Long-Term Results of Pediatric Cardiac Surgery in Finland: Education, Employment, Marital Status, and Parenthood
* Department of Pediatrics, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
Department of Pediatrics, University of Kuopio, Kuopio, Finland
Department of Pediatrics, University of Oulu, Oulu, Finland
|| Department of Pediatrics, University of Turku, Turku, Finland
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Objective. This population-based study was designed to examine the psychosocial outcome of Finnish patients who had been operated on for congenital heart disease during childhood.
Methods. A questionnaire was mailed to 3789 adult patients who had been operated on for congenital heart defects in Finland. Of these, 2896 (76%) answered the questionnaire. The mean age of patients was 33 years (range: 18–59 years), and they had had their first operation 9 to 46 years earlier.
Results. The patients had coped well with their defects when compared with the general Finnish population. The educational level of patients was comparable to and employment level was higher than expected (70% vs 66%, respectively). They were living in a steady relationship as often as the general population, but the number of parents among the patients was lower than that expected (47% vs 49%, respectively). The incidence of congenital heart disease among the 2697 children of the patients was 2.4%.
Conclusion. Our results confirm that in addition to high survival rate, the long-term psychosocial outcome of patients with surgically treated congenital heart defects is good if they do not have any additional syndromes that cause mental retardation.
Key Words: heart defects • congenital • population • education • employment • marital status
Abbreviations: NYHA, New York Heart Association • PDA, patent ductus arteriosus • CoA, coarctation of the aorta • ASD, atrial septal defect • TOF, tetralogy of Fallot • TGA, transposition of the great arteries • PS, pulmonary stenosis • AS, valvular aortic stenosis • UVH, univentricular heart • CHD, congenital heart disease
The progress of medicine has allowed an increasing number of congenital heart defects to be corrected or alleviated surgically while maintaining high overall survival rate. In fact, most patients, especially those with simple defects, have a normal life expectancy after a successful operation.1 However, from the patient’s point of view, survival may not be the most important measure of therapeutic success. A long life burdened with disability and dissatisfaction can be of questionable value to a patient who, by survival criteria, represents a good outcome. To evaluate our operative results beyond survival, we examined the basic psychosocial aspects of life, such as education, employment, and marital status, by sending a questionnaire to all adult patients who had been operated on for congenital heart defects in Finland. The patient data came from the Finnish national research registry of pediatric cardiac surgery.1 The results were compared with the age-matched general population.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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During the years 1953 to 1989, a total of 7240 cardiac operations were performed on 6461 children in Finland. A total of 3842 patients had reached the age of 18, and 3789 of them had a known address on October 28, 1998. All of these adult patients were included in this study. In addition, 226 patients who were operated on in Finland may have reached adulthood, but their outcome was not known as they were either not identified from population registry (84) or had emigrated (142).
Each operating hospital sent the inquiry to its own patients, and the results were combined. All units used the same questionnaire designed to provide information about the patient’s general state of health, exercise tolerance, education, occupation, marital status, offspring, and cardiac follow-up. The questionnaire was designed to be easy and quick to complete and unambiguous to interpret. The patients were asked to classify their general state of health as good, moderately good, or poor and to list their concurrent illnesses. The patients estimated their exercise tolerance by classifying their physical fitness as normal, less than normal, or significantly less than normal and by describing their ability to climb stairs and run. The investigators translated the patients’ answers into the New York Heart Association (NYHA) classification. Because the questions did not differentiate between NYHA classes I and II, these classes were combined for the analysis.
We classified education into 3 levels: compulsory, vocational, and university. Compulsory education in Finland consists for 9 years of comprehensive school. The vocational level includes graduation from vocational school or high school. The university level required a degree from an institute of postsecondary education.
The patients were divided into different groups by the main diagnosis according to a previously published hierarchy.1 The 9 most common diagnoses were patent ductus arteriosus (PDA), coarctation of the aorta (CoA), atrial septal defect (ASD), ventricular septal defect, tetralogy of Fallot (TOF), transposition of the great arteries (TGA), pulmonary stenosis (PS), valvular aortic stenosis (AS), and univentricular heart (UVH). The patients with TOF, TGA, and UVH were combined into 1 group (cyanotic) to evaluate the impact of a complex defect on coping.
Statistical Analysis
The educational, employment, and family status were compared with that of the general population, using data from the national statistical center, Statistics Finland. The expected values were calculated as weighted averages of published age- and sex- specific rates. The calculations were made separately for each patient group. In the education section, the patients who were younger than 20 years were excluded. Unpaired t test was used to compare the ages of male and female patients; the 
2 test was used in comparing of frequencies between patients and the general population.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A total of 2896 patients (76%) completed and returned the questionnaire. Women answered the inquiry more often than men (80% vs 72%, respectively; P < .001). The number of replies received from patients in each diagnostic group varied from 72% to 82% (Fig 1). The age and defect type distributions were similar between the patients who completed the questionnaire and those who did not. Henceforth, in this report, the term "patient" refers to patients who provided data.
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, all patients; 
, patients who answered.The median age of the patients at first operation was 6.7 years (range: 0–15). Their median follow-up time was 25.6 years (range: 9–46), and their median age was 31.7 years (range: 18–59) at the time of data collection. Men had more complex defects than women: 67% of CoA, 56% of TGA, and 62% of AS patients were male. There was a female predominance among the patients with PDA (76%) and ASD (61%). Men were younger than women (P < .001) with a median age of 30.8 years (range: 18–57); the median age of women was 32.5 years (range: 18–59). Of the 3789 patients, 100 (2.6%) had received a diagnosis of mental retardation. Seventy-six questionnaires were received from them, in most cases completed by their guardians.
General State of Health
Most patients (2227 [77%] of 2896) described their general health to be good. One fifth of the patients (611 [22%]) classified their health as moderately good, and only 36 patients (1%) believed their condition to be poor. In most cases, poor health was attributable to a condition unrelated to the cardiac defect or its treatment. Surprising was that no patients with UVH (n = 22) or TGA (n = 64) reported poor health. Five patients with PDA (n = 1066) could be considered to be in poor condition because of their heart defect.
Exercise Tolerance
Most patients assessed their exercise tolerance to be good. A vast majority, 97% (2320 of 2896), were classified into NYHA I and II; 68 patients (2%) were in NYHA III. Only 7 patients were symptomatic at rest (NYHA IV). The distribution was similar between diagnostic groups, except for the TOF (n = 180) and UVH groups. Fifteen patients (8%) had TOF, and 5 patients (23%) had UVH in NYHA class III; 1 patient from the TOF group and 1 from the UVH group were classified as NYHA IV.
Education
The educational profile of the patients was comparable to the expected (Table 1). Most of the patients (2100 [79%] of 2676) had more than compulsory education, and 10% (257 of 2676) had a university degree. The level of education was significantly different from the general population in 3 patient groups. The number of patients with a vocational or university degree in the CoA group (356 [85%] of 420) was 6% higher than expected (P = .003). In the ASD group, more patients than expected had compulsory education only (24% [101 of 421] vs 21%, respectively; P = .038). The educational level was low also among the patients with a cyanotic defect. Of the 235 patients, 63 (27%) had compulsory education only, as compared with the expected 21% (P = .025). When the 13 patients with mental retardation (12 with TOF, 1 with TGA) were excluded, the proportion of patients with only compulsory education decreased to 22%, which was comparable to the expected frequency. A university degree was less common than expected (3% vs 7%; P = .014) among patients with cyanotic defects. The exclusion of patients with mental retardation did not eliminate this difference.
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Employment
The employment rate (70%) was higher among the patients than in the general population (66%; P < .001; Table 2). The patients with PDA and CoA (n = 456) were employed significantly more often than their reference populations (77% vs 69% and 74% vs 66%, respectively; P < .001). As seen in Table 2, the patients with cyanotic defects were employed less often than expected. The difference disappeared when the patients with mental retardation were excluded.
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The overall unemployment rate of only 6% among the patients contrasted with the expected rate, which was nearly twice as high (11%; P < .001). The proportion of students was similar to the general population. The observed retirement rate was 7% and the expected was 3%. Only 38 of the 207 retired patients were clearly disabled because of their heart defect. The most common reason for retirement was mental retardation, in 66 patients.
Marital Status
The number of married patients was comparable to the general population. A total of 1043 (36%) patients were married, women more often than men (40% vs 30%, respectively; P < .001; Table 3). The proportion of patients who were unmarried but living with a partner was greater than expected (23% vs 20%, respectively; P < .001). However, there also were more single patients than expected (37% vs 35%; P = .048). The concurrency of a high number of patients living in a relationship and a high number of singles was possible because the divorce rate among the patients was lower (4%; 105 patients) than the expected 7%. There was not significant difference in the marital status between the cyanotic group and the general population, except the low divorce rate of patients (1% vs 5%).
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Offspring
The patients had become parents less often than expected. The difference was similar for both sexes (Table 4). The number of children in a family was comparable to that of the general population, except that there were only 45 female patients who had 4 or more children. The difference to the expected 67 was statistically significant (P = .006). The number of parents with PDA (620 of 1066) and PS (60 of 123) was lower than expected (58% vs 61% [P = .032] and 49% vs 58% [P = .045], respectively). The female patients with cyanotic defect became mothers less often than expected (Table 4). There were only 45 mothers (35%), while the expected proportion was 46% (P = .008). The difference diminished (P = .039) but did not vanish when the patients with mental retardation were excluded.
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The incidence of congenital heart disease (CHD) among the offspring of the patients was 2.4 times that of the general incidence of approximately 1%.2 Of the 2697 children, 64 (2.4%) had a heart disease. Women had a higher risk of having children with CHD (Table 4). The incidence of CHD in the offspring was 2.7% for women and 1.6% for men (P < .001). Relatively high risk of recurrence of CHD was seen in the PDA (2.7%), ASD (2.6%), and PS (5.8%) groups (P < .001 in all). Two patients with PDA had 3 children and 3 mothers (2 PDA, 1 PS) had 2 children with CHD.
Cardiac Follow-up
Of the adult patients, only 26% (742) were in cardiac follow-up. After exclusion of the patients with PDA and ASD there were still 53% (724 of 1374) of patients without follow-up. Most patients (78%; 564 of 724) who had dropped out of follow-up believed themselves to be in good condition and in NYHA class I to II. The only patient group in which all patients had regular appointments was UVH. Several patients with known high residual risk were not seen regularly; for instance, 36% of TOF and 60% of CoA patients and even 2 patients after Mustard operation for TGA.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This population-based study reveals the late results of pediatric cardiac surgery beyond survival curves. A comprehensive and accurate national research registry of pediatric cardiac surgery in Finland1 guarantees the reliability of the results. With good cooperation between hospitals, we were able to include 3789 patients in the study and receive a completed questionnaire of the basic elements of psychosocial life from 2896 adult patients. The national population registry and statistics center gave us the opportunity to compare patients with the general population, which is recognized as the most relevant control group 3. To maintain a high completion rate, we designed the questionnaire to be simple. The decision was made to address only the basic elements of life: health, fitness, education, employment, and family. Hence, we were able to achieve a relatively high reply rate of 76%, yet the most important and unavoidable bias of this study is the inability to define the difference between the patients who answered and who did not. Another important bias is that the results are based solely on the patients’ own report of their conditions. This might have given slightly overestimated values toward the awaited "good results." For example, if patients had been retired and a student at the same time, then it is more likely that the answer to the employment question would be student rather than retired.
A chronic disease has been reported to produce both negative and positive effects on the patient’s life.3,4 In many studies, good coping has resulted in an excellent quality of life, even for severely physically disabled patients.5–7 The documented positive effect usually relates to education and employment,5–9 whereas difficulties in reaching independence and finding a partner are the most common negative effects reported.8,10
Subjectively, the vast majority of the patients estimated their health in general to be good. Poor health was usually associated with noncardiac conditions. The overall health of patients within different diagnosis groups has previously been reported to be equal or better than in our material.11–14
The overall exercise tolerance of the patients who were operated on also was good. Most patients were assigned to NYHA classes I and II in all diagnostic groups. Our results were comparable to previous reports in patients with CoA, ventricular septal defect, PS, AS, and TGA.11,15–17 Both similar18,19 and better20,21 exercise tolerance has been reported previously after TOF repair. In our results, the patients with late corrective surgery or only palliative surgery worsened the estimated exercise capacity.
The patients had coped surprisingly well with their defects. The level of education was equivalent, the employment level was higher than expected, and they were living in a steady relationship as often as the general population.
A high level of education has been reported frequently in several studies of different diagnostic groups.7,11,17,22 After exclusion of the patients with mental retardation, the number of patients with vocational or university education was higher than expected. However, we found that patients with cyanotic defects were less likely to have graduated from a university. Whether this was caused by lack of encouragement or a decreased capacity for performance remains open.
The patients clearly were employed more often than expected. Even the exclusion of the most frequently employed group, the PDA patients, did not change this positive result. The patients with cyanotic defects were not employed as often as expected, but after exclusion of patients with mental retardation, the number was comparable to the general population. The low unemployment rate reflects the high value of work among these patients, a finding that has been reported previously.8,9
Marital status of the patients was comparable to normal. We do not know how many of the single patients were still living with their parents and thus could not entirely contradict the previous idea of a low level of independence.8,23 The low divorce rate could be a sign of either a successful relationship or overadherence and lack of independence. Our data do not provide an answer to this interesting matter.
The patients did not have children as often as the general population, a tendency seen also among the women in the Second Natural History Study.11 It was expected that the women with cyanotic defects would often be childless, but the large number of patients (both female and male) without children in the PDA group was surprising.
The risk of having a child with congenital heart defect was 2.4 times higher than expected. The recurrence of a CHD varies widely between different defects. The patients with TOF and TGA have repeatedly reported not to have children with CHD,20,24–27 whereas the patients with minor lesions have had children with CHD approximately 3 times17,26,28 more often than expected. The overall risk of only 2 to 3 of 100 children can be considered small enough to encourage these patients to have offspring. However, they should also be provided with sufficient genetic counseling.
When patients with mental retardation were excluded, the proportion of those retired and having only compulsory education dropped to the level present in the general population. The effect of mental retardation in quality-of-life studies has to be considered carefully, because the retardation is usually not a consequence of the heart disease but can have an overwhelming effect on the quality of life. Furthermore, a sufficient degree of mental retardation precludes self-assessment of the quality of life, in which case its evaluation becomes dependent on a third party.
The frequent lack of adequate cardiac follow-up surfaced as a serious problem among this patient group. In this respect, our results are comparable to previous studies.11,13,20 The reason for the high rate of follow-up dropouts likely is attributable to unsuccessful transfer of care from pediatric to adult clinic. The potential for hazardous consequences from lack of follow-up has been documented previously.29
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In the Finnish culture, it is appreciated, for both sexes, to have more than compulsory education, to be employed, and to start a family. When evaluated with these goals in mind, the results of pediatric cardiac surgery are very good. The good results should encourage us to treat the patients with congenital heart defects intensively even when the treatment is costly and often long-lasting.
Approximately half of the patients who were operated on for congenital heart defect should be in cardiac follow-up for the rest of their lives. However, in our material, 53% of patients who needed follow-up had dropped out. There should be an intense effort to develop an efficient chain of services to ensure the transition of patients and expertise from pediatric to adult cardiac follow-up.
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ACKNOWLEDGMENTS |
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This study was financially supported by the Finnish Slot Machine Association, Sydänlapset (Parent Organization for Children with Heart Disease), Finnish Foundation for Cardiovascular Research, and Finnish Foundation for Pediatric Research.
We thank Hanna Oksanen, PhD, for the statistical review.
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FOOTNOTES |
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Received for publication Sep 23, 2002; Accepted Mar 6, 2003.
Reprint requests to (E.J.) Hospital for Children and Adolescents, Box 281, FIN-00029 HUS, Finland. E-mail: eero.jokinen{at}hus.fi
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
- Nieminen HP, Jokinen EV, Sairanen HI. Late results of pediatric cardiac surgery in Finland. A population-based study with 96% follow-up.
Circulation.2001; 104
:570
–575
[Abstract/Free Full Text] - Hoffman JIE. Incidence of congenital heart disease: I. postnatal incidence. Pediatr Cardiol.1995; 16 :103 –113[CrossRef][Web of Science][Medline]
- Gledhill J, Rangel L, Garralda E. Surviving chronic physical illness: psychosocial outcome in adult life.
Arch Dis Child.2000; 83
:104
–110
[Free Full Text] - Pless IB, Cripps HA, Davies JMC, Wadsworth MEJ. Chronic physical illness in childhood: psychological and social effects in adolescence and adult life. Dev Med Child Neurol.1989; 31 :746 –755[Web of Science][Medline]
- Saliba Z, Butera G, Bonnet D, et al. Quality of life and perceived health status in surviving adults with univentricular heart.
Heart.2001; 86
:69
–73
[Abstract/Free Full Text] - Lönnberg F. Late onset polio sequelae in Denmark. Socio-medical adaptation of polio survivors. Results of a nation-wide survey of 3,607 polio survivors. Scand J Rehabil Med Suppl.1993; 28 :1 –32[Medline]
- Ternestedt BM, Wall K, Oddsson H, Riesenfeld T, Groth I, Schollin J. Quality of life 20 and 30 years after surgery in patients operated on for tetralogy of Fallot and for atrial septal defect. Pediatr Cardiol.2001; 22 :128 –132[CrossRef][Web of Science][Medline]
- Utens EMWJ, Verhulst FC, Erdman RAM, et al. Psychosocial functioning of young adults after surgical correction for congenital heart disease in childhood: a follow-up study. J Psychosom Res.1994; 38 :745 –758[CrossRef][Web of Science][Medline]
- Horner T, Liberthson R, Jellinek MS. Psychosocial profile of adults with complex congenital heart disease. Mayo Clin Proc.2000; 75 :31 –36[Abstract]
- Kokkonen J. The social effects in adult life of chronic physical illness since childhood. Eur J Pediatr.1995; 154 :676 –681[CrossRef][Web of Science][Medline]
- Gersony WM, Hayes CJ, Driscoll DJ, et al. Second natural history study of congenital heart defects. Quality of life of patients with aortic stenosis, pulmonary stenosis, or ventricular septal defect. Circulation.1993; 87(suppl I) :52 –65[Web of Science][Medline]
- Horneffer PJ, Zahka KG, Rowe SA, et al. Long-term results of total repair of tetralogy of Fallot in childhood. Ann Thorac Surg.1990; 50 :179 –185[Abstract]
- Meijboom F, Szatmari A, Deckers JW, et al. Cardiac status and health-related quality of life in the long term after surgical repair of tetralogy of Fallot in infancy and childhood. J Am Coll Cardiol.1995; 110 :883 –891
- Meijboom F, Szatmari A, Utens E, et al. Long-term follow-up after surgical closure of ventricular septal defect in infancy and childhood. J Am Coll Cardiol.1994; 24 :1358 –1364[Abstract]
- Cohen M, Fuster V, Steele PM, Driscoll DJ, McGoon DC. Coarctation of the aorta. Long-term follow-up and prediction of outcome after surgical correction.
Circulation.1989; 80
:840
–845
[Abstract/Free Full Text] - Hucin B, Voriskova M, Hruda J, et al. Late complications and quality of life after atrial correction of transposition of the great arteries in 12 to 18 year follow-up. J Cardiovasc Surg.2000; 41 :233 –239[Medline]
- Lillehei CW, Patton C, Moller JH. Quality of life 30 to 36 years after closure of isolated ventricular septal defect in 341 patients. In: Walter PJ, ed. Quality of Life After Open Heart Surgery. Vol 1. Netherlands: Kluwer Academic Publishers; 1992:253–265
- Nollert G, Fischlein T, Bouterwek S, Böhmer C, Klinner W, Reichart B. Long-term survival in patients with repair of tetralogy of Fallot: 36-year follow-up of 490 survivors of the first year after surgical repair. J Am Coll Cardiol.1997; 30 :1374 –1383[Abstract]
- Shampaine EL, Nadelman l, Rosenthal A, Behrendt D, Sloan H. Longitudinal psychological assessment in tetralogy of Fallot. Pediatr Cardiol.1989; 10 :135 –140[CrossRef][Web of Science][Medline]
- Jonsson H. Survival and clinical results up to 26 years after repair of tetralogy of Fallot. Scand J Thorac Cardiovasc Surg.1995; 29 :43 –52[Web of Science][Medline]
- Bacha EA, Scheule AM, Zurakowski D, et al. Long-term results after early primary repair of tetralogy of Fallot.
J Thorac Cardiovasc Surg.2001; 122
:154
–161
[Abstract/Free Full Text] - Lillehei CW, Varco RL, Cohen M, et al. The first open heart corrections of tetralogy of Fallot. A 26–31 year follow-up of 106 patients. Ann Surg.1986; 204 :490 –502[CrossRef][Web of Science][Medline]
- Kokkonen J, Paavilainen T. Social adaptation of young adults with congenital heart disease. Int J Cardiol.1992; 36 :23 –29[CrossRef][Web of Science][Medline]
- Clarkson PM, Wilson NJ, Neutze JM, North RA, Calder AL, Barratt-Boyes BG. Outcome of pregnancy after the Mustard operation for transposition of the great arteries with intact ventricular septum. J Am Coll Cardiol.1994; 24 :190 –193[Abstract]
- Miyamura H, Eguchi S, Asano K-I. Long-term results of the intracardiac repair of tetralogy of Fallot: a follow-up study conducted over more than 20 years on 100 consecutive operative survivors. Surg Today1993; 23 :1049 –1052[CrossRef][Web of Science][Medline]
- Zuber M, Gautschi N, Oechslin E, Widmer V, Kiowski W, Jenni R. Outcome of pregnancy in women with congenital shunt lesions.
Heart.1999; 81
:271
–275
[Abstract/Free Full Text] - Genoni M, Jenni R, Hoerstrup S, Vogt P, Turina M. Pregnancy after atrial repair for transposition of the great arteries.
Heart.1999; 81
:276
–277
[Abstract/Free Full Text] - Driscoll DJ, Michels VV, Gersony WM, et al. Occurrence risk for congenital heart defects in relatives of patients with aortic stenosis, pulmonary stenosis, or ventricular septal defect. Circulation.1993; 87(suppl I) :114 –120
- Somerville J. Near misses and disasters in the treatment of grown-up congenital heart patients. J R Soc Med.1997; 90 :124 –127[Web of Science][Medline]
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