR ≥1.5:1) should undergo VSD closure, if PA
systolic pressure is less than 50% systemic
of pressures, quantification of shunt magnitude, and pulmonary vascular resistance is less
and measurement of pulmonary arterial resist- than one third systemic.S4.1.3-1
ance and responsiveness to pulmonary vasodi- 2. Surgical closure of perimembranous or
lator therapy. Invasive hemodynamic assessment IIa C-LD
supracristal VSD is reasonable in adults when
is especially important in adult patients who are there is worsening aortic regurgitation (AR)
caused by VSD.S4.1.3-1,S4.1.3-2
being considered for surgical correction.
3. Surgical closure of a VSD may be reasonable
3. It is unusual for a single anomalous pulmonary IIb C-LD in adults with a history of IE caused by VSD
venous connection of only 1 pulmonary lobe to if not otherwise contraindicated.S4.1.3-3
result in a sufficient volume load to justify sur- 4. Closure of a VSD may be considered in the
gical repair. However, if a patient has symptoms presence of a net left-to-right shunt (Qp:Qs
referable to the shunt, there is >1 anomalous ≥1.5:1) when PA systolic pressure is 50%
IIb C-LD
or more than systemic and/or pulmonary
vein, and a moderate or large left-to-right shunt, vascular resistance is greater than one third
then surgical repair is associated with a reduc- systemic.S4.1.3-4–S4.1.3-6
tion in RV size and PA pressure.S4.1.2-5 Pulmonary 5. VSD closure should not be performed in
hypertension is a risk for adverse outcomes adults with severe PAH with PA systolic
pressure greater than two thirds systemic,
with surgery. III: Harm C-LD
pulmonary vascular resistance greater than
4. Surgery usually involves intracaval baffling into two thirds systemic and/or a net right-to-left
the left atrium, Warden procedure,S4.1.2-12 or direct shunt.S4.1.3-7–S4.1.3-9
reimplantation of the anomalous pulmonary vein
directly into the left atrium.
5. Surgical repair of a scimitar vein includes direct
Synopsis
reimplantation of the scimitar vein into the left Ventricular septal defects (VSDs) initially create a vol-
atrium, conduit placement to the left atrium, or ume load to the left heart, and the magnitude of he-
intracaval baffling. This surgery can be technically modynamic impact is directly related to the size of the
challenging with a greater risk of postoperative shunt and afterload to the ventricles. Isolated VSDs are
vein thrombosis than is associated with more the most commonly encountered form of CHD in the
common and simpler anomalous pulmonary vein pediatric population.S4.1.3-10–S4.1.3-14 Most isolated mus-

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Stout et al 2018 ACHD Guideline

cular and perimembranous VSDs are small and close management of severe PAH and Eisenmenger

CLINICAL STATEMENTS
spontaneously. The spectrum of isolated residual VSDs syndrome; Figure 2 for a diagnostic and treatment

AND GUIDELINES
encountered in the adult patient includes: algorithm for ventricular level shunt; and Table 14
1. Small restrictive defects. The pulmonary vascular for routine testing and follow-up intervals.
resistance is not significantly elevated and the
left-to-right shunt is small (Qp:Qs <1.5:1).
2. Large nonrestrictive defects in cyanotic patients
Recommendation-Specific
who have developed Eisenmenger syndrome, Supportive Text
with pulmonary vascular resistance at systemic 1. In the absence of aortic valve prolapse and regur-
levels and shunt reversal (right-to-left). gitation or IE, small restrictive defects of the mus-
3. Patients with moderately restrictive defects (Qp:Qs cular or membranous septum may be watched
≥1.5:1 and <2:1) who have not undergone clo- conservatively without need for operative inter-
sure for some reason. These patients often have vention. In a long-term follow-up registry, the
mild-to-moderate PAH. overall survival rate was 87% for all patients with
4. Patients who have had their defects closed in unoperated VSD at 25 years.S4.1.3-1 For patients with
childhood. These patients may have VSD patch small defects (Qp:Qs <1.5:1 and low PA pressure),
leaks.See Section 3.3 for recommendations on the survival rate was 96%. Patients with moderate
who should perform surgeries, cardiac catheter- and large defects fared worse with 25-year sur-
ization, and other procedures in these patients; vival of 86% and 61%, respectively. Those with
Section 3.4 for recommendations on diagnostic Eisenmenger syndrome (cyanosis/hypoxemia
evaluation; Section 4.4.6 for evaluation and caused by reversal of shunt to right-to-left) had a
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Figure 2. Hemodynamically significant ventricular level shunt.


*Combination therapy with bosentan and PDE-5 inhibitor, if symptomatic improvement does not occur with either alone. ACHD indicates adult congenital heart
disease; AR, aortic regurgitation; IE, infective endocarditis; LV, left ventricular; PAH, pulmonary artery hypertension; PASP, pulmonary artery systolic pressure; PDE-5,
phosphodiesterase type-5 inhibitors; PH, pulmonary hypertension; Qp:Qs, pulmonary–systemic blood flow ratio; and VSD, ventricular septal defect.

Circulation. 2019;139:e698–e800. DOI: 10.1161/CIR.0000000000000603 April 2, 2019 e731


Stout et al 2018 ACHD Guideline

Table 14.  VSD: Routine Follow-Up and Testing Intervals


CLINICAL STATEMENTS

Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological


AND GUIDELINES

and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 36 24 6–12 3–6
ECG 36 24 12 12
TTE 36 24 12 12
Pulse oximetry As needed As needed Each visit Each visit
Exercise test† As needed As needed 12–24 6–12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†6-minute walk test or CPET, depending on the clinical circumstance.
ACHD indicates adult congenital heart disease; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; TTE, transthoracic
echocardiogram; and VSD, ventricular septal defect.

much lower 25-year survival (42%). Larger defects mortality, and the practice was quickly abandoned.
may be repaired but only in the absence of severe However, there are adult patients with large VSD
PAH and severely elevated pulmonary vascular re- and PAH who may benefit from closure of the VSD
sistance, the presence of which incurs a high peri- if the net shunt is left-to-right either at baseline or
operative risk.S4.1.3-15 with PAH therapies. The use of fenestrated devices
Life expectancy after VSD closure in an adult is and fenestrated surgical patches in these patients
not normal but has improved over the past 50 years. leaves a small residual shunt to allow decompres-
Transcatheter device occlusion of muscular and peri- sion of the right heart.S4.1.3-5,S4.1.3-6 In theory, treat-
membranous VSD is feasible, and trials have dem- ment of these patients with PAH therapies before
onstrated a good safety and efficacy profile.S4.1.3-16, closure could improve outcomes.
S4.1.3-17
VSD in adults is most commonly either small, 5. Closure of nonrestrictive VSD in adults with
or large and associated with Eisenmenger syn- Eisenmenger syndrome who do not demonstrate
drome; therefore, data regarding optimal manage- left-to-right shunting and a decline in pulmo-
ment of moderate VSD in adults are lacking because nary vascular resistance with PAH therapies car-
of relative infrequency of a hemodynamically signif-
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ries a high risk of mortality and should not be


icant VSD for which closure is an option. performed.S4.1.3-7-S4.1.3-9
2. Small restrictive defects of the muscular or mem-
branous septum may be managed by observa- 4.1.4. Atrioventricular Septal Defect
tion without need for operative intervention. Recommendations for Atrioventricular Septal Defect
However, 6% of patients with small supracristal Referenced studies that support recommendations are summarized
(subaortic) or perimembranous defects may de- in Online Data Supplement 29.
velop aortic valve prolapse and resultant AR that COR LOE Recommendations
may be progressive.S4.1.3-1,S4.1.3-2,S4.1.3-18 There is a Diagnostic
paucity of data supporting the timing of VSD clo- 1. Cardiac catheterization can be useful in
sure in patients with AR. Ideally, the VSD is closed IIa C-EO adults with atrioventricular septal defect
if AR is progressive to avoid the continued wors- when pulmonary hypertension is suspected.

ening of AR and the need for aortic valve replace- Therapeutic


ment. In the presence of a VSD, an aortic valve 2. Surgery for severe left atrioventricular
cusp (usually the right coronary cusp) may pro- I C-LD
valve regurgitation is recommended
per GDMT indications for mitral
lapse and partially or completely close the VSD, regurgitation.S4.1.4-1–S4.1.4-4
often with associated AR. At the time of VSD
3. Surgery for primary repair of atrioventricular
closure, aortic valve repair may be performed in septal defect or closure of residual shunts in
an effort to stabilize or improve AR. For patients adults with repaired atrioventricular septal
who meet GDMT criteria for aortic valve replace- defect is recommended when there is a
I C-EO
net left-to-right shunt (Qp:Qs ≥1.5:1), PA
ment, this may be performed concomitant with systolic pressure less than 50% systemic and
VSD closure.S4.1.3-19 pulmonary vascular resistance less than one
3. In patients with unrepaired VSD, there is an third systemic.

increased risk of IE, typically involving the tricuspid 4. Operation for discrete LVOT obstruction in
adults with atrioventricular septal defect is
and pulmonic valves. reasonable with a maximum gradient of 50
4. Early attempts at surgical closure of nonrestric- IIa C-EO
mm Hg or greater, a lesser gradient if HF
tive VSD in patients with Eisenmenger syndrome symptoms are present, or if concomitant
moderate-to-severe mitral or AR are present.
were associated with an unacceptably high risk of

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Stout et al 2018 ACHD Guideline

Recommendations for Atrioventricular Septal Defect (Continued) most effective and efficient timing and type of surveil-

CLINICAL STATEMENTS
lance are still being evaluated.

AND GUIDELINES
COR LOE Recommendations
The atrioventricular node is typically displaced infe-
Therapeutic (Continued)
riorly in AVSD and is associated with relative hypopla-
5. Surgery for primary repair of atrioventricular
septal defect or closure of residual shunts in
sia of the left anterior fascicle.S4.1.4-9 Late-onset com-
adults with repaired atrioventricular septal plete heart block (as late as 15 years after surgery) has
IIb C-EO
defect may be considered in the presence of been noted after surgery in patients operated on for
a net left-to-right shunt (Qp:Qs ≥1.5:1), if PA
systolic pressure is 50% or more systemic,
AVSD who were discharged from the hospital with
and/or pulmonary vascular resistance is normal conduction, although more commonly seen
greater than one third systemic. in those patients with transient postoperative heart
6. Surgery for primary repair of atrioventricular block. Regular monitoring for symptoms and screening
septal defect or closure of residual shunts in with an ECG are important to evaluate for conduction
adults with repaired atrioventricular septal
defect should not be performed with PA abnormalities.S4.1.4-10
III: Harm C-LD
systolic pressure greater than two thirds See Section 3.3 for recommendations on who
systemic, pulmonary vascular resistance should perform surgeries, cardiac catheterization,
greater than two thirds systemic, or a net
right-to-left shunt.S4.1.4-5,S4.1.4-6 and other procedures in these patients; Section 3.4
for recommendations on diagnostic evaluation; Sec-
tion 4.1.1 for recommendations on primum ASD;
Synopsis Section 4.4.6 for evaluation and management of se-
AVSDs represent about 4% to 5% of congenital heart vere PAH and Eisenmenger syndrome associated with
defects and include a primum ASD, inlet VSD, and com- AVSD; and Table 15 for routine testing and follow-up
mon atrioventricular valve. They can occur in several intervals.
anatomic variations including partial AVSD with only a
primum ASD component and typically a cleft left atri-
oventricular valve, complete AVSD with both ASD and
Recommendation-Specific
VSD and a common atrioventricular valve, and transi- Supportive Text
tional and intermediate AVSD with incomplete atrial 1. Invasive hemodynamic assessment still has an im-
and VSDs and/or incomplete abnormalities of the com- portant role as a confirmatory tool and for the
mon atrioventricular valve. AVSD anatomy is also com- evaluation of pulmonary vasoreactivity, which
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monly described by the Rastelli classification.S4.1.4-7,S4.1.4-8 does carry prognostic significance for adults with
The Rastelli classification describes anatomic variations shunts.
of the superior bridging leaflet of the atrioventricular 2. Although the left atrioventricular valve in an
valve. In addition to the Rastelli classification or other AVSD malformation is not anatomically the
similar descriptors, the relative sizes of the ventricles as same as a mitral valve, one can extrapolate the
balanced or unbalanced guide the type of repair (eg, bi- criteria for consideration of left atrioventric-
ventricular or single ventricle repair). This section refers ular valve surgery from the VHD guideline for
to patients with balanced AVSD and biventricular repair. mitral regurgitation and mitral stenosis.S4.1.4-1
AVSD also occurs in association with other congenital In extrapolating these criteria, there are impor-
lesions including TOF, CoA, and heterotaxy. There is tant potential differences in this patient popula-
also a strong association with syndromes, most com- tion compared with those with acquired mitral
monly trisomy 21 (Down syndrome). valve disease. There are anatomic differences
From a management perspective, most adults with in position of the annulus, papillary muscles
AVSD will have had surgical repair as children. If those and the morphology of the LVOT, which is an
with complete AVSD (with large ASD and VSD) are not anterior, narrow, and potentially obstructed
repaired early in life (typically <6 months of age), ir- structure, such that congenital surgical exper-
reversible pulmonary vascular disease usually develops tise is needed. Patients with an AVSD have
resulting in Eisenmenger physiology, precluding com- typically had at least 1 prior attempt to repair
plete repair. For those who underwent a surgical repair, the AVSD, have different risks of arrhythmia,
long-term follow-up is required to monitor for left atri- and may have other anatomic lesions (eg, sub-
oventricular valve regurgitation and stenosis, left ven- aortic stenosis [subAS]). In 1 meta-analysis of
tricular outflow tract (LVOT) obstruction attributable to studies of adult left atrioventricular valve sur-
the abnormal shape of the LVOT, and tachyarrhythmias gery in patients with AVSD, the risk of needing
and bradyarrhythmias. Left atrioventricular valve regur- a pacemaker was higher in those who under-
gitation is the most common reason for later surgical went valve replacement than in those who un-
reintervention. There are few long-term follow-up stud- derwent repair.S4.1.4-2 In another single-center
ies of patients after AVSD repair in childhood, so the study, one third of repaired patients required

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Stout et al 2018 ACHD Guideline

Table 15.  AVSD: Routine Follow-Up and Testing Intervals


CLINICAL STATEMENTS

Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological


AND GUIDELINES

and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 24–36 24 6–12 3–6
ECG 24–36 24 12 12
TTE 24–36 24 12 12
Pulse oximetry As needed As needed Each visit Each visit
Exercise test† As needed As needed 12–24 6–12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†6-minute walk test or CPET, depending on the clinical indication.
ACHD indicates adult congenital heart disease; AVSD, atrioventricular septal defect; CPET, cardiopulmonary exercise testing;
ECG, electrocardiogram; and TTE, transthoracic echocardiogram.

an additional reoperation.S4.1.4-3 When replace- 5. Patients with AVSD, particularly those with Down
ment is required, the choice to use mechanical syndrome, are at high risk of developing pulmo-
versus bioprosthetic valve is individualized, but nary vascular disease resulting in Eisenmenger
a mechanical valve is usually necessary because syndrome.S4.1.4-18,S4.1.4-19 For those who continue
of the potential for LVOT obstruction from the to have a net left-to-right shunt despite elevated
struts of the bioprosthetic valve. Nevertheless, PA pressures, closure of the defect may prevent
valve repair is preferred to valve replacement exacerbation of PAH. This is an unusual circum-
when it is technically feasible. stance and decision-making requires collabora-
3. There are no large studies on residual shunts in tion with ACHD and pulmonary hypertension
patients with AVSD, but extrapolating from in- providers.
formation on residual isolated ASD or isolated 6. Morbidity and mortality are prohibitively high
VSD, a moderate or large residual shunt is likely when surgical repair is attempted in patients with
to result in worsening clinical status over time and open shunts such as AVSD when Eisenmenger
thus merits consideration of repair.S4.1.4-11–S4.1.4-13 syndrome is present.S4.1.4-5,S4.1.4-6
See Sections 4.1.1 and 4.1.3 for related consider-
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4.1.5. Patent Ductus Arteriosus


ations regarding ASD and/or VSD. Pulse oximetry
at rest and with ambulation may identify patients Recommendations for Patent Ductus Arteriosus
Referenced studies that support recommendations are summarized
with increased pulmonary resistance and shunt in Online Data Supplement 30.
reversal. There is a subset of patients with rest-
COR LOE Recommendations
ing systemic oxygen saturation >90% who will
Diagnostic
have a decrease in oxygen saturation with activity
to <90%, emphasizing the importance of per- 1. Measurement of oxygen saturation should
be performed in feet and both hands in
forming resting and ambulatory pulse oximetry I C-EO
adults with a PDA to assess for the presence
assessment. of right-to-left shunting.
4. Patients with AVSD are at risk of LVOT obstruc- 2. In addition to the standard diagnostic tools,
tion because of the abnormal anatomy of the IIa C-EO
cardiac catheterization can be useful in
patients with PDA and suspected pulmonary
LVOT. Surgical resection of LVOT obstruction in hypertension (Section 3.5).
association with AVSD is reasonable when there
Therapeutic
is moderate-to-severe obstruction or less obstruc-
3. PDA closure in adults is recommended if
tion but associated HF or mitral regurgitation or
left atrial or LV enlargement is present and
AR. In isolated subAS studies, worse outcomes attributable to PDA with net left-to-right
I C-LD
were revealed in patients with maximum gradi- shunt, PA systolic pressure less than 50%
systemic and pulmonary vascular resistance
ents ≥50 mm Hg or with gradients <50 mm Hg less than one third systemic.S4.1.5-1–S4.1.5-3
in association with symptoms of HF.S4.1.4-14–S4.1.4-17
4. PDA closure in adults may be considered in
Importantly the LVOT obstruction in AVSD may the presence of a net left-to-right shunt if PA
not be discrete and, therefore, surgical repair IIb B-NR systolic pressure is 50% or greater systemic,
may be more complex. When evaluating patients and/or pulmonary vascular resistance is
greater than one third systemic.S4.1.5-3,S4.1.5-4
with tunnel-like or complex LVOT obstruction,
5. PDA closure should not be performed in
the peak Doppler gradients and Bernoulli equa- adults with a net right-to-left shunt and
tion may inaccurately reflect the severity of ob- III: Harm C-LD PA systolic pressure greater than two thirds
struction, and cardiac catheterization may be systemic or pulmonary vascular resistance
greater than two thirds systemic.S4.1.5-5
needed.

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Stout et al 2018 ACHD Guideline

Table 16.  PDA: Routine Follow-Up and Testing Intervals

CLINICAL STATEMENTS
Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological

AND GUIDELINES
and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 36–60 24 6–12 3–6
ECG 36–60 24 12 12
TTE 36–60 24 12 12
Pulse oximetry† As needed As needed Each visit Each visit
Exercise test‡ As needed As needed 12–24 6–12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†Upper and lower extremity.
‡6-minute walk test or CPET, depending on the clinical indication.
ACHD indicates adult congenital heart disease; ECG, electrocardiogram; CPET, cardiopulmonary exercise test; PDA, patent ductus
arteriosus; and TTE, transthoracic echocardiogram.

Synopsis arterial resistance and dynamic shunt reversal in-


duced by exercise. A subset of patients with rest-
The ductus arteriosus is a vascular connection be-
ing systemic oxygen saturation >90% will have
tween the aorta and PA that is present in fetal life. It
a decrease in oxygen saturation with activity
typically closes shortly after birth but, in some people,
it will remain patent. Patent ductus arteriosus (PDA) is to <90%, emphasizing the importance of per-
found in about 0.3% to 0.8% of term infants and is forming resting and ambulatory pulse oximetry
twice as common in females as males.S4.1.5-6–S4.1.5-8 The assessment.
clinical and physiological manifestations of the PDA 2. Invasive hemodynamic assessment still has an im-
are dependent on the size of the vessel and the rel- portant role as a confirmatory tool and for the
ative systemic and pulmonary vascular resistances. evaluation of pulmonary vasoreactivity, which car-
The PDA can range from a small hemodynamically ries prognostic significance.S4.1.5-1,S4.1.5-4
insignificant lesion that is not heard on auscultation 3. When signs of volume overload are indicative of
to one that without intervention is large enough to significant left-to-right shunt, closing the PDA is
cause congestive HF and pulmonary hypertension. likely to prevent further left atrial or LV enlarge-
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Many PDAs are now closed in infancy or childhood ment, progression or development of PAH, and
with catheter-based or surgical approaches. For those pulmonary hypertension secondary to left HF
whose ductus remains patent in adulthood, catheter- and will possibly provide symptom relief if symp-
based or surgical intervention consideration depends toms are present. Closure is typically performed
on the symptoms and physiological expression of the percutaneously with good success and minimal
lesion. Follow-up of these patients as adults is impor- complications.S4.1.5-2 Pulmonary blood flow and
tant for all, although timing and testing will vary a- thus Qp:Qs can be difficult to calculate accurately
mong individuals. because of differences in right/left PA blood flow
See Section 3.3 for recommendations on who should caused by the flow from the PDA. Invasive he-
perform surgeries, cardiac catheterization, and other modynamics including pulmonary vascular resist-
procedures in these patients; Section 3.4 for recom- ance are generally relied on for decision-making.
mendations on diagnostic evaluation; Section 4.4.6 for Surgical closure can be performed but is poten-
recommendations on severe PAH (4.4.6.1) and Eisen- tially hazardous in adults because of calcification
menger syndrome (4.4.6.2) associated with PDA; and and tissue fragility.
Table 16 for routine testing and follow-up intervals. 4. Even with elevated pulmonary pressure and el-
evated pulmonary vascular resistance, closure
of a PDA may improve clinical status in some
Recommendation-Specific patients with persistent left-to-right shunting and
Supportive Text prevent further progression of PAH.S4.1.5-3,S4.1.5-4
1. Because cyanosis caused by right-to-left shunting Consultation with ACHD and pulmonary hyper-
in PDA may manifest predominantly downstream tension providers is important given the low fre-
from the ductal insertion into the aorta, accurate quency of this circumstance and the complexity
assessment of oxygen saturation by oximetry and of decision-making.
assessment of cyanosis should be done in the feet 5. Morbidity and mortality are high when closure of
and both hands. As with other types of shunts, a shunt is attempted in patients with Eisenmenger
pulse oximetry with ambulation as well as at rest physiology with elevated pulmonary pressure and
may identify patients with increased pulmonary net right-to-left shunting.S4.1.5-5

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Stout et al 2018 ACHD Guideline

4.2. Left-Sided Obstructive Lesions been demonstrated before and after surgery,S4.2.1-2
CLINICAL STATEMENTS

it is not usually progressive over time and has not


4.2.1. Cor Triatriatum
AND GUIDELINES

been associated with PAH.


Recommendations for Cor Triatriatum 2. Pulmonary venous stenosis has been demon-
Referenced studies that support recommendations are summarized strated before and after surgery, but it is not
in Online Data Supplement 31.
usually progressive over time and has not been
COR LOE Recommendations
associated with PAH.
Diagnostic 3. Although risks of isolated cor triatriatum sinister
1. Adults presenting with cor triatriatum sinister surgery is low, it should be performed when there
should be evaluated for other congenital
I B-NR is evidence of a substantial gradient. In 1 series,
abnormalities, particularly ASD, VSD, and
anomalous pulmonary venous connection.S4.2.1-1 the mean gradient at the time of surgical repair
2. In adults with prior repair of cor triatriatum
was at least 8 mm Hg.S4.2.1-3 It is conceivable that
sinister and recurrent symptoms, it is on occasion, clinical circumstances (ie, symp-
IIa B-NR
reasonable to evaluate for pulmonary vein toms, arrhythmia) would warrant intervention in
stenosis.S4.2.1-2
patients with lower gradients.
Therapeutic
3. Surgical repair is indicated for adults with cor
4.2.2. Congenital Mitral Stenosis
triatriatum sinister for symptoms attributable Recommendation for Congenital Mitral Stenosis
I B-NR
to the obstruction or a substantial gradient
Referenced studies that support the recommendation are
across the membraneS4.2.1-3
summarized in Online Data Supplement 32.
COR LOE Recommendation
Synopsis 1. Adults with congenital mitral stenosis
Cor triatriatum occurs when a membrane divides either I B-NR
or a parachute mitral valve should be
evaluated for other left-sided obstructive
the left atrium (sinister), or right atrium (dexter). Cor tria- lesions.S4.2.2-1,S4.2.2-2
triatum sinister is usually associated with other congen-
ital malformations, specifically ASD, VSD, or anomalous
pulmonary venous connection (partial or total).S4.2.1-1– Synopsis
S4.2.1-4
The left atrial appendage is invariably in the same Congenital mitral valve disease may be anatomically
chamber as the mitral valve, separated from the pulmo- complex and is often accompanied by other lesions.
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nary veins by the membrane. Supravalvular mitral steno- Indications for intervention in mitral stenosis are de-
sis is typically caused by a fibrous ring on the atrial side scribed in the 2014 VHD guidelineS4.2.2-3 and apply to
of the mitral valve, separating the mitral valve from both those patients with congenital mitral stenosis. Balloon
the left atrial appendage and the pulmonary veins. The mitral valvuloplasty is rarely, if ever, indicated or effec-
finding will have similar physiology to cor triatriatum and tive in congenital mitral stenosis.
similar indications for intervention. It can be associated See Section 3.3 for recommendations on who
with an abnormal mitral valve that may also require in- should perform surgeries, cardiac catheterization, and
tervention. Supravalvular mitral stenosis often comprises other procedures in these patients; Section 3.4 for rec-
one part of a more complex sequence of serial left-sided ommendations on diagnostic evaluation; and Table 17
inflow and outflow obstructions (ie, Shone complex). for routine testing and follow-up intervals.
See Section 3.3 for recommendations on who
should perform surgeries, cardiac catheterization, and
other procedures in these patients; and Section 3.4 for Recommendation-Specific
recommendations on diagnostic evaluation. Supportive Text
1. Parachute mitral valve is most commonly found
in the presence of other congenital abnormali-
Recommendation-Specific
ties such as the components of Shone complex.
Supportive Text Recurrence and progression of the various asso-
1. Cor triatriatum sinister is a membrane spanning ciated lesions are expected, subsequent surger-
the left atrium. Surgery has been largely success- ies are common, and mortality may be associated
ful with relatively few early or late deaths, which with other defects.S4.2.2-2 Therefore, these patients
are usually attributable to associated congenital require follow-up at a center where such abnor-
abnormalities.S4.2.1-4 The gradient across the de- malities can be followed and future interventions
fect at the time of surgery was at least 8 mm Hg considered. Choices and techniques for valve re-
(mean 17 mm Hg; range 8 to 40 mm Hg).S4.2.1-3 pair or replacement are based on consideration of
After repair, recurrence of stenosis is not ex- coexisting abnormalities including the likelihood
pected. Although pulmonary vein stenosis has of future surgery.

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Stout et al 2018 ACHD Guideline

Table 17.  Congenital Mitral Stenosis: Routine Follow-Up and Testing Intervals

CLINICAL STATEMENTS
Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological

AND GUIDELINES
and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 24 24 6–12 3–6
ECG 24 24 12 12
TTE 24 24 12 12
Exercise test† As needed 24 24 12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†6-minute walk test or CPET, depending on the clinical indication.
ACHD indicates adult congenital heart disease; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; and TTE,
transthoracic echocardiogram.

4.2.3. Subaortic Stenosis thy when LV hypertrophy of sufficient severity has de-
Recommendations for Subaortic Stenosis
veloped such that the subaortic membrane is less evi-
Referenced studies that support recommendations are summarized dent on imaging.
in Online Data Supplement 33. The recommendations in this guideline apply to
COR LOE Recommendations subAS caused by a discrete membrane or tunnel-like
Diagnostic
obstruction. Similar principles may apply to more com-
plex causes of subAS, but insufficient data exist to sup-
1. Stress testing for adults with LVOT
obstruction to determine exercise capacity, port recommendations for more complex lesions, and
IIb C-LD
symptoms, electrocardiographic changes, extrapolation needs to take the additional anatomic
or arrhythmias may be reasonable in the complexity into account.
presence of otherwise equivocal indications
for intervention.S4.2.3-1,S4.2.3-2 Turbulent flow created distal to the subaortic ob-
Therapeutic
struction may cause barotrauma to the adjacent aortic
valve leaflets and result in progressive AR, which may
2. Surgical intervention is recommended for
adults with subAS, a maximum gradient 50
itself become clinically significant. Resection of the sub-
I C-EO
mm Hg or more and symptoms attributable aortic obstruction ideally delays or prevents the even-
to the subAS. tual need for aortic valve replacement, and concomi-
tant aortic valve repair could also help delay the need
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3. Surgical intervention is recommended for


adults with subAS and less than 50 mm
for aortic valve replacement in these cases.
I C-LD Hg maximum gradient and HF or ischemic
symptoms, and/or LV systolic dysfunction See Section 3.3 for recommendations on who
attributable to subAS.S4.2.3-3 should perform surgeries, cardiac catheterization, and
4. To prevent the progression of AR, surgical other procedures in these patients; Section 3.4 for rec-
intervention may be considered for ommendations on diagnostic evaluation; and Table 18
IIb C-LD asymptomatic adults with subAS and at least
mild AR and a maximum gradient of 50 mm
for routine testing and follow-up intervals.
Hg or more.S4.2.3-4–S4.2.3-6

Recommendation-Specific
Synopsis Supportive Text
SubAS may occur as a discrete membrane below the 1. Exercise stress testing may be reasonable in the
aortic valve in the LVOT, as a longer tunnel-like obstruc- assessment of exercise capacity, stress-induced
tion, as a consequence of chordal attachments in pa- arrhythmias, and ischemia in patients with subAS
tients with abnormalities such as AVSD, or because of and may be considered as an adjunct to echocar-
surgical repairs involving VSD baffled to a transposed diographic imaging.
aorta, such as seen in the Rastelli operation. SubAS may 2. Patients with symptomatic subAS should attain
occur in isolation or as part of a suite of abnormalities. symptomatic improvement from surgical relief
In adults with Shone complex or its variants, subAS may of the obstruction. In some cases, concomitant
be one of several LV obstructive lesions, including vari- AVR may be needed, if indicated according to
ants of congenital mitral stenosis, supravalvular mitral GDMT.
stenosis, valvular aortic stenosis, supravalvular aortic 3. Patients with depressed LV systolic function and
stenosis, and CoA.S4.2.3-7 severe subAS may not manifest a resting gradient
SubAS tends to recur, particularly when initial resec- of ≥50 mm Hg. In this population, evaluation and
tion is needed in childhood. Surgical repair for subAS decisions regarding surgical relief of LVOT obstruc-
carries a 10% to 15% risk of complete heart block.S4.2.3-6 tion can be extrapolated from the existing aortic
SubAS may be first diagnosed in adulthood and may be stenosis data and should be considered as per the
confused with hypertrophic obstructive cardiomyopa- 2014 VHD guideline.S4.2.3-8 Additionally, patients

Circulation. 2019;139:e698–e800. DOI: 10.1161/CIR.0000000000000603 April 2, 2019 e737


Stout et al 2018 ACHD Guideline

Table 18.  Subaortic Stenosis: Routine Follow-Up and Testing Intervals


CLINICAL STATEMENTS

Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological


AND GUIDELINES

and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 24 24 6–12 3–6
ECG 24 24 12 12
TTE 24 24 12 12
Exercise test† As needed 24 24 12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†6-minute walk test or CPET, depending on the clinical indication.
ACHD indicates adult congenital heart disease; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; SubAS,
subaortic stenosis; and TTE, transthoracic echocardiogram.

with preserved LV systolic function but poor LV Recommendations for Congenital Valvular Aortic Stenosis
compliance may present with signs or symptoms (Continued)
of HF and a resting maximum gradient <50 mm COR LOE Recommendations
Hg. These patients may benefit from surgical re- Therapeutic
lief of LVOT obstruction. Patients with evidence of
3. In adults with bicuspid aortic valve stenosis
resting or stress-induced ischemia in the absence and a noncalcified valve with no more than
of obstructive coronary artery disease and in the IIb B-NR mild AR meeting indications for intervention
per GDMT,S4.2.4-5 it may be reasonable to
presence of moderate subAS (maximum gradient
treat with balloon valvuloplasty.S4.2.4-6
>30 mm Hg and <50 mm Hg) may benefit from
surgical relief of subAS.S4.2.3-9 Synopsis
4. Discrete subAS tends to be progressive with age,
and patients with a resting maximum gradient Indications for aortic valve replacement according to
≥50 mm Hg are more likely to have progressive the 2014 VHD guidelineS4.2.4-5 generally apply. Recom-
subAS and concomitant moderate or severe aortic mendations above deal with issues specific to congen-
valve regurgitation.S4.2.3-4 Therefore, surgical inter- ital aortic valve disease, which includes BAV, as well as
vention may be considered in the asymptomatic unicuspid aortic valve and aortic stenosis caused by hy-
poplastic aortic annulus. The underlying anatomy must
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patient with severe subAS. Tunnel-type subAS,


which is often associated with a small aortic valve be taken into account in patients with congenital aortic
annulus, is associated with worse long-term out- stenosis, as intervention may need to include annular
comes and a higher risk of recurrence after sur- enlarging procedures and other surgical techniques not
gical resection compared with subAS caused by commonly used in valvular aortic stenosis. These pa-
a discrete membrane.S4.2.3-5 Surgical intervention tients are often young adults, for whom lifestyle consid-
on patients with asymptomatic subAS (maximum erations such as athletic endeavors, employment, and
gradient ≥50 mm Hg) with preserved LV ejection childbearing may influence the type of intervention.
fraction may delay progression of, or improve the See Section 3.4 for recommendations on diagnos-
degree of, aortic valve regurgitation. SubAS in tic evaluation; and Table 19 for routine testing and fol-
adults may progress more slowly than in children, low-up intervals.
and although mild AR is common, it may not be
progressive in medium-term follow-up.S4.2.3-10 Recommendation-Specific
4.2.4. Congenital Valvular Aortic Stenosis Supportive Text
1. CoA has a male-to-female ratio of 1.5:1.S4.2.4-7–S4.2.4-13
Recommendations for Congenital Valvular Aortic Stenosis
Referenced studies that support recommendations are summarized
A BAV is present in 50% to 70% of cases of CoA.
in Online Data Supplement 34.
Table 19.  Congenital Aortic Stenosis: Routine Follow-Up and Testing
COR LOE Recommendations Intervals*

Diagnostic Stage Frequency of Echocardiogram


1. Adults with bicuspid aortic valve should Progressive (Stage B) Every 3–5 y (mild severity, Vmax 2.0–2.9 m/s)
be evaluated for coarctation of the aorta Every 1–2 y (moderate severity, Vmax 3.0–3.9 m/s)
I B-NR
by clinical examination and imaging
studies.S4.2.4-1 Severe (Stage C) Every 6–12 mo (Vmax ≥4.0 m/s)

2. It is reasonable to screen first-degree Aortic dilation >4.5 cm Every 12 mo (echocardiogram, MRI or CT)
relatives of patients with bicuspid aortic
*Modified from existing GDMT for valvular heart disease.S4.2.4-5
IIa B-NR valve or unicuspid aortic valve with
CT indicates computed tomography; GDMT, guideline-directed
echocardiography for valve disease and
management and therapy; MRI, magnetic resonance imaging; and Vmax,
aortopathy.S4.2.4-2–S4.2.4-4
maximum velocity.

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Stout et al 2018 ACHD Guideline

Given the association of these abnormalities, eval- Synopsis

CLINICAL STATEMENTS
uation of patients with BAV for CoA is warranted.
The management of valve dysfunction is generally as

AND GUIDELINES
2. BAV is the most prevalent congenital cardiac directed by the 2014 VHD guideline.S4.2.4.1-3 Aortopathy
abnormality with an estimated prevalence of is a commonly associated condition, and frequently in-
4.6 per 1000 live births, and is 1.5 times more volves the mid-ascending aorta, which may not be re-
prevalent in males than females.S4.2.4-7–S4.2.4-13 liably seen on TTE. Measurement of aortic dimensions
Most cases are spontaneous; however, familial with magnetic resonance angiography and CCT has
inheritance may occur in an autosomal domi- not been standardized, and clinicians should be wary
nant pattern with variable penetrance. On ech- of comparisons of reported diameters between modali-
ocardiographic screening, 1 study reports the ties. Side-by-side comparisons are more reliable for de-
prevalence of asymptomatic BAV in first-degree tecting changes over time. Baseline and routine serial
relatives of patients is 9%, and 32% of first-de- measurements of the aortic size are useful, with im-
gree relatives without a BAV will have an ab- aging interval determined by the indexed size and rate
normal aorta.S4.2.4-4 of progression. Pregnancy in Turner syndrome, which
3. Calcification of the aortic valve in adults neces- often requires assisted reproductive technology, is asso-
sitates that most patients who require therapy ciated with an increased risk of aortic dissection, espe-
for aortic stenosis will require aortic valve re- cially if there is a preexisting abnormality of the aortic
placement per GDMT.S4.2.4-5 However, young valve or aorta.S4.2.4.1-4
patients with congenitally abnormal valves and
relatively little calcification may be candidates
for balloon valvuloplasty. Balloon valvuloplasty Recommendation-Specific
may improve the degree of stenosis and symp- Supportive Text
toms in patients with mobile noncalcified BAV 1. Women with Turner syndrome are at substantial
stenosis. In general, the valves that would be risk of BAV, CoA, and aortic enlargement, which
amenable to successful balloon valvuloplasty can result in morbidity and mortality if left un-
are found in young patients, who are often <25 treated. Therefore, evaluation is necessary to help
years of age. Restenosis will occur over time decide what interventions may be necessary and
and in a relatively short time in some patients. provide accurate risk assessment for exercise,
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Balloon valvuloplasty of calcified BAV is associ- pregnancy, or other considerations that could be
ated with decreased efficacy and an increased influenced by aortic pathology.
risk of AR.S4.2.4-14,S4.2.4-15 Although transcatheter 2. Because of case series reporting dissection at
interventions for aortic stenosis are increasingly smaller aortic diameters than in non-Turner aor-
commonly performed in older adults and, thus, topathy, prophylactic surgery is reasonable at
there are increasing numbers of interventional lower diameters, particularly if rapid dilation is
cardiologists technically skilled at balloon aortic present. Measurements must take into account
valvuloplasty and transcatheter aortic valve re- the patient's stature either by indexing to body
placement, the differences in anatomy and pa- surface area utilizing Turner-specific norma-
tient population necessitate collaboration with tive data or by using ratio of aortic area to body
an ACHD cardiologist for younger patients. height.S4.2.4.1-5–S4.2.4.1-7
4.2.4.2. Aortopathies
4.2.4.1. Turner Syndrome
Several CHD subtypes and/or repairs are associated
Recommendations for Turner Syndrome with enlargement of the aorta. The management of
Referenced studies that support recommendations are summarized
in Online Data Supplement 35.
these varies by condition, as some are perceived to have
a stronger association with aortic dissection or rupture
COR LOE Recommendations
than others, although the true natural history of most
Diagnostic
is unknown. There is wide heterogeneity of timing of
1. Women with Turner syndrome should surgical referral, which makes interpretation of longitu-
be evaluated for bicuspid aortic valve,
I B-NR
coarctation of the aorta, and enlargement of
dinal studies problematic.
the ascending aorta.S4.2.4.1-1 BAV is the most common CHD, is associated with
Therapeutic aortopathy, and is of high concern for aortic complica-
2. Prophylactic replacement of the aortic root
tions, as discussed in other guideline statements.S4.2.4.2-1–
or ascending aorta in adults with Turner
S4.2.4.2-3
Although in many published series of aortic dis-
IIa B-NR
syndrome is reasonable when the aortic section, BAV patients account for a higher proportion
diameter is 2.5 cm/m2 or greater.S4.2.4.1-2
of dissections than expected from prevalence of BAV

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Stout et al 2018 ACHD Guideline

in the general population alone, the risk of dissection 4.2.5. Supravalvular Aortic Stenosis
CLINICAL STATEMENTS

or rupture amongst all BAV patients is less clear. The


AND GUIDELINES

Recommendations for Supravalvular Aortic Stenosis


largest population study reported a 0.5% risk of aortic Referenced studies that support recommendations are summarized
rupture or dissection after a mean of 16 years of follow- in Online Data Supplement 37.
up,S4.2.4.2-4 although 11% underwent elective aortic sur- COR LOE Recommendations
gery. Risk factors for aortic complications were age and Diagnostic
an enlarged aorta at baseline. Frequency of dissection
1. Aortic imaging using TTE, TEE, CMR, or CTA
in BAV disease is higher in adults with Turner syndrome. is recommended in adults with Williams
I C-LD
A dilated neoaortic root after a Ross procedure is not syndrome or patients suspected of having
supravalvular aortic stenosis.S4.2.5-1
uncommon, although only a single dissection has been
reported.S4.2.4.2-5 Because of this, it is generally believed 2. Coronary imaging is recommended in
patients with Williams syndrome and
that prophylactic root replacement strategies based on I C-LD
supravalvular aortic stenosis presenting with
sinus of Valsalva diameters can be less aggressive after a symptoms of coronary ischemia.S4.2.5-2–S4.2.5-4
Ross procedure than in a native BAV patient, but practice Therapeutic
patterns vary. Most patients with a Ross repair had under- 3. Surgical repair is recommended for adults
lying congenitally abnormal aortic valves (BAV or unicus- with supravalvular aortic stenosis (discrete
pid aortic valve) and, therefore, are at risk of the ascend- I B-NR or diffuse) and symptoms or decreased LV
systolic function deemed secondary to aortic
ing aortic dilation typical of those abnormalities. Thus, in obstruction.S4.2.5-5–S4.2.5-8
addition to the dilation at the sinuses of Valsalva associ-
4. Coronary artery revascularization is
ated with the Ross repair, dilation of the native ascending recommended in symptomatic adults with
I C-LD
aorta above the sinotubular junction can also occur. supravalvular aortic stenosis and coronary
ostial stenosis.S4.2.5-4,S4.2.5-9
Although patients with conotruncal abnormalities (TOF,
dextrotransposition of the great arteries [d-TGA] after arte-
rial switch,S4.2.4.2-6–S4.2.4.2-8 pulmonary atresia with VSD, trun- Synopsis
cus arteriosus) commonly have aortic diameters of 40 mm Supravalvular aortic stenosis is a relatively rare condition o-
to 50 mm, aortic complications are extremely rare (only verall but is seen commonly in patients with Williams syn-
6 published case reports).S4.2.4.2-9–S4.2.4.2-14 Therefore, there drome or homozygous familial hypercholesterolemia. The
is no strong justification for empiric prophylactic surgery stenotic ridge tends to occur distal to the coronary artery
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in such patients based solely on aortic diameter. Watchful orifices at the sinotubular junction. In addition to pressure
observation has often been recommended unless surgery load physiology similar to other causes of LVOT obstruc-
is being undertaken for other indications.S4.2.4.2-15 However, tion, coronary abnormalities can occur, including signifi-
there are rare patients who develop substantially greater cant coronary ostial stenosis resulting in risk of SCD and
aortic enlargement and for whom prophylactic surgery anesthesia risk.S4.2.5-10–S4.2.5-14 Unlike subAS or valvular aortic
may have more of a role. Risk factor management such stenosis, the coronary arteries are exposed to the higher
as control of hypertension is important. There are no RCTs pressure generated by the supravalvular obstruction.
evaluating the efficacy of medical therapy to reduce the See Section 3.3 for recommendations on who
rate of progression of aortic dilation or incidence of aortic should perform surgeries, cardiac catheterization, and
dissection in this population. other procedures in these patients; Section 3.4 for rec-
See Online Data Supplement 36 for referenced ommendations on diagnostic evaluation; and Table 20
studies. for routine testing and follow-up intervals.
Table 20.  Supravalvular Aortic Stenosis: Routine Follow-Up and Testing Intervals

Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological


and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 24 24 6–12 3–6
ECG 24 24 12 12
TTE† 24 24 12 12
CMR‡/CCT§ 36–60 36–60 36–60 36–60

Exercise test‖ As needed 24 24 12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†Routine TTE may be unnecessary in a year when CMR imaging is performed unless clinical indications warrant otherwise.
‡CMR may be indicated for assessment of aortic anatomy. Baseline study is recommended with periodic follow-up CMR, with
frequency of repeat imaging determined by anatomic and physiological findings.
§If CCT is used instead of CMR imaging, the frequency should be weighed against radiation exposure.
‖6-minute walk test or CPET, depending on the clinical indication.
ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; CMR, cardiovascular magnetic resonance; CPET,
cardiopulmonary exercise test; ECG, electrocardiogram; and TTE, transthoracic echocardiogram.

e740 April 2, 2019 Circulation. 2019;139:e698–e800. DOI: 10.1161/CIR.0000000000000603


Stout et al 2018 ACHD Guideline

Recommendation-Specific Recommendations for Coarctation of the Aorta (Continued)

CLINICAL STATEMENTS
Supportive Text

AND GUIDELINES
COR LOE Recommendations

1. TTE with Doppler imaging is useful in deriving Diagnostic (Continued)


peak and mean pressure gradients across the area 3. Ambulatory blood pressure monitoring in
of supravalvular aortic stenosis from apical, supra- adults with coarctation of the aorta can be
IIa C-LD
useful for diagnosis and management of
sternal, and right parasternal views; however, vis- hypertension.S4.2.6-4
ualization of the full extent of supravalvular aortic 4. Screening for intracranial aneurysms by
stenosis with TTE is limited. TEE is superior in this magnetic resonance angiography or CTA
IIb B-NR
regard, and 3D TEE allows excellent visualization may be reasonable in adults with coarctation
of the aorta.S4.2.6-5,S4.2.6-6
of the narrowed ascending aorta. CMR and CTA
provide comprehensive and detailed images of 5. Exercise testing to evaluate for exercise-
induced hypertension may be reasonable
supravalvular aortic stenosis and are used with IIb C-LD
in adults with coarctation of the aorta who
echocardiography in the assessment of patients exercise.S4.2.6-4,S4.2.6-7
before and after repair.S4.2.5-15 Therapeutic
2. Impaired coronary perfusion may occur because 6. Surgical repair or catheter-based stenting is
of varying degrees of aortic valve leaflet adhe- recommended for adults with hypertension
I B-NR
sion to the narrowed sinotubular junction or and significant native or recurrent coarctation
of the aorta.S4.2.6-1,S4.2.6-2,S4.2.6-8–S4.2.6-12
because of fibrotic thickening in the area im-
7. GDMT is recommended for treatment of
mediately surrounding the coronary ostia. This
I C-EO hypertension in patients with coarctation of
causes ostial stenosis with restriction in diastolic the aorta.S4.2.6-13
filling of the coronary arteries; the left coronary 8. Balloon angioplasty for adults with native and
is most frequently involved. TEE with Doppler can recurrent coarctation of the aorta may be
IIb B-NR
be used in the assessment of proximal coronary considered if stent placement is not feasible
and surgical intervention is not an option.S4.2.6-14
patency and to search for flow turbulence. CMR
can also be used in assessing the coronary ostia.
Electrocardiographic-gated CT coronary angiog- Synopsis
raphy or invasive selective coronary angiography
CoA typically occurs near the ductal remnant and left
provides excellent visualization of the coronary ar-
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subclavian artery. Hypertension is the most common se-


terial anatomy.
quela of CoA, whether repaired or unrepaired. BAV is
3. Supravalvular aortic stenosis is usually a progres-
commonly associated with CoA and is present in more
sive problem with a progressive increase in LV
than half of CoA patients.S4.2.6-15–S4.2.6-21 Intracranial aneu-
systolic pressure resulting in exertional symptoms
rysms may occur. Ascending aortic aneurysms are often
and, if the stenosis is severe, eventual decreases
found in those with BAV, and aneurysms are seen at the
in LV systolic function.
site of coarctation repair in the descending thoracic aorta
4. Impaired coronary perfusion may occur because
or arch. Dissection can occur, presumably more likely in
of varying degrees of aortic valve leaflet adhesion
the setting of poorly controlled hypertension. Even with
to the narrowed sinotubular junction with restric-
excellent repair, hypertension remains common and pre-
tion in diastolic filling of the coronary arteries; the
disposes to later myocardial infarction, stroke, and HF.
left coronary is most frequently involved. Surgical
See Section 3.3 for recommendations on who
coronary revascularization is recommended for
should perform surgeries, cardiac catheterization, and
patients with symptoms of coronary ischemia. other procedures in these patients; Section 3.4 for rec-
4.2.6. Coarctation of the Aorta ommendations on diagnostic evaluation; and Table 21
for routine testing and follow-up intervals.
Recommendations for Coarctation of the Aorta
Referenced studies that support recommendations are summarized
in Online Data Supplement 38. Recommendation-Specific
COR LOE Recommendations Supportive Text
Diagnostic 1. Complications of CoA repair include recoarcta-
1. Initial and follow-up aortic imaging using tion, aneurysm, pseudoaneurysm, and dissection.
CMR or CTA is recommended in adults Long-term follow-up after successful surgical in-
I B-NR with coarctation of the aorta, including
those who have had surgical or catheter tervention for CoA reveals that 11% of patients
intervention.S4.2.6-1–S4.2.6-3 may require reintervention for restenosis, visual-
2. Resting blood pressure should be measured ized by CMR or CTA (if CMR is contraindicated or
I C-EO in upper and lower extremities in all adults there is a history of stent therapy) and supported
with coarctation of the aorta.
by physical examination findings.S4.2.6-1 Although

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Stout et al 2018 ACHD Guideline

Table 21.  CoA: Routine Follow-Up and Testing Intervals


CLINICAL STATEMENTS

Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological


AND GUIDELINES

and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 24 24 6–12 3–6
ECG 24 24 12 12
TTE† 24 24 12 12
CMR‡/CCT§ 36–60 36–60 12–24 12–24

Exercise test‖ 36 24 24 12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†Routine TTE may be unnecessary in a year when CMR imaging is performed unless clinical indications warrant otherwise.
‡CMR may be indicated for assessment of aortic size and aortic arch/coarctation repair site anatomy. Baseline study is recommended with
periodic follow-up CMR, with frequency of repeat imaging determined by anatomic and physiological findings.
§CCT may be used if CMR is not feasible and to evaluate cross-sectional imaging status–post-stent therapy for coarctation of the aorta;
the frequency should be weighed against radiation exposure.
‖6-minute walk test or CPET, depending on the clinical indication.
ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; CMR, cardiovascular magnetic resonance imaging;
CoA, coarctation of the aorta; CPET, cardiopulmonary exercise; ECG, electrocardiogram; and TTE, transthoracic echocardiogram.

evidence of recoarctation can be found on clinical the expected outcome and ideal management
examination and echocardiography, aneurysms of such aneurysms are not clear. Providers and
near the site of repair may not be well seen by patients should be aware of management uncer-
echocardiography. Patients who have undergone tainties when considering routine screening for
surgical patch repair are at an increased risk of aneurysms.S4.2.6-22 Additionally, there are some
developing aneurysms that can be evaluated by data suggesting that intracranial aneurysms are
CMR or CTA. After successful transcatheter in- not commonly found in children and teenagers
tervention with stenting or balloon angioplasty, with CoA,S4.2.6-23 reinforcing the possibility that
follow-up CMR or CTA imaging is recommended coarctation alone may not be sufficient for devel-
to evaluate for long-term complications (eg, opment of intracranial aneurysm, and other fac-
aneurysm formation, stent fracture, or stent tors, such as hypertension and/or age, play a role
migration).S4.2.6-1 The same CMR or CTA study will in development and progression of aneurysms.
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also evaluate the ascending aorta, which may be- 5. Despite successful surgical repair or transcatheter
come aneurysmal over the years of follow-up. intervention, hypertension can persist and may not
2. Unoperated adults with CoA almost invari- be identified during resting blood pressure meas-
ably present with systemic arterial hypertension urement. Up to 80% of patients with prior CoA in-
measured in the upper extremities. Brachial and tervention manifest an abnormally elevated upper
femoral pulse timing and amplitude evaluation extremity exercise blood pressure response, and
on physical examination reveals a delay or de- peak blood pressure is correlated with increased LV
crease in amplitude of the femoral pulse. Upper mass.S4.2.6-24 Moreover, restenosis of the previously
and lower extremity noninvasive blood pressure repaired or stented region may be identified by
measurement is recommended in all patients with increased peak blood pressure response, increased
unoperated or operated/intervened CoA. upper to lower extremity blood pressure gradient
3. Upper body systemic hypertension is prevalent with exercise, and increased Doppler velocity
in patients with unoperated coarctation and across the coarctation site during exercise TTE.
may be present in up to one third of patients 6. Significant native or recurrent aortic coarctation
who have undergone operative or transcatheter has been defined as follows: upper extremity/
intervention.S4.2.6-2 Systemic hypertension may not lower extremity resting peak-to-peak gradient
consistently be identifiable at rest; therefore, am- >20 mm Hg or mean Doppler systolic gradient >20
bulatory blood pressure monitoring can be use- mm Hg; upper extremity/lower extremity gradient
ful in identifying and appropriately managing >10 mm Hg or mean Doppler gradient >10 mm
patients with ambulatory hypertension. Hg plus either decreased LV systolic function or
4. Multiple studies have demonstrated an increased AR; upper extremity/lower extremity gradient >10
frequency of intracranial aneurysm in adults with mm Hg or mean Doppler gradient >10 mm Hg
CoA. Approximately 10% of patients with CoA with collateral flow.S4.2.6-2,S4.2.6-8,S4.2.6-12 This should
have intracranial aneurysms identified on mag- be coupled with anatomic evidence for CoA, typ-
netic resonance angiography or CTA. Increasing ically defined by advanced imaging (CMR, CTA).
age has been identified as a risk factor. Many The best evidence to proceed with intervention
such identified aneurysms are small; however, for CoA includes systemic hypertension, upper

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extremity/lower extremity blood pressure gra- Table 22.  Severity of RVOT Obstruction

CLINICAL STATEMENTS
dient and echocardiography Doppler gradient as Mild Peak gradient <36 mm Hg (peak velocity <3 m/s)

AND GUIDELINES
defined above, and anatomic evidence of CoA. Moderate Peak gradient 36–64 mm Hg (peak velocity 3–4 m/s)
Multiple factors help determine whether surgery
Severe Peak gradient 64 mm Hg (peak velocity >4 m/s); mean
or stenting is optimal, including anatomic features gradient >35 mm Hg
such as proximity of native coarctation to head
Estimations of RV systolic pressure by TR velocity is part of the
and neck vessels or concomitant aneurysm, and, echocardiographic assessment of RV obstruction, as Doppler measurements
if stenting, whether a covered stent is needed. across the RV obstruction itself may be unreliable.
RV indicates right ventricular; RVOT, right ventricular outflow tract; and TR,
7. The long-term complications of CoA are gener- tricuspid regurgitation.
ally related to chronic upper body systemic hyper-
tension, therefore, systemic hypertension should usually require intervention in childhood with a good
be identified by resting, ambulatory, or exercise prognosis into adulthood.S4.3.1-6 Patients with moderate
blood pressure assessment and medical treatment stenosis (Table 22) have more variable histories, with
should follow GDMTS4.2.6-13,S4.2.6-25 some having received surgical or catheter intervention
8. Balloon angioplasty alone is associated with a in childhood or adulthood and some not. Patients with
higher rate of intimal tears and aneurysm forma- moderate PS, whether native or postintervention, have
tion compared with stent placement. a good long-term outcome, although some will go on
to require an intervention in adulthood because of pro-
4.3. Right-Sided Lesions gressive PS or, commonly, significant PR as a sequela of
earlier intervention.
4.3.1. Valvular Pulmonary Stenosis
Pulmonary atresia with intact ventricular septum is a
Recommendations for Valvular Pulmonary Stenosis rare congenital heart lesion that is associated with vary-
Referenced studies that support recommendations are summarized ing degrees of RV hypoplasia and tricuspid valve hy-
in Online Data Supplement 39.
poplasia in addition to pulmonary valve atresia. Adults
COR LOE Recommendations with pulmonary atresia with intact ventricular septum
1. In adults with moderate or severe valvular followed various surgical pathways in childhood, ei-
pulmonary stenosis and otherwise
unexplained symptoms of HF, cyanosis from
ther biventricular repair, 1 1/2 ventricular repair, Fontan
I B-NR
interatrial right-to-left communication, and/ procedure, transplant, or shunt palliation.S4.3.1-13 Adults
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or exercise intolerance, balloon valvuloplasty with history of pulmonary atresia with intact ventricu-
is recommended.S4.3.1-1–S4.3.1-4
lar septum have a high incidence of need for reinter-
2. In adults with moderate or severe valvular
vention and management of atrial arrhythmias.S4.3.1-14,
pulmonary stenosis and otherwise
unexplained symptoms of HF, cyanosis, and/
S4.3.1-15
Restrictive RV physiology is common in adults
I B-NR
or exercise intolerance who are ineligible for with history of pulmonary atresia with intact ventric-
or who failed balloon valvuloplasty, surgical
repair is recommendedS4.3.1-1,S4.3.1-5–S4.3.1-8
ular septum and may be associated with substantial
ventricular fibrosisS4.3.1-16 and RV-dependent coronary
3. In asymptomatic adults with severe
IIa C-EO valvular pulmonary stenosis, intervention is circulation.
reasonable. See Section 3.3 for recommendations on who
should perform surgeries, cardiac catheterization, and
other procedures in these patients; Section 3.4 for rec-
Synopsis ommendations on diagnostic evaluation; Table 23 for
Valvular PS is one of the most common congeni- routine testing and follow-up intervals; and Figure 3 for
tal heart defects, estimated to occur in up to 7% of a diagnostic and treatment algorithm for isolated PR
children born with CHD.S4.3.1-9–S4.3.1-11 Some common after repair of PS.
findings associated with isolated valvular PS include
a dilated main PA and dysplastic valve cusps. Surgical
or catheter-based intervention depends on degree of
Recommendation-Specific
obstruction, RV pressure and function, and associated Supportive Text
symptoms. Patients with isolated pulmonary valve ste- 1. In patients with moderate or severe isolated pul-
nosis (native or recurrent after an intervention) require monary valve stenosis, pulmonary balloon val-
ongoing cardiac follow-up and monitoring for evi- vuloplasty is safe and effective in reducing the
dence of progressive valve stenosis or regurgitation, pulmonary valve gradient and improving symp-
RV hypertrophy, HF, and arrhythmias.S4.3.1-12 Patients toms in most patients
with mild native pulmonary valve stenosis (Table 22) 2. Surgical valvotomy is usually sufficient, particularly
have a reassuring natural history, and intervention is when the pulmonary annulus is not hypoplastic.
not usually necessary. Patients with severe PS (Table 22) Pulmonary valve replacement may be necessary

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Stout et al 2018 ACHD Guideline

Table 23.  Valvular PS: Routine Follow-Up and Testing Intervals


CLINICAL STATEMENTS

Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological


AND GUIDELINES

and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 36–60 24 6–12 3–6
ECG 36–60 24 12 12
TTE 36–60 24 12 12
Exercise test† As needed 24 24 12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†6-minute walk test or CPET, depending on clinical indication.
ACHD indicates adult congenital heart disease; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; PS, pulmonary
stenosis; and TTE, transthoracic echocardiogram.
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Figure 3. Isolated PR after repair of PS.


*Significant PR causes RV dilation. If a patient has moderate or greater PR and normal RV size, most likely the estimation of PR severity is inaccurate or there may
be restrictive RV physiology, which would warrant further investigation. †Symptoms may include dyspnea, chest pain, and/or exercise intolerance referable to PR or
otherwise unexplained. ACHD indicates adult congenital heart disease; CPET, cardiopulmonary exercise test; PR, pulmonary regurgitation; PS, pulmonary stenosis;
and RV, right ventricular.

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Stout et al 2018 ACHD Guideline

when there is marked dysplasia of the pulmonary attributable to moderate or greater PR, and can

CLINICAL STATEMENTS
valve or significant hypoplasia of the annulus. improve RV size and/or RV function if there is RV

AND GUIDELINES
3. Relief of a severely stenotic pulmonary valve in dilation or decreased RV ejection fraction.
an asymptomatic patient will reduce the RV pres- 2. PR resulting from treatment of isolated PS may have
sure and the possibility of potential sequelae. As in progressive impact on RV size and function, and
symptomatic patients, the procedure can be per- may result in symptoms, such that pulmonary valve
formed by surgery or interventional catheterization replacement would be considered. Serial follow-up
with low morbidity and mortality. If intervention is for clinical evaluation, CPET, and imaging to eval-
deferred, careful follow-up to evaluate for symp- uate for symptoms, exercise intolerance attribut-
toms, decline in exercise capacity, worsening RV able to PR, and/or RV dilation or RV dysfunction will
function, or development of cyanosis is important allow appropriate timing of intervention if needed.
and may prompt reconsideration of intervention. 3. There are no data to suggest appropriate timing
4.3.1.1. Isolated PR After Repair of PS for pulmonary valve replacement in the presence
of RV dilation, but it is likely inappropriate to di-
Recommendations for Isolated PR After Repair of Pulmonary
rectly extrapolate the data applicable to patients
Stenosis
with TOF.S4.3.1.1-1 However, RV dilation or dysfunc-
COR LOE Recommendations
tion should improve, or at least not progress fur-
1. In symptomatic patients with moderate or
greater PR resulting from treated isolated
ther, if the volume overload from PR is alleviated
I C-EO pulmonary stenosis, with RV dilation or RV by pulmonary valve replacement. Thus, although
dysfunction, pulmonary valve replacement is specific RV size criteria are not available for these
recommended.
patients to determine timing of pulmonary valve
2. For asymptomatic patients with residual
PR resulting from treatment of isolated
replacement, patients with progressively worsen-
I C-EO
pulmonary stenosis with a dilated right ing RV size or function presumably represent a
ventricle, serial follow-up is recommended. subset of patients for whom valve replacement
3. In asymptomatic patients with moderate could be beneficial.
or greater PR resulting from treatment of
IIb C-EO isolated pulmonary stenosis with progressive
RV dilation and/or RV dysfunction, pulmonary
4.3.2. Branch and Peripheral Pulmonary Stenosis
valve replacement may be reasonable.
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Recommendations for Branch and Peripheral PS


Referenced studies that support recommendations are summarized
in Online Data Supplement 40.
Synopsis
COR LOE Recommendations
Although many patients with valvular PS do not require Diagnostic
intervention, some have PS that is severe enough to
1. For adults with peripheral or branch
warrant intervention, often in infancy or childhood. PS I B-NR PS, ongoing surveillance is
can be alleviated either by surgical valvotomy or with recommended.S4.3.2-1,S4.3.2-2
balloon valvuloplasty. Either surgical or catheter inter- Therapeutic
vention may result in hemodynamically important PR 2. In adults with peripheral or branch PA
that can result in symptoms, RV enlargement, and/or IIa B-NR stenosis, PA dilation and stenting can be
dysfunction requiring pulmonary valve replacement. useful.S4.3.2-2,S4.3.2-3

Recommendation-Specific Synopsis
Supportive Text Pulmonary branch and peripheral PS can be isolated,
1. Patients with isolated PS who have previously occur as part of a constellation of right ventricular out-
undergone an intervention on the pulmonary flow tract (RVOT) obstruction, or be found in associa-
valve require ongoing clinical follow-up and mon- tion with a syndrome (eg, Noonan, Alagille, Williams,
itoring of PR, RV size and function, and functional maternal rubella exposure). Intervention decisions are
capacity. This may include echocardiography, typically based on symptoms, distribution of pulmonary
CPET, and advanced imaging. The right ventricle blood flow, RV function, and RV systolic pressure. TTE is
in patients with PR after intervention for PS may a good modality to obtain RV pressure and function but
be smaller than in patients with TOF; however, does not adequately image the peripheral pulmonary
patients with PR may have evidence of decreased arteries. Alternative imaging (eg, CMR, CCT) can vis-
RV ejection fraction or decreased exercise ca- ualize anatomic obstructions and branch PA anatomy.
pacity. Pulmonary valve replacement can improve In addition, CMR and pulmonary perfusion testing can
symptoms for patients with symptoms that are quantify relative pulmonary blood flow.

Circulation. 2019;139:e698–e800. DOI: 10.1161/CIR.0000000000000603 April 2, 2019 e745


Stout et al 2018 ACHD Guideline

Table 24.  Branch and Peripheral PS: Routine Follow-Up and Testing Intervals
CLINICAL STATEMENTS

Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological


AND GUIDELINES

and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 24–36 24 6–12 3–6
ECG 24–36 24 12 12
TTE† 24–36 24 12 12
CMR‡/CCT§ 36–60 36–60 24–36 24–36

Exercise test‖ 36 24 24 12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†Routine TTE may be unnecessary in a year when CMR imaging is performed unless clinical indications warrant otherwise.
‡CMR may be indicated for assessment of branch PS. Baseline study is recommended with periodic follow-up CMR, with frequency of
repeat imaging determined by anatomic and physiological findings.
§CCT may be used if CMR is not feasible and to evaluate cross-sectional imaging status and post-stent therapy for peripheral PS; the
frequency should be weighed against radiation exposure.
‖6-minute walk test or CPET, depending on clinical indication.
ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; CMR, cardiovascular magnetic resonance
imaging; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; PS, pulmonary stenosis; and TTE, transthoracic echocardiogram.

See Section 3.3 for recommendations on who 4.3.3. Double-Chambered Right Ventricle
should perform surgeries, cardiac catheterization, and Recommendations for Double-Chambered Right Ventricle
other procedures in these patients; Section 3.4 for rec- Referenced studies that support recommendations are summarized
ommendations on diagnostic evaluation; and Table 24 in Online Data Supplement 41.
for routine testing and follow-up intervals. COR LOE Recommendations
1. Surgical repair for adults with double-
Recommendation-Specific chambered right ventricle and moderate or
greater outflow obstruction is recommended
Supportive Text I C-LD
in patients with otherwise unexplained
symptoms of HF, cyanosis, or exercise
1. Cardiac follow-up and imaging may include limitationS4.3.3-1–S4.3.3-3 (Table 22).
evaluation of RV pressure; quantifying relative
2. Surgical repair for adults with double-
pulmonary blood flow and imaging for evidence
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chambered right ventricle with a severe


IIb C-LD
of residual lesions or PA obstruction or aneu- gradient may be considered in asymptomatic
patientsS4.3.3-3,S4.3.3-4 (Table 22).
rysm at sites of prior intervention; and in-stent
stenosis and/or stent fracture (the latter often
best seen by fluoroscopy). Stenting of branch Synopsis
PA stenosis is effective in reducing the pressure
gradients, but patients often require further Double-chambered right ventricle is uncommon in
intervention.S4.3.2-2 In-stent stenosis with a re- adults. Hypertrophied muscle bundles develop in the RV
duction in the ipsilateral pulmonary blood flow cavity, creating RVOT obstruction.S4.3.3-5,S4.3.3-6 It is com-
is seen in approximately 25% of patients after monly associated with a VSD. Double-chambered right
percutaneous PA angioplasty and stent place- ventricle can be missed on TTE if not sought specifically,
ment, more common in patients with abnormal and alternative imaging or cardiac catheterization is of-
pulmonary arteries, such as those with TOF or ten required to confirm the diagnosis and establish the
Williams syndrome.S4.3.2-1 Regular surveillance hemodynamic impact.
and imaging, with intervention as required, may See Section 3.3 for recommendations on who
prevent the development of RV hypertension should perform surgeries, cardiac catheterization, and
and its sequelae.S4.3.2-1 other procedures in these patients; Section 3.4 for rec-
2. Balloon angioplasty or stenting of a peripheral ommendations on diagnostic evaluation; and Table 25
PA is effective in reducing pressure gradients and for routine testing and follow-up intervals.
improving pulmonary blood flow. Indications for
pulmonary angioplasty or stenting include symp-
Recommendation-Specific
toms attributed to the decreased pulmonary
blood flow, focal narrowing, abnormal differen- Supportive Text
tial perfusion, and/or elevated RV pressure. The 1. Surgery typically involves transatrial or transven-
decision for intervention with PA angioplasty or tricular resection of obstructing muscle bundles
stenting includes assessment of clinical symp- and VSD closure if present. Occasionally, patch
toms, imaging, and discussion with an ACHD in- enlargement of RVOT may be necessary to ade-
terventional cardiologist. quately relieve obstruction.

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Stout et al 2018 ACHD Guideline

Table 25.  Double-Chambered Right Ventricle: Routine Follow-Up and Testing Intervals

CLINICAL STATEMENTS
Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological

AND GUIDELINES
and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 24–36 24 6–12 3–6
ECG 24–36 24 12 12
TTE 24–36 24 12 12
Exercise test† As needed 24 24 12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†6-minute walk test or CPET, depending on clinical indication.
ACHD indicates adult congenital heart disease; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; and TTE, transthoracic
echocardiogram.

2. VSD is often present and may communicate with Recommendations for Ebstein Anomaly (Continued)
the higher or lower pressure chamber in the right COR LOE Recommendations
ventricle, with resulting differences in shunt di-
Therapeutic (Continued)
rection and flow characteristics. In patients with
6. Catheter ablation is recommended for
a severe gradient through the right ventricle, the adults with Ebstein anomaly and high-risk
I C-LD
VSD may be associated with right-to-left shunting pathway conduction or multiple accessory
if proximal to the obstruction, or associated with pathways.S4.3.4-3,S4.3.4-11,S4.3.4-12

left-to-right shunting if distal. Exercise testing 7. Surgical repair or reoperation for adults
performed in a subjectively asymptomatic patient with Ebstein anomaly and significant
TR can be beneficial in the presence of
will often be abnormal. Patients may benefit from IIa B-NR progressive RV enlargement, systemic
repair of both the VSD and outflow obstruction, desaturation from right-to-left atrial
shunt, paradoxical embolism, and/or atrial
especially if exercise capacity is decreased.
tachyarrhythmias.S4.3.4-11,S4.3.4-13,S4.3.4-14

4.3.4. Ebstein Anomaly 8. Bidirectional superior cavopulmonary


(Glenn) anastomosis at time of Ebstein
Recommendations for Ebstein Anomaly anomaly repair may be considered for
Referenced studies that support recommendations are summarized adults when severe RV dilation or severe RV
IIb B-NR
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in Online Data Supplement 42. systolic dysfunction is present, LV function


is preserved, and left atrial pressure and
COR LOE Recommendations LV end diastolic pressure are not
Diagnostic elevated.S4.3.4-6,S4.3.4-15

1. In adults with Ebstein anomaly, CMR


IIa B-NR can be useful to determine anatomy, RV
dimensions, and systolic function.S4.3.4-1,S4.3.4-2 Synopsis
2. In adults with Ebstein anomaly, TEE can be Ebstein anomaly is an uncommon congenital heart
IIa B-NR
useful for surgical planning if TTE images defect occurring in about 0.005% of live births.S4.3.4-16–
are inadequate to evaluate tricuspid valve
morphology and function.S4.3.4-1
S4.3.4-18
It is a malformation of the tricuspid valve and
the right ventricle and varies in severity, including
3. Electrophysiological study with or
without catheter ablation can be useful babies who do not survive infancy, asymptomatic adults
IIa B-NR
in the diagnostic evaluation of adults diagnosed incidentally in the sixth and seventh decades
with Ebstein anomaly and ventricular of life, and many variations in severity between those
preexcitation but without supraventricular
tachycardia.S4.3.4-3,S4.3.4-4 extremes. Ebstein anomaly can occur with other defects
4. In adults with Ebstein anomaly,
including ASD, VSD, and PS. A patent foramen ovale,
electrophysiological study (and catheter otherwise usually considered normal, may have signif-
IIa B-NR
ablation, if needed) is reasonable before icant impact in Ebstein anomaly. Accessory pathways
surgical intervention on the tricuspid valve
even in the absence of preexcitation or
and arrhythmias are relatively common. Patient sur-
supraventricular tachycardia.S4.3.4-5 veillance and management varies depending on age,
Therapeutic severity of the lesion, and associated abnormalities
5. Surgical repair or reoperation for adults
including HF, cyanosis, and arrhythmias. Surveillance
with Ebstein anomaly and significant TR includes echocardiographic and other advanced imag-
is recommended when one or more of ing to assess RV size and function, rhythm assessment,
the following are present: HF symptoms,
I B-NR
objective evidence of worsening
pulse oximetry, and stress testing. Treatments include
exercise capacity, progressive RV systolic medical and surgical therapy for patients with manifest
dysfunction by echocardiography or symptoms as well as catheter-based structural and elec-
CMR.S4.3.4-6–S4.3.4-10
trophysiological interventions when indicated.

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Stout et al 2018 ACHD Guideline

Table 26.  Ebstein Anomaly: Routine and Follow-Up and Testing Intervals
CLINICAL STATEMENTS

Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological


AND GUIDELINES

and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 12–24 12 6–12 3–6
ECG 12–24 12 12 12
CXR As needed As needed 12–24 12–24
TTE† 12–24 12–24 12 12
Pulse oximetry 24 12 Each visit Each visit
Holter monitor As needed As needed 24 12–24
CMR‡/CCT§ 60 36 24–36 12–24

Exercise test‖ 36 24–36 24 12

*See Tables 3 and 4 for details on the ACHD AP classification system.


†Routine TTE may be unnecessary in a year when CMR imaging is performed unless clinical indications warrant otherwise.
‡CMR may be indicated for assessment of right ventricular size and function. Baseline study is recommended with periodic follow-up
CMR, with frequency of repeat imaging determined by anatomic and physiological findings.
§CCT may be used if CMR is not feasible; the frequency should be weighed against radiation exposure.
‖6-minute walk test or CPET, depending on clinical indication.
ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; CMR, cardiovascular magnetic resonance
imaging; CPET, cardiopulmonary exercise test; CXR, chest x-ray; ECG, electrocardiogram; and TTE, transthoracic echocardiogram.

See Section 3.3 for recommendations on who accessory pathways. In addition, preexcitation
should perform surgeries, cardiac catheterization, and may be present but difficult to appreciate on the
other procedures in these patients; Section 3.4 for rec- surface ECG. Tricuspid valve surgery can hinder
ommendations on diagnostic evaluation; and Table 26 transcatheter access to right-sided accessory
for routine testing and follow-up intervals. pathways and the slow pathway in AV node reen-
try, such that it may be reasonable to assess for
arrhythmia substrates and proceed with catheter
Recommendation-Specific ablation if identified, before surgery.
Supportive Text 5. Data demonstrate that delay of surgery until HF
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1. Deciphering the anatomy and size of the right or RV systolic dysfunction ensues is associated
atrium and right ventricle in Ebstein anomaly is with poorer outcomes; surgery before either of
often difficult using echocardiography alone, par- those develops is recommended.S4.3.4-6,S4.3.4-7,S4.3.4-10
ticularly in adults. Data obtained from CMR can Ebstein anomaly is understood as not just valve di-
inform clinical care and surgical planning or de- sease but also a myopathic process. Consequently,
cision-making, because CMR data correlate well threshold for operation may be different than in
with intraoperative findings. other RV volume-loading lesions, because there is
2. Two-dimensional and 3D TEE can better define more concern regarding the capacity of the myo-
the anatomy and function of the tricuspid valve pathic Ebstein right ventricle to tolerate a volume
before surgery and provide valuable information load. Also, there are cohort series of Ebstein
in planning surgical repair. patients to inform decisions.S4.3.4-6,S4.3.4-7,S4.3.4-10
3. Approximately one third of adults with Ebstein Surgical repair generally consists of tricuspid valve
anomaly and ventricular preexcitation have multiple repair (preferred when feasible) or replacement,
accessory pathways, associated with a high risk of selective plication of atrialized right ventricle, re-
SCD. Adults with Ebstein anomaly also have a high duction atrioplasty, arrhythmia surgery, and/or
prevalence of atrial tachyarrhythmia.S4.3.4-3,S4.3.4-4 closure of atrial level shunt. Surgery may result in
In the setting of ventricular preexcitation, atrial improvement of symptoms and functional ability,
tachyarrhythmia may expose the patient to a and prevent or delay worsening symptoms.
higher risk of lethal ventricular arrhythmia. In 6. Adults with Ebstein anomaly and ventricular pre-
patients with clinical supraventricular tachycardia, excitation often have multiple accessory path-
management is according to existing GDMT.S4.3.4-19 ways, which are associated with a higher risk of
A Pediatric & Congenital Electrophysiology SCD. Surgical interruption of accessory pathways
Society (PACES)/HRS expert consensus document is largely reserved for patients who have failed
provides additional information on the manage- attempts at catheter ablation. High-risk path-
ment of arrhythmias.S4.3.4-20 ways are those with an increased risk of SCD,
4. Concealed accessory pathways are common in largely related to VF resulting from rapidly con-
Ebstein anomaly and may coexist with manifest ducting AF. Definition and discussion of high-risk

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Stout et al 2018 ACHD Guideline

pathways is beyond the scope of these guide- Recommendations for TOF (Continued)

CLINICAL STATEMENTS
lines but can be found elsewhere, such as the

AND GUIDELINES
COR LOE Recommendations
“PACES/HRS Expert Consensus Statement on the
Therapeutic
Recognition and Management of Arrhythmias in
5. Pulmonary valve replacement (surgical or
ACHD.”S4.3.4-21 percutaneous) for relief of symptoms is
7. Systemic desaturation and arrhythmias are fre- I B-NR
recommended for patients with repaired
quently signs of worsening hemodynamics, pro- TOF and moderate or greater PR with
cardiovascular symptoms not otherwise
gressive TR, or worsening RV function. Surgery explained.S4.3.5-9–S4.3.5-11
for the tricuspid valve as well as closure of the 6. Pulmonary valve replacement (surgical
ASD or stretched patent foramen ovale and ar- or percutaneous) is reasonable for
rhythmia surgery can be beneficial. When ar- preservation of ventricular size and function
IIa B-NR in asymptomatic patients with repaired
rhythmia surgery is required, it typically involves a TOF and ventricular enlargement or
modified right atrial maze procedure. In the pres- dysfunction and moderate or greater
ence of AF, the addition of a left atrial Cox Maze PR.S4.3.5-1,S4.3.5-9,S4.3.5-12–S4.3.5-14

III procedure can be beneficial to reduce the risk 7. Primary prevention ICD therapy is reasonable
IIa B-NR in adults with TOF and multiple risk factors
of recurrent AF. for SCD.S4.3.5-15–S4.3.5-17
8. The use of the bidirectional cavopulmonary
8. Surgical pulmonary valve replacement may
shunt is much more common in children than in be reasonable for adults with repaired TOF
IIb C-EO
adults. When it is applied in the adult, it is usu- and moderate or greater PR with other
lesions requiring surgical interventions.
ally reserved for patients with severe RV dysfunc-
tion with concern that the right ventricle will 9. Pulmonary valve replacement, in addition
to arrhythmia management, may be
not tolerate supporting the entirety of stroke IIb C-EO considered for adults with repaired TOF
volume.S4.3.4-6,S4.3.4-15 Preoperative catheterization and moderate or greater PR and ventricular
tachyarrhythmia.
to determine hemodynamics and feasibility of
applying the bidirectional cavopulmonary shunt
becomes progressively more important in older Synopsis
patients, particularly those with longstanding hy-
Long-term survival after surgery for TOF continues to
pertension with LV hypertrophy, which can lead
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improve. However, residual hemodynamic and electro-


to diastolic dysfunction and elevated pulmonary
physiological abnormalities are common in adulthood.
pressures.
Adults with repaired TOF face an increased risk of ar-
4.3.5. Tetralogy of Fallot rhythmias, exercise intolerance, HF, and death begin-
ning in early adulthood.S4.3.5-1,S4.3.5-18–S4.3.5-20 Surgical re-
Recommendations for TOF
pair of TOF has evolved over time, with relief of the
Referenced studies that support recommendations are
summarized in Online Data Supplement 43. (See Section 4.3.6. for RVOT obstruction usually involving infundibulotomy,
recommendations regarding evaluation and management of right resection of obstructive muscle bundles, and the use of
ventricle–to-PA conduits.)
a patch to enlarge the pathway from the right ventricle
COR LOE Recommendations to the pulmonary arteries. These procedures result in
Diagnostic scar tissue and create a dyskinetic and often aneurys-
1. CMR is useful to quantify ventricular size mal area in the RVOT. Residual RVOT stenosis, branch
and function, pulmonary valve function, PA stenosis, residual ASD or VSD, TR, RV dilation and
I B-NR pulmonary artery anatomy, and left heart
dysfunction, aortic dilation, AR, and LV dysfunction are
abnormalities in patients with repaired
TOF.S4.3.5-1 some of the anatomic and functional abnormalities en-
2. Coronary artery compression testing is
countered in patients with repaired TOF. The most com-
indicated before right ventricle–to-PA mon hemodynamic sequela of TOF repair is PR. Cur-
I B-NR
conduit stenting or transcatheter valve rent evidence confirms that adults with repaired TOF
placement in repaired TOF.S4.3.5-2
are at risk of severe PR, RV dilation and dysfunction,
3. Programmed ventricular stimulation can be LV dysfunction and electromechanical dyssynchrony, all
IIa B-NR useful to risk-stratify adults with TOF and
additional risk factors for SCD.S4.3.5-3–S4.3.5-8 of which contribute to adverse clinical outcomes late
4. In patients with repaired TOF, cardiac
after TOF repair.S4.3.5-1,S4.3.5-20–S4.3.5-24 Despite intense in-
catheterization with angiography, terest and numerous publications on pulmonary valve
if indicated, is reasonable to assess replacement in adults with repaired TOF, optimal tim-
hemodynamics when adequate data cannot
IIa C-EO
be obtained noninvasively in the setting of
ing for this intervention remains uncertain, and most
an arrhythmia, HF, unexplained ventricular studies have focused on preoperative RV volumes that
dysfunction, suspected pulmonary would result in normalization of postoperative RV
hypertension or cyanosis.
volumes.S4.3.5-9,S4.3.5-14,S4.3.5-25–S4.3.5-27 In adults with repaired

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Stout et al 2018 ACHD Guideline
CLINICAL STATEMENTS
AND GUIDELINES
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Figure 4. Pulmonary valve replacement in patients with TOF repair and PR.
*Symptoms may include dyspnea, chest pain, and/or exercise intolerance referable to PR or otherwise unexplained. †See recommendation 6 supporting text.
ACHD indicates adult congenital heart disease; HF, heart failure; LV, left ventricular; LVEDV, left ventricular end diastolic volume; PR, pulmonary regurgitation; RV,
right ventricular; RVEDV, right ventricular end diastolic volume; RVEDVI, right ventricular end diastolic volume index; RVESVI, right ventricular end systolic volume
index; RVOT, right ventricular outflow tract; RVSP, right ventricular systolic pressure; and TOF, tetralogy of Fallot.

TOF, prevalence rates for atrial and ventricular arrhyth- Primary prevention ICDs should generally be consid-
mias have been estimated to be 20% and 15%, respec- ered in patients who otherwise meet standard qualify-
tively, with steep increases after 45 years of age.S4.3.5-28 ing criteria (ie, LV ejection fraction ≤35% with NYHA
The incidence of SCD after surgical repair of TOF is class II or III symptoms).S4.3.5-31–S4.3.5-33 There may be a role
approximately 2% per decade.S4.3.5-18,S4.3.5-21,S4.3.5-24,S4.3.5-29, for primary prevention ICDs in selected adults with TOF
S4.3.5-30
Currently, factors associated with SCD in patients who have additional risk factors for SCD but would not
with TOF have largely been identified from observa- meet standard criteria otherwise.
tional, predominantly retrospective studies. Despite nu- See Section 3.3 for recommendations on who
merous studies that identified factors associated with should perform surgeries, cardiac catheterization, and
malignant ventricular arrhythmias and SCD, risk stratifi- other procedures in these patients; Section 3.4 for rec-
cation remains imperfect. ommendations on diagnostic evaluation; Figure 4 for

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Stout et al 2018 ACHD Guideline

Table 27.  TOF: Routine Follow-Up and Testing Intervals

CLINICAL STATEMENTS
Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological

AND GUIDELINES
and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 12–24 12 6–12 3–6
ECG 24 12 12 12
TTE† 24 12–24 12 6–12
Pulse oximetry As needed As needed Each visit Each visit
Holter monitor As needed As needed 12–24 12–24
CMR‡/CCT§ 36 24–36 12–24 12–24

Exercise test‖ 36–60 24–60 12–24 12–24

*See Tables 3 and 4 for details on the ACHD AP classification system.


†Routine TTE may be unnecessary in a year when CMR imaging is performed unless clinical indications warrant otherwise.
‡CMR may be indicated for assessment of right ventricular size and function, pulmonary valve function, pulmonary artery anatomy and
left heart abnormalities. Baseline study is recommended with periodic follow-up CMR, with frequency of repeat imaging determined by
anatomic and physiological findings.
§CCT may be used if CMR is not feasible and to evaluate origin and course of the coronary arteries, and cross-sectional imaging status–
post-stent therapy. If cardiac CCT is used instead of CMR imaging, the frequency should be weighed against radiation exposure.
‖6-minute walk test or CPET, depending on clinical indication.
ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; CMR, cardiovascular magnetic resonance imaging;
CPET, cardiopulmonary exercise test; ECG, electrocardiogram; TOF, tetralogy of Fallot; and TTE, transthoracic echocardiogram.

a diagnostic and treatment algorithm for repaired TOF a balloon expanded stent will compress the cor-
with residual PR; and Table 27 for routine testing and onary artery.
follow-up intervals. 3. Additional risk factors for SCD include:S4.3.5-24,S4.3.5-38,
S4.3.5-39

a. LV systolic or diastolic dysfunction


Recommendation-Specific
b. Nonsustained VT, QRS duration ≥180 ms
Supportive Text c. Extensive RV fibrosis by CMR
1. Cardiac magnetic resonance imaging is the gold In adults with TOF, inducible sustained VT has
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standard imaging modality for quantification been associated with an increased risk of clinical
of right ventricular size and function in patients VT or SCD, beyond standard ECG, hemodynamic,
with repaired TOF. It also allows for quantification and clinical factors.S4.3.5-5 Programmed ventricular
of valve regurgitation and pulmonary and sys- stimulation is most useful in risk stratifying pa-
temic flows as well as delineating pulmonary ar- tients at moderate risk of SCD rather than as a rou-
tery anatomy and detection of scar tissue in the tine surveillance tool in low-risk populations.S4.3.5-7
ventricular myocardium. Serial cardiac magnetic 4. Cardiac catheterization is the only method that
resonance imaging examinations allows for longi- can accurately and reliably determine PA pressure
tudinal follow-up of patients with repaired TOF and and pulmonary vascular resistance.
provides useful information that aids in the timing 5. Symptomatic patients (with dyspnea, chest pain,
of pulmonary valve replacement.S4.3.5-1,S4.3.5-34–S4.3.5-37 and/or exercise intolerance otherwise unex-
2. Before any surgical or percutaneous intervention plained) with repaired TOF and severe PR who
in patients with TOF, the origins and proximal undergo pulmonary valve replacement often re-
courses of the coronary arteries should be delin- port improved functional class after intervention.
eated. Patients with repaired TOF and abnormal Improvement in symptoms often correlates with
coronary artery anatomy have a substantial risk a reduction in RV size and relief of PR.S4.3.5-9–S4.3.5-11
of coronary artery compression during percuta- Symptom improvement is more likely in patients
neous pulmonary valve replacement or direct in- with underlying PS and PR than in patients with
jury to the coronary during surgical pulmonary PR alone. For patients with significant LV or RV
valve replacement. During cardiac catheteriza- dysfunction, pulmonary valve replacement may
tion, the coronary pattern may be demonstrated not be tolerated or sufficient; therefore, evalua-
by performing simultaneous RVOT angiography tion by ACHD cardiologists and HF cardiologists
and coronary angiography.S4.3.5-2 Coronary com- is appropriate to decide appropriate course of
pression testing generally involves simultaneous action, particularly in deciding if a patient may be
coronary angiography or aortography and bal- appropriate for mechanical circulatory support or
loon dilation of the RVOT to ascertain whether heart transplant.

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Stout et al 2018 ACHD Guideline

6. There are data that indicate that pulmonary valve per year), lead-related complications, and unfa-
CLINICAL STATEMENTS

replacement performed prior to specific ventric- vorable patient-reported outcomes, including im-
AND GUIDELINES

ular size is associated with normalization of RV paired QoL, anxiety, depression, and psychosexual
volumes. However, it is not yet evident that this complications.S4.3.5-15,S4.3.5-17,S4.3.5-40
correlates with an improvement in mortality. 8. In patients with repaired TOF and moderate or
Clinically, it therefore is most compelling to per- greater PR who are undergoing cardiac surgery for
form pulmonary valve replacement if 2 of the fol- a separate lesion (eg, RVOT aneurysm, TR, branch
lowing are met:S4.3.5-1,S4.3.5-9,S4.3.5-12–S4.3.5-14 PA stenosis, residual VS D, arrhythmia ablation,
a. Mild or moderate RV or LV systolic dysfunction coronary artery revascularization, aortic root re-
b. Severe RV dilation (RV end-diastolic volume placement), it may be reasonable to concurrently
index ≥160 mL/m2, or RV end-systolic volume perform pulmonary valve replacement.S4.3.5-41
index ≥80 mL/m2, or RV end-diastolic volume 9. Although correction of the hemodynamic lesion
(ie, PR), may be clinically beneficial, pulmonary
≥2x LV end-diastolic volume). valve replacement alone has not consistently
c. RV systolic pressure due to RVOT obstruction been demonstrated to reduce risk of subsequent
≥2/3 systemic pressure VT or SCD.S4.3.5-42 Thus, in addition to pulmonary
d. Progressive reduction in objective exercise valve replacement, VT surgery and/or ICD implan-
tolerance tation may be considered.S4.3.5-43
The increasing use of CMR in the long-
term follow-up for patients with repaired TOF 4.3.6. Right Ventricle–to-Pulmonary
has provided quantification of ventricular size, Artery Conduit
function, and PR. However, there is lack of con- Recommendations for Right Ventricle–to-PA Conduit
sensus regarding optimal indications and timing Referenced studies that support recommendations are summarized
of pulmonary valve replacement in this popula- in Online Data Supplement 44.
tion. Pulmonary valve replacement results in re- COR LOE Recommendations
duction of RV volume and relief of PR; however, Diagnostic
these are only surrogates for outcomes. Many
1. Coronary artery compression testing with
patients with repaired TOF may deny symptoms simultaneous coronary angiography and
yet demonstrate reduced exercise tolerance.
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high-pressure balloon dilation in the conduit


I B-NR
is indicated before right ventricle–to-PA
Pulmonary valve replacement in such patients conduit stenting or transcatheter valve
has been associated with improved functional placement.S4.3.6-1,S4.3.6-2
status.S4.3.5-9,S4.3.5-10 2. In patients with stented right ventricle–to-PA
7. Risk factors for SCD include: conduits and worsening PS or PR, evaluation
a. LV systolic or diastolic dysfunction I B-NR
for conduit complications should be
performed, including fluoroscopy to evaluate
b. Nonsustained VT for stent fracture and blood cultures to
c. QRS duration ≥180 ms assess for IE.S4.3.6-3,S4.3.6-4
d. Extensive RV scarring 3. In adults with right ventricle–to-PA conduit
e. Inducible sustained VT at electrophysiological and arrhythmia, congestive HF, unexplained
IIa C-LD ventricular dysfunction or cyanosis cardiac
study catheterization is reasonable to assess the
The largest study of patients with repaired hemodynamics.S4.3.6-5,S4.3.6-6
TOF and ICDs included 121 patients from 11 Therapeutic
North American and European sites followed for
4. Right ventricle–to-PA conduit intervention
a median of 3.7 years after ICD implantation. is reasonable for adults with right ventricle–
Overall, 30% of patients received at least 1 ap- IIa B-NR
to-PA conduit and moderate or greater
PR or moderate or greater stenosis (Table
propriate ICD discharge, corresponding to annual
22) with reduced functional capacity or
appropriate shock rates of 7.7% and 9.8% for arrhythmia.S4.3.6-7–S4.3.6-11
primary and secondary prevention indications, 5. Right ventricle–to-PA conduit intervention
respectively.S4.3.5-16 Unlike patients with acquired may be reasonable for asymptomatic
HF, evidence suggests that patients with TOF who IIb B-NR
adults with right ventricle–to-PA conduit
and severe stenosis or severe regurgitation
have inducible sustained polymorphic VT (hazard with reduced RV ejection fraction or RV
ratio: 12.9) fare as poorly as or worse than those dilation.S4.3.6-12–S4.3.6-14
with inducible sustained monomorphic VT.S4.3.5-5
Negative consequences associated with ICDs in
adults with TOF must be carefully considered in Synopsis
selecting appropriate candidates. These include Right ventricle–to-PA conduits are widely used in the
high rates of inappropriate shocks (5% to 6% treatment of severe RVOT obstructive lesions including

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Stout et al 2018 ACHD Guideline

Table 28.  Right Ventricle–to-PA Conduit: Routine Follow-Up and Testing Intervals

CLINICAL STATEMENTS
Frequency of Routine Follow-Up Physiological Physiological Physiological Physiological

AND GUIDELINES
and Testing Stage A* (mo) Stage B* (mo) Stage C* (mo) Stage D* (mo)
Outpatient ACHD cardiologist 12–24 12 6–12 3–6
ECG 12–24 12 12 12
TTE† 12–24 12 12 12
CMR‡/CCT§ 36–60 36–60 12–24 12–24

Exercise test‖ As needed As needed 12–24 12–24

*See Tables 3 and 4 for details on the ACHD AP classification system.


†Routine TTE may be unnecessary in a year when CMR imaging is performed unless clinical indications warrant otherwise.
‡CMR may be indicated for assessment of right ventricular size and function and valvular function, conduit anatomy and pulmonary
artery anatomy. Baseline study is recommended with periodic follow-up CMR, with frequency of repeat imaging determined by anatomic
and physiological findings.
§CCT may be used if CMR is not feasible and to evaluate cross-sectional imaging status–post-stent therapy. If CCT is used instead of
CMR imaging, the frequency should be weighed against radiation exposure.
‖6-minute walk test or CPET, depending on clinical indication.
ACHD indicates adult congenital heart disease; CCT, cardiac computed tomography; CMR, cardiovascular magnetic resonance; CPET,
cardiopulmonary exercise test; ECG, electrocardiogram; PA, pulmonary artery; and TTE, transthoracic echocardiogram.

pulmonary atresia. These conduits may be homografts fracture typically presents with progressive ste-
or prosthetic conduits with bioprosthetic valves used nosis and in those with transcatheter valves may
within the conduit. A minority of conduits may show also present with worsening PR. Patients with an
early dysfunction because of kinking or aneurysmal di- increase in PR or PS should have fluoroscopic or
lation. The remainder will become dysfunctional over x-ray assessment to rule out stent fracture.
time and usually require replacement or intervention Annualized rate of IE is up to 2.4% of patients
because of progressive stenosis within the conduit or at treated with Melody valve implantation, but in-
the valve, and/or valvular regurgitation, at a mean inter- fection in most cases involves valves other than
val of 10 to 15 years from placement, although some the Melody valve, including left-sided valves.S4.3.6-3,
conduits may last much longer than that.S4.3.6-15,S4.3.6-16 S4.3.6-17–S4.3.6-20
Patients typically present with fever
See Section 3.3 for recommendations on who and malaise as well as worsening PS or PR. Cases
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should perform surgeries, cardiac catheterization, and may respond well to medical management with
other procedures in these patients; Section 3.4 for rec- intravenous antibiotics if IE is identified and
ommendations on diagnostic evaluation; and Table 28 treatment initiated early in the disease course,
for routine testing and follow-up intervals. although sometimes surgical removal of the valve
may be necessary.
3. Although noninvasive imaging with echocardiog-
Recommendation-Specific raphy, CMR, or CTA provides a reasonably com-
Supportive Text prehensive assessment of ventricular function,
1. Coronary compression testing generally involves conduit function, and patency as well as pulmo-
simultaneous selective coronary angiography or nary arterial anatomy, cardiac catheterization
aortography and balloon dilation in the RVOT, to is reasonable to directly assess hemodynamics
ascertain whether a balloon expanded stent will in the setting of clinical decompensation. Direct
compress the coronary artery. Coronary artery assessment of intracardiac and pulmonary arterial
compression with conduit balloon angioplasty pressures and cardiac output provides useful infor-
or stenting occurs in approximately 5% to 6% mation regarding volume status, pulmonary arte-
of patients with right ventricle–to-PA conduits rial resistance, and degree of conduit stenosis or
and usually involves the left main/left anterior regurgitation. Because of anatomic and technical
descending in those with conventional coronary factors, noninvasive imaging may provide equiv-
anatomy. Patients with anomalous right or left ocal information and may underestimate the de-
coronary arteries are at risk of coronary com- gree of conduit stenosis or regurgitation; invasive
pression as are those with reimplanted coronary assessment is especially important in such cases.
arteries. 4. Right ventricle–to-PA conduit intervention includes
2. Right ventricle–to-PA conduit stent fracture is surgical replacement or percutaneous stenting
common and occurred in approximately 26% and/or transcatheter valve placement. Patients with
of patients in the Melody Valve Investigational moderate or greater conduit stenosis (Table 22)
Device Exemption trial,S4.3.6-7 especially in patients and/or regurgitation who have reduced exercise
who did not undergo conduit prestenting. Stent capacity or arrhythmias can benefit from surgical

Circulation. 2019;139:e698–e800. DOI: 10.1161/CIR.0000000000000603 April 2, 2019 e753


Stout et al 2018 ACHD Guideline

or transcatheter conduit intervention to relieve ste- Synopsis


CLINICAL STATEMENTS

nosis and/or regurgitation. Transcatheter stenting


Common problems for patients with d-TGA with atrial
AND GUIDELINES

and pulmonary valve replacement may be per-


switch (Mustard or Senning procedure) include leak
formed with high procedural success and low mor-
across or obstruction of the venous pathways, arrhyth-
tality rates, and result in improved hemodynamics
mias, need for pacemakers/defibrillators, and systolic
and improved exercise capacity. Surgical conduit
dysfunction of the systemic ventricle. Although re-
replacement carries a higher risk of periprocedural
ports describing these sequelae abound, data that in-
complications with good long-term outcomes.
form management decisions are sparse, and many of
Predictors of conduit dysfunction and reopera-
tion include placement of small diameter conduits; the most common clinical issues cannot be addressed
therefore, insertion of conduits with the largest by data-supported recommendations. Two such issues
possible diameter should be attempted,S4.3.6-8 antic- are medical therapy for RV dysfunction and prevention
ipating that subsequent valve replacement may be of SCD.
via a transcatheter approach. The systematic review report, “Medical Therapy for
5. Right ventricle–to-PA conduit intervention, which Systemic Right Ventricles: A Systematic Review (Part 1)
includes surgical replacement or percutaneous for the 2018 AHA/ACC Guideline for the Management
stenting and/or transcatheter valve placement, of Adults With Congenital Heart Disease,” has the
may be reasonable in asymptomatic patients complete systematic evidence reviewS4.4.1.1-3 for addi-
with severe right ventricle–to-PA conduit stenosis tional data and analyses. The results from the question
or regurgitation in the presence of reduced RV “Are outcomes improved with angiotensin-converting
systolic function or dilation in the expectation of enzyme inhibitors, angiotensin-receptor blockers, beta
improvement in hemodynamics, decreased RV blockers, or aldosterone antagonists alone or in combi-
size, improved RV stroke volume, and improved nation in patients with a systemic right ventricle?” and
RV ejection fraction. Moreover, peak oxygen con- the writing committee’s review of the totality of the
sumption and anaerobic threshold may also im- literature demonstrated that medical therapy for sys-
prove with conduit intervention. tolic ventricular dysfunction remains largely uncertain.
Consequently, no recommendations regarding specific
medical therapy for systolic dysfunction of the systemic
4.4. Complex Lesions right ventricle can be made.
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4.4.1. Transposition of the Great Arteries In addition to the report provided by the ERC regard-
4.4.1.1. Transposition of the Great Arteries With ing angiotensin-converting enzyme inhibitor, angioten-
Atrial Switch sin-receptor blocker, and aldosterone antagonist use
for patients with systemic right ventricles, beta block-
Recommendations for d-TGA With Atrial Switch
ers and other commonly used HF medications lack data
Referenced studies that support recommendations are summarized
in Online Data Supplement 45. to support recommendations in the treatment of atrial
COR LOE Recommendations switch patients.S4.4.1.1-4–S4.4.1.1-7 Concerns regarding rou-
tine use of beta blockers for asymptomatic RV dysfunc-
Diagnostic
tion include potentially greater predisposition to brady-
1. Ambulatory monitoring for bradycardia or
sinus node dysfunction is recommended
cardia and limited distensibility of the interatrial baffle,
I C-EO for adults with d-TGA with atrial switch, which creates a preload limited physiology.S4.4.1.1-8 Al-
especially if treated with beta blockers or though no clear benefit has been demonstrated for HF
other rate-slowing agents.
medical therapy overall, there is speculation of benefit
2. Adults with d-TGA with atrial switch repair