"Adult congenital heart disease did not exist as a subspecialty during the 1980s, but children were now surviving into adolescence and adulthood. We were beginning to see problems that had never been seen before," recounts Dr. Rosenbaum, Director of the Schneeweiss Adult Congenital Heart Disease Center at Columbia and one of the few specialists in the United States who devotes full time to this field.
The unique needs of this patient population now demand the expertise of specialists who can place congenital defects and their repairs in the context of an adult patient. "The whole spectrum of pediatric cardiology is superimposed on the problems encountered by the adult cardiologist," comments Dr. Rosenbaum. "Traditionally, pediatric cardiologists followed their adult patients because there were very few adult cardiologists familiar with their anatomy and management. Today, adult congenital heart specialists can bridge the gap between pediatric and adult cardiology, and are often best suited to manage difficult adult-related problems such as complex arrhythmias and chronic heart failure." These patients present with a broad range of problems, which may include the need to revise a childhood repair, the development of new lesions superimposed on an early repair, newly recognized congenital heart defects, complex arrhythmias, and pregnancy issues.
Dr. Rosenbaum, who coauthored Congenital Heart Disease in the Adult with Welton Gersony, MD in 2002, says that treatment of difficult cases may require a complex plan involving congenital heart surgeons, interventional cardiologists, electrophysiologists, and other specialists. "For example, our patients may have both hemodynamic problems and complex arrhythmias, and require both reoperation and sophisticated arrhythmia mapping with radiofrequency ablation." At the same time, "the emergence of catheter-based interventions has an important place in the treatment of congenital heart defects, and in some cases, may be used in lieu of an operation," says Dr. Rebecca Hahn, Director of Clinical Echocardiography at Weill Cornell and a specialist in both heart disease in pregnancy and adults with congenital heart disease.
According to Dr. Rosenbaum, "The reality is that we do not know exactly what problems these patients will face as they reach their 50s and 60s. Even for those of us who work in this area day to day, the field continues to evolve." Dr. Rosenbaum and Dr. Hahn concur that the lessons learned during follow-up of adults with congenital heart disease can provide feedback that is crucial for the pediatric cardiologist and surgeon. "For example," states Dr. Rosenbaum, "late problems with the early surgical repair forD-transposition of the great arteries and single ventricle led to a change in the type of surgery performed for these lesions. This is a very dynamic field likely to pose new challenges not only as the initial survivors age, but as we are confronted by new problems from the subsequent innovations in pediatric repairs."
Marlon S. Rosenbaum, MD
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