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In the Older ACHD Population, Coordination of Care is Key

Wednesday, March 03, 2021

By Pankaj Madan, MD, MS

As an active and energetic 54-year-old, Mr. Trevino (whose name and certain details have been changed here for privacy) will likely chuckle at being a subject of discussion in this blog about congenital heart disease (CHD) in the geriatric population.

I met Mr. Trevino, a retired pharmacist, about two years ago when he presented with chest discomfort and was found to have a severely leaking pulmonic valve from a previously operated congenital pulmonic stenosis and blockages in his three coronary arteries supplying the heart. Surgery was advised to replace the leaky pulmonic valve, along with coronary artery bypass surgery.

We know that patients with congenital heart conditions have the best outcomes in the hands of congenital heart surgeons. Similarly, outcomes of coronary artery bypass graft are best when best performed by high-volume adult cardiothoracic surgeons. Therefore, Mr. Trevino’s cardiac problems required collaboration between two cardiac surgeons. The congenital heart surgeon performed the pulmonic valve replacement, and the adult cardiothoracic surgeon performed the coronary artery bypass grafting.

Mr. Trevino’s situation is not unique and is part of a growing trend. With the advances in medical care, we are seeing and will continue to see an expansion of older individuals with adult congenital heart disease (ACHD). While some of the older adults that we see have undergone intervention in childhood, there are others in whom CHD was discovered for the first time only in later years of adulthood. These folks mostly have a bicuspid aortic valve, atrial septal defect, partial anomalous venous connections, or anomalous coronary arteries.

As this population ages, we are also seeing a rise in traditional coronary artery disease risk factors such as diabetes, hypertension, high cholesterol, chronic kidney disease, and obstructive sleep apnea. Due to their multiple medical conditions, our older patients often see multiple physicians of different subspecialties in addition to seeing us as their adult congenital cardiology providers. This is quite in contrast to pediatric cardiology practices where, in a majority of the affected children, CHD is pretty much their only affliction.

As a program providing care to a large geographical region through our main location in San Antonio and satellite clinic in Corpus Christi, TX, one of the most difficult things that we do is help our older ACHD patients navigate through the challenges of a complex and fragmented medical system of multiple medical providers and ensure coordinated and high-quality care.

It goes without saying that coordination of care is of vital importance to reduce hospitalizations and avoid medical errors. It is also worth mentioning that hospitalizations in the ACHD population have increased by more than 100% in the last decade. Multiple comorbidities in older patients often require the services of multiple specialty physicians during their hospital stays. As adult congenital cardiology physicians, we need to ensure that our programs and our hospitals are ready to take care of our older patients, who will often need additional care for their coexistent problems beyond their CHD issues.

We at the South Texas Adult Congenital Heart Center in San Antonio are extremely fortunate to be located in a combined adult and pediatric hospital (Methodist Hospital), where expertise in adult and pediatric subspecialties including adult cardiothoracic surgery and congenital heart surgery is available in the same hospital. Mr. Trevino is one of the several patients at our program who have benefited from this collegiality, cooperation, and coordination of care.


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