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Provider photo for Jeremy Swartzberg

Jeremy Swartzberg, MD

Hospital Medicine

Welcome to My Doctor Online, a web site that my colleagues and I developed to make it easier for you to take care of your healthcare needs. On this site you will find answers to many of your questions about my clinical practice. Also included are several online features that will allow you to e-mail me, check your laboratory results and refill prescriptions. I hope you find its content informative and useful.

My Offices

Oakland Medical Center
Appt/Advice: 510-752-1190

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Overview

Between 8 and 10 of every 1,000 children are born with some type of structural abnormality in their hearts. These are known as congenital heart defects. There are numerous types of defects.  

Most children are diagnosed at birth and require multiple surgeries and interventions during childhood. Some defects, although present since birth, are not diagnosed until adulthood.

Because of advances in pediatric cardiovascular surgery, catheter-based procedures, imaging technology, intensive care, and medical management, many children with complex congenital heart disease are reaching adulthood.  As a result, the number of adults with congenital heart disease in the United States has:

  • Increased and currently exceeds 1 million.
  • Surpassed the number of children with congenital heart disease.

Most adults with this condition require lifelong monitoring from a congenital heart disease specialist and/or a cardiologist. Some will need surgical, catheter-based, or medical therapies during their adult life. Because adults may not show symptoms of problems, ongoing follow-up is very important to determine if a procedure is needed.

Types

There are many types of congenital heart disease. These are some of the more common heart defects.

Atrial septal defect (ASD). An ASD is a hole in the wall that separates the 2 upper chambers of your heart, known as the atria. If the opening is small, it may cause no symptoms. Larger holes can lead to serious conditions, such as: 

  • Arrhythmias (abnormal heartbeat).
  • Right-sided heart enlargement and failure.
  • Pulmonary arterial hypertension (high blood pressure in the lung arteries). This is rare.

Some atrial septal defects are more complex and have other abnormalities, such as abnormal connections with the veins draining the lungs. 

Simple ASDs can be closed using a simple procedure. Complex ASDs usually require surgery.

Ventricular septal defect (VSD). VSD is the most common type of heart defect. A VSD is a hole in the wall that divides the heart's lower chambers, or ventricles. Often, a VSD closes by itself early in life. If it has not closed by the time a child is 10, it is unlikely that it will close on its own. 

A VSD is usually not serious, but it depends on the size and location of the hole. Potential complications include: 

  • Left-sided heart enlargement and failure.
  • Leaky aortic valve.
  • Infective endocarditis (infection of the heart valves).
  • Pulmonary arterial hypertension (high blood pressure in the lung arteries). This can occur if the hole is large.

Coarctation of the aorta. This condition occurs when the aorta, the main artery through which blood flows from the heart to the rest of the body, is abnormally narrowed. Coarctation of the aorta can range from severe (requiring urgent treatment in infancy) to mild (diagnosed in adulthood).  

Even if it is repaired in infancy, patients with this condition may have: 

  • Recurrence
  • High blood pressure (at rest or with exercise)
  • Abnormal aortic valve (born with only 2 leaflets instead of 3) 

Frequently, patients with coarctation of the aorta also have a bicuspid aortic valve.

Bicuspid aortic valve and congenital aortic stenosis. The aortic valve is the valve that allows blood flow to the aorta (and the rest of the body). A bicuspid aortic valve is usually not leaky or narrow in infancy but progresses with age. 

Patients with bicuspid aortic valve are at risk for developing: 

  • Calcific (old age) narrowing of the valve earlier in life.
  • Enlargement (aneurysm) of the aorta that needs to be replaced to prevent a tear (dissection).

Ebstein's anomaly of the tricuspid valve. Ebstein's anomaly is a structural abnormality of the tricuspid valve, the valve between the heart's right atrium (upper chamber) and right ventricle (lower chamber). Patients with this condition have abnormal back flow through the tricuspid valve, which leads to right heart enlargement. Ebstein's anomaly varies in severity, ranging from severe and life-threatening in infancy to mild and without symptoms until adulthood. 

Patients with Ebstein's are at risk for:

  • Right-sided heart enlargement and failure.
  • Atrial arrhythmias (fast heartbeats).
  • Cyanosis, in which the heart does not supply enough oxygen-rich blood to the body (causing blue skin). This is a common condition. 

The symptoms experienced by patients with Ebstein's usually get worse. Our ability to repair this defect has greatly improved in the past decade.

Pulmonary valve stenosis. This is a condition in which the valve connecting the right ventricle to the lungs is narrowed. In severe cases, a patient may need therapy in childhood, or this may be mild and the patient never needs treatment.

Transposition of the great arteries. This is a condition in which a baby is born with the 2 major arteries attached to the wrong ventricles. When this occurs:

  • Blood that contains oxygen is pumped back to the lungs.
  • Blood that does not contain oxygen is pumped to the rest of the body. 

This must be corrected surgically soon after birth. The repair either switches the: 

  • Circulation at the atrial level (Mustard or Senning procedure).
  • Great arteries (arterial switch procedure).

Depending on the type of surgery performed to repair the condition, the late complications are different, though all patients will need yearly follow-up care after surgery. 

Eisenmenger's syndrome. This syndrome can occur when an unrepaired congenital heart defect exposes the pulmonary (lung) arteries to high pressure over many years. Patients with Eisenmenger syndrome have low oxygen levels and are at risk for: 

  • Arrhythmias (fast heart rhythms)
  • Stroke
  • Heart failure 

Newer medical therapies can improve symptoms and long-term survival.

Tetralogy of Fallot. This condition is the most common type of cyanotic (lack of oxygen) congenital heart disease. It results from a single abnormality in the development of the heart that leads to: 

  • Pulmonary stenosis
  • Ventricular septal defect
  • Thick right ventricle 

Children born today with this defect have surgery in the first few months of life. 

Years ago, shunts were performed to improve oxygen levels until repair could be performed at a later date. Today, patients with tetralogy of Fallot do quite well, though complications that occur later in adulthood may require a pulmonary valve replacement or arrhythmia management.  

Frequently, the need for repair occurs before symptoms, making monitoring and ongoing follow-up (at least yearly) important. Truncus arteriosus and double outlet right ventricle are similar to tetralogy of Fallot with similar causes.

Atrioventricular canal defect. A common atrioventricular canal defect consists of an abnormality in the development of the tricuspid and mitral valves (the valves connecting the atria to the ventricles). It also includes incomplete formation of the atrial septum (wall) and ventricular septum. 

Complete defects require surgery early in childhood before Eisenmenger syndrome develops. Some patients with partial defects (primum, or simple, ASDs) are not diagnosed until later in life. Most atrioventricular canal defects require repair at some point.

Single ventricle. There are a number of complex structural abnormalities of the heart that leave patients with only a single pumping chamber (or ventricle). Today, most of these patients undergo a procedure called the Fontan procedure. Years ago, these defects were treated with shunts. Patients with single ventricles have a number of unique complications that require frequent follow-up with a specialist in the care of adults with congenital heart disease.

Symptoms

Congenital heart disease in adults can have a range of symptoms, including:

  • Shortness of breath with activity (or exertional intolerance)
  • Fatigue and low energy
  • Swollen ankles and swollen belly
  • Cyanosis (lack of oxygen), resulting in bluish skin
  • Palpitations (fast or slow heart rates)
  • Fainting
  • Chest pain

Contact your doctor if you are having ongoing symptoms.

Causes and Risk Factors

Congenital heart defects occur during pregnancy as the heart is forming. There are a number of congenital heart defects, such as tetralogy of Fallot and specific gene mutations associated with trisomy 21, that can be linked to genetic causes.

Although most other defects are thought to be genetic, the actual genes are not yet known. 

A person is more likely to be born with a heart defect if one or both parents have a heart defect. Viral infections or medications taken during pregnancy may also contribute to the formation of heart defects.

Diagnosis

If you were diagnosed with a heart defect as an infant, your doctor will give you tests periodically to check on the status of your condition. Whether or not you had surgery to correct the heart defect as a baby, your condition may change and require attention as you get older.

If you were not diagnosed with a heart defect as a child, signs that you may have a defect as an adult include: 

  • Shortness of breath with activity
  • Palpitations (extra beats or fast heart rates)
  • Heart murmur 

A heart murmur is an unusual whooshing or whistling sound that a doctor may hear while listening to your heart through a stethoscope. 

We may also request heart imaging tests for you. Tests that can show a heart defect include:

  • Echocardiogram, which uses sound waves to produce an image of the heart.
  • Electrocardiogram (ECG/EKG), which checks the electrical activity of the heart.
  • Chest X-ray, which produces a photographic image of the heart.
  • Cardiac catheterization, which provides images of the heart and measures blood flow and pressures to assess how the heart is functioning.
  • Exercise stress test, which checks how well your heart works under stress.
  • Cardiac magnetic resonance imaging (MRI)andcomputed tomography scan (CAT scan), which are scans that produce 3-dimensional imaging of the heart.
  • Transesophageal echocardiogram, which combines the use of sound waves with a special imaging instrument (known as an endoscope) that is guided down into the throat (esophagus). The patient is sedated for this procedure.

Possible Complications

Though not all heart defects are serious, severe defects can lead to potentially life-threatening or ongoing complications, including:

  • Arrhythmias (abnormal heartbeat)
  • Heart failure
  • Stroke
  • Infection of the heart valves (infective endocarditis)
  • High blood pressure in the lungs (pulmonary arterial hypertension)

Specific conditions may lead to other serious problems as well, such as kidney or liver failure.

Treatments

Many congenital heart defects require therapies including surgery, catheter-based procedures, or medicines to control heart failure or fast heart rhythms. We can discuss a range of options with you.

Nonsurgical procedures

These are the common nonsurgical procedures to treat heart defects in adults.

Radiofrequency ablation. This procedure is used to correct an abnormal heartbeat. A long, thin tube called a catheter is inserted into a vein, usually in the upper inner thigh, and then guided to the heart. The catheter sends a tiny electric charge to a targeted section of the heart. The charge stops the cells from sending the electrical signals that cause arrhythmias.

Catheter-based VSD or ASD repair. For some ventricular septal defects (VSD) and atrial septal defects (ASD), a catheter may be used to deliver a device that closes the opening in the septum (wall). 

Angioplasty. This procedure is sometimes done for coarctation of the aorta. A catheter carrying a small uninflated balloon is guided to the aorta. Once inside the aorta, the balloon is inflated to widen the narrow portions. Often a small wire mesh tube called a stent is deposited in the aorta to hold it open after the catheter is withdrawn.

Valvuloplasty. This procedure is sometimes done to treat severe narrowing of valves (including aortic and pulmonary valves). It is similar to angioplasty, using a balloon to stretch the valve opening and to repair valve function.

Surgery

These are some of the surgeries done in adults with congenital heart disease.

Open-heart repair of septal defects. Ventricular septal (wall) defects (and some atrial septal defects) may require open-heart surgery to close the hole and fix other associated defects.

Valve replacement or repair surgery. An abnormal heart valve may need to be replaced with an artificial valve made of metal or animal tissue. Some valves can be surgically repaired.

Maze surgery for arrhythmia. During this open-heart procedure, the surgeon creates a small amount of scar tissue in the heart, using small incisions, freezing, or heating. As with radiofrequency ablation, this stops the targeted cells from sending the electric signals that cause an irregular heartbeat.

Heart transplant. For people with advanced, life-threatening heart defects, a heart transplant may be necessary.

It is important to note that it normally takes 6 to 12 weeks to recover from open-heart surgery. The time to recovery depends on the patient's age, the number of previous surgeries, and the complexity of the repair. 

There are also many other, more complex surgeries for adults with congenital heart disease. Your doctor can discuss these with you.

Lifestyle Changes

If you have a congenital heart defect, you should keep all of your regularly scheduled appointments. If you have had surgery for your condition, you will continue to require regular follow-up exams for the rest of your life. These may include imaging tests and exercise stress tests.

You may also need to be: 

  • On medication, such as blood thinners, for life if you have a metal heart valve.
  • Restricted from certain types of activities, such as strenuous lifting, depending on your condition. However, aerobic exercise is usually safe and healthy.

Very frequently, patients with congenital heart disease will be on salt- and fluid-restricted diets. Maintaining a healthy weight and physical fitness is very important for a healthy heart.

If you are a woman with a congenital heart condition, there may be risks involved with pregnancy. You may require: 

  • Special care during your pregnancy for your own well-being and that of your child.
  • Special considerations for birth control. 

If you are pregnant, you should speak with your cardiologist about the risks.

Coping and Support

It can be overwhelming to live with a heart defect. Yet many adults with congenital heart disease live long and healthy lives. It may be helpful to connect with other people who have the same condition. Support groups for people with adult congenital heart disease are available.

It is important to learn all you can about your condition. Read about your condition, and keep current with any new available treatments and information.

Your Care with Me

If you think you may be having a heart attack, or if you have chest pain or pressure that lasts more than 5 minutes, call 911 or seek other emergency services immediately.

If you have emergency symptoms as described above, do not use this website to e-mail your doctor.

Please call us right away if you experience a complication such as:

  • Increased pain, swelling, redness, or bruising in or around your incisions
  • Drainage from an incision or opening of an incision
  • Fever over 100.4° F (38.0° C), chills, fainting, or severe headache

Monday through Friday, 9 a.m. to 5 p.m., please call the Surgery department directly. A cardiac care advice nurse can help evaluate your condition and make a recommendation for self-care or book you an appointment.

After hours or on weekends, please call the Appointment and Advice number at your local facility.

Sacramento:
Department of Cardiothoracic Surgery            (916) 733-4100

San Francisco:
Division of Cardiothoracic Surgery                  (415) 833-3800

Santa Clara:
Cardiothoracic Surgery Department               (408) 851-3780

Coordinating Your Care

Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit
  • At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
  • At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
  • To help you prepare for your visit, please see additional details under Office Visit. 
If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

  • Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
  • Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.
If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If Surgery or a Procedure is a Treatment Option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

If you are considering surgery or a procedure or want more information about your heart problem, please review our health tool called “Preparing for Your Procedure” (Emmi). Emmi programs are available for the following cardiology topics:

  • Anesthesia for an Adult
  • Angiogram with Possible Angioplasty
  • Atrial Fibrillation Overview
  • Aortic Valve Replacement
  • Cardiac Catheter Ablation (SVT)
  • Cardiac Catheter Ablation (VT)
  • Cardiac Pacemaker
  • Coronary Artery Bypass Surgery (CABG)
  • Defib (Cardiac Resynchronization Therapy Defibrillator)
  • Defib (Implantable Cardioverter Defibrillator)
  • Mitral Valve Repair or Replacement
  • Taking Warfarin (Coumadin®)

Convenient Resources for You

As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely
  • View and compose secure e-mail messages.
  • Manage your prescriptions.
  • View your past visits and test results.
  • View your preventive services to see whether you are due for a routine screening or updated immunization.
Learn more about your condition
  • Read about causes, symptoms, treatments, and procedures.
  • Find interactive health tools, videos, and podcasts to help you manage your condition.
  • View programs to help you decide on or prepare for a surgery or procedure.
Stay healthy
  • Locate health education classes and support groups offered at every medical center.
  • Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
  • View your Preventive Services to see whether you are due for a routine screening or updated immunization.

If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is any of the following: (1) a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or body functions or organs; (2) active labor when there isn't enough time for safe transfer to a Plan hospital (or designated hospital) before delivery, or if transfer poses a threat to your (or your unborn child's) health and safety, or (3) a mental disorder that manifests itself by acute symptoms of sufficient severity such that either you are an immediate danger to yourself or others, or you are not immediately able to provide for, or use, food, shelter, or clothing, due to the mental disorder.

This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.

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