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Pediatric and Congenital Heart Surgery, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, 9500 Euclid Ave, Cleveland, OH 44195
(Email: mavrouc{at}ccf.org).
Kogon and associates [1] have presented their experience with adult congenital heart patients who underwent operations at a pediatric hospital versus an adult hospital. They concluded that adult patients with congenital heart disease should have their care at an adult institution with operations performed by a congenital heart surgeon. A recent study by Karamlou and associates [2] confirmed similar trends using the Nationwide Inpatient Sample from 1988 to 2003 (152,277 patients).
Institutions with separate pediatric and adult facilities have debated the optimal care dilemma for adults with congenital heart disease for many years. There is a curious approach-avoidance situation in regard to these patients. Adult practitioners, directors of residency training programs, nursing personnel, and administrators have disagreed with their pediatric counterparts and not always from the same perspective. Some adult program practitioners want to care for these patients, others are hesitant for many reasons owing to clinical competence, visionary commitment, and resident training; and the same is true for pediatric practitioners.
Economic, practical, educational, and programmatic considerations come to the fore. Unfortunately, payer mix can play a major role in patient referral and institutional zeal in caring for these patients. Pediatric resident program directors argue that pediatric residents should not be responsible for adult patients. Pediatric nurses often say, "The reason that I went into pediatric nursing was to take care for kids, not adults."
On the other side of this conundrum is the fact that the congenital heart surgery team is usually based at a free-standing children's hospital. The operations that are performed on adult congenital heart patients are generally the same as those performed on children. Consequently, the operating team that is best suited to care for these patients is the pediatric heart surgery team.
The obvious important issues are by whom, where, and under what circumstances do these patients obtain the best possible care? It seems that free-standing pediatric hospitals will be permanently challenged to perform adult congenital heart surgery for a variety of reasons owing to expert clinical care. The most that anyone could ask of the system is to perform congenital heart surgery on patients less than 25 to 30 years of age. After this age range, the problems of adult acquired diseases come into consideration.
Kogon and associates [1] have had the foresight to understand these issues and propose that congenital heart surgeons perform the operations on adult patients with congenital heart disease in an adult facility with all the supportive care that might be required for age-related disease entities.
In the end, participating centers will determine what levels of care are necessary for the adult patient with congenital heart disease. So far, the published determinant of success is decreased mortality. In the future, it will be more important to document and compare mortality and morbidity as determining success factors.
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