One of medicine's greatest triumphs is hitting a snag: Up to 1 million people born with once-lethal heart defects now have grown up, a pioneering generation largely unaware that heart repairs can wear out as middle age approaches.
Few even get cardiac checkups, apparently believing they were cured as children. Worse, few cardiologists outside of children's hospitals know how to care for these special hearts.
"The disease as an adult is completely different than the other kinds of heart disease adults get," warns Dr. Karen Kuehl, a pediatric cardiologist at Children's National Medical Center in Washington, D.C., who recently helped open one of the nation's few specialty clinics for adults with congenital heart disease.
"Here are people in their early young adulthood who have thought that they went through this [childhood surgery] ... and they were going to be fine. In fact, we don't know that," Kuehl says. "Now we're seeing things nobody would have predicted."
Open heart surgery for babies and young children didn't become common until the 1970s. Before then, only a quarter of "blue babies" and other infants born with complex heart defects lived beyond a year. Now more than 95% of these children will grow up, living near-normal lives for many years.
Only recently have enough of the early survivors reached adulthood for doctors to notice a disturbing trend: Starting about 20 years after childhood surgery, the risk for some serious problems -- irregular heartbeats, an enlarged heart, heart failure, occasionally even sudden death -- begins to rise among people who had complex defects repaired.
Caught early, many such problems are treatable or, better, preventable. Too often, patients have serious damage or even need a heart transplant by the time someone links their survived birth defect to the new illness, says Dr. Roberta Williams of the American College of Cardiology.
Doctors don't yet know the size of the risk or who most needs preventive care, although pregnancy does demand extra caution. There have been no large-scale studies of survivors' long-term health, partly because so many patients disappear once they outgrow the pediatric cardiologist. Fewer than half of adults with congenital heart disease are thought to receive any regular cardiac care.
Denial plays a role. Young adults who feel well, and who no longer are on a parent's insurance policy, desperately want to be normal and may not see a need for checkups.
Even if they want ongoing care, there are only about 100 cardiologists nationwide specially trained in adult congenital heart disease. Considering that 1 in 150 babies is born with a heart defect, a soon-to-skyrocket new population of adult patients will compete for limited specialists.
"There's a setup for people to fall between the cracks," says Dr. George Ruiz of the Washington Hospital Center, who with Kuehl runs the new Washington Adult Congenital Heart Center -- and is combing through boxes of dusty surgical records dating to the '70s, hoping to track down now-grown "miracle babies" who don't know their repairs may not last for life.
New moves could help. Williams is co-writing new guidelines, due later this year, on how to treat adult patients. The advice is aimed both at cardiologists and at other doctors, such as obstetricians, whose care decisions may be complicated by heart abnormalities.
Meanwhile, cardiologists and patient advocates are pushing for funding for the National Institutes of Health to open the first registry to track long-term health. A registry could help uncover which of 35 cardiac defects are most likely to cause late-in-life problems for those with congenital heart disease, determining who needs specialty care and who will do fine with a general physician's checkups.
"I don't mean to say we're going to die or do poorly," says Amy Verstappen of the Adult Congenital Heart Assn., an advocacy group. "But we are likely to need reoperations, likely to develop things like heart arrhythmias where we're going to need additional care. Better to get it sooner than later."
For now, symptoms are what send many patients back for heart care, but they can be subtle, easy to dismiss.
Deepa Sinha of Herndon, Va., is a classic example. She had a complex but common defect called tetralogy of Fallot repaired at age 8, a final checkup around 21 and "went on with my life." Then weakness hit in her mid-30s.
Tetralogy repair frequently spurs a leak in the pulmonary valve that over time damages the heart's right ventricle, making exercise difficult and risking a fatal irregular heartbeat. Sinha didn't know that. For a year she attributed worsening fatigue to being out of shape and the demands of two kids and a career -- until the day she couldn't lift her 4-year-old.
"Life has totally changed," she says after getting a new valve last year. "I should have gotten this done years ago, if I had known."