The effectiveness of transition care models in patients with congenital heart disease: a systematic review of the literature and implications for nursing practice

Igiene e Sanità Pubblica 2025; 99 (4): 174-180

Chiara Gatti¹, Stefano Marcelli², Gloria D’Angelo³, Cinzia Borgognoni⁴, Isabella Baglioni⁵, Romina Molinari⁶

¹CORRESPONDING AUTHOR: Incarico di Funzione Organizzativa SOD Cardiochirurgia e Cardiologia Pediatrica e Congenita, AOU delle Marche, (MSN). 3487337277. chiara.gatti2019@gmail.com
²Direttore ADP, UNIVPM CDL Infermieristica AST Ascoli Piceno (MSN)
³Tutor clinico di tirocinio, UNIVPM CDL Infermieristica AST Ascoli Piceno (MSN)
⁴Incarico di Funzione Organizzativa Dipartimento Scienze Cardiovascolari, AOU delle Marche (PhD)
⁵Direttore ADP, UNIVPM CDL Magistrale Scienze Infermieristiche e Ostetriche sede Fermo
⁶Infermiera, UNIVPM CDL Infermieristica Ancona (RN) Corso di Laurea in Scienze Infermieristiche e Ostetriche, Insegnamento di Ricerca Organizzativa.

INTRODUCTION

Over the past few decades, advances in prenatal diagnosis, cardiac surgery, and perioperative management have substantially improved survival among individuals with congenital heart disease (CHD). As a result, CHD has evolved from a predominantly pediatric condition into a lifelong chronic disease requiring specialized follow-up tailored to disease complexity to prevent long-term complications, including arrhythmias, heart failure, and infective endocarditis [1]. The transition from pediatric to adult healthcare services represents a critical stage in the care pathway. Many adolescents transfer to adult care through unstructured processes, increasing the risk of discontinuity of care, loss to follow-up, and adverse clinical outcomes. Transition care is defined as a purposeful, planned, and coordinated process that ensures continuity of care, promotes patient autonomy, and facilitates transfer to specialized adult congenital heart disease (ACHD) services [2]. Although international guidelines strongly recommend structured transition programs, considerable heterogeneity persists regarding the timing of transition, intervention components, and the healthcare professionals involved. Consequently, standardized models and evidence-based recommendations for clinical practice remain limited. Therefore, a comprehensive synthesis of the available evidence is needed. The aim of this systematic review was to evaluate the effectiveness of transition care interventions for adolescents and young adults with CHD, with particular emphasis on clinical, educational, and organizational outcomes.

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