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McDonald JA, Ye XT, Jones B, Zannino D, Konstantinov I, Brink J, Brizard C, d'Udekem Y. Exercise Capacity and Reoperation Late After Transatrial Fallot Repair. Heart Lung Circ 2024:S1443-9506(24)00199-9. [PMID: 38755045 DOI: 10.1016/j.hlc.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 01/21/2024] [Accepted: 03/31/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND The exercise capacity long after repair of tetralogy of Fallot, when performed exclusively with a transatrial repair, is unclear. It is also unknown whether echocardiography and cardiopulmonary exercise testing can predict the risk of reoperation in this patient group. METHOD We retrospectively reviewed the clinical records of 59 patients who underwent cardiopulmonary exercise testing after transatrial Fallot repair at a single centre. Patients underwent cardiopulmonary exercise testing at a mean age of 16.6±4.4 years, and at 15.3±4.1 years after Fallot repair. RESULTS At testing, the volume of oxygen consumption at maximal exercise (VO2 max) was 71%±13% and the oxygen pulse was 80%±17% of predicted values. Seventeen (17) patients (29%) had a VO2 max superior to 80% of the predicted value. Thirty-two (32) patients (56%) had severe pulmonary regurgitation, three (5%) had moderate pulmonary regurgitation, and 12 (21%) had mild pulmonary regurgitation. After a mean of 7.8±3.9 years following cardiopulmonary exercise testing (23±5.3 years after the repair), 21 (40%) patients underwent reoperation. Right ventricular dilation and systolic function on echocardiography were both significantly associated with subsequent reoperation rates. Patients who had severe right ventricular dilation were eight times more likely to undergo subsequent reoperation (hazard ratio 8.67; 1.82-41.3; p=0.007). No cardiopulmonary exercise testing variable independently predicted reoperation. CONCLUSIONS The exercise capacity at adolescence following transatrial repair of tetralogy of Fallot is maintained at around 70% of predicted values. Only the patients with normal right ventricular size and normal right ventricular function seemed to be protected from reoperation over the subsequent decade. We found no exercise variables which predicted reoperation.
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Affiliation(s)
- Jodie A McDonald
- Department of Paediatrics, The University of Melbourne, Parkville, Vic, Australia
| | - Xin Tao Ye
- Department of Paediatrics, The University of Melbourne, Parkville, Vic, Australia
| | - Bryn Jones
- Department of Cardiology, Royal Children's Hospital Melbourne, Parkville, Vic, Australia
| | - Diana Zannino
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, Vic, Australia
| | - Igor Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, Vic, Australia
| | - Johann Brink
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, Vic, Australia
| | - Christian Brizard
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, Vic, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, Vic, Australia.
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Drastal M, Layton AM, Fremed MA. Characterizing the Use of Exercise Testing in Repaired Tetralogy of Fallot Patients: A Multi-Institutional Survey. Pediatr Cardiol 2023; 44:1821-1830. [PMID: 37610637 DOI: 10.1007/s00246-023-03269-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
Cardiopulmonary exercise testing (CPET) is an important tool used in the management of patients with congenital heart disease. However, there are no clear guidelines for its use in specific populations, such as repaired Tetralogy of Fallot (rTOF). We sought to characterize current practice patterns and attitudes regarding exercise testing in the rTOF population using an online survey distributed to pediatric cardiologists. Analyses were performed using qualitative statistics, Wilcoxon rank-sum, Kruskal-Wallis test, and chi-squared analysis. 103 clinicians completed the survey with 83% routinely sending symptomatic rTOF patients for exercise testing and 59% for asymptomatic patients. Respondents who routinely test asymptomatic patients reported higher levels of perceived helpfulness of exercise testing (p < 0.01) and comfort with CPET interpretation (p < 0.01). Although a large majority of respondents found exercise testing to be helpful (81% either "somewhat" or "very" helpful"), a considerably smaller portion indicated comfort with CPET interpretation (49% either "comfortable" or "very comfortable"). Nearly all respondents (92%) reported changing management primarily based on exercise testing results. However, the frequency of changes varied, with 10% "frequently", 62% "occasionally", 19% "rarely" changing management. There was a statistically significant relationship between the perceived helpfulness of exercise testing and the likelihood of management changes (p < 0.01). While exercise testing is used to make clinical decisions, our findings suggest that in some cases, management changes may be made without a similar degree of confidence in interpreting CPET findings. The variability in attitudes and practices highlights the need for evidence-based guidelines addressing exercise testing in rTOF, particularly for asymptomatic patients.
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Affiliation(s)
- Meghan Drastal
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA.
| | - Aimee M Layton
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork Presbyterian Morgan Stanley Children's Hospital, New York, NY, 10032, USA
| | - Michael A Fremed
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork Presbyterian Morgan Stanley Children's Hospital, New York, NY, 10032, USA
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3
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Buchanan M, Spence C, Keir M, Khoury M. Physical Activity Promotion Among Individuals With Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:322-334. [PMID: 38161681 PMCID: PMC10755793 DOI: 10.1016/j.cjcpc.2023.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/11/2023] [Indexed: 01/03/2024]
Abstract
In the general population, the most cited barriers to physical activity (PA) are time, energy, and motivation. Consequently, despite the significant contribution of PA to health and well-being, many individuals are insufficiently active. Physical inactivity and sedentary lifestyles increase the risk of acquired cardiometabolic disease, a risk that may complicate and is compounded by the anatomic and physiologic features inherent in the patient with repaired tetralogy of Fallot (ToF). Individuals with ToF commonly present with reduced exercise capacity and PA levels. In light of historically PA restrictive management of their heart disease, known reductions in exercise capacity among individuals with ToF are combined with psychosocial barriers to their participation, potentially establishing a cycle of further detraining, inactivity, and disease progression/health decline. To this end, children and young adults with ToF are known to have reduced self-efficacy towards PA, defined as their confidence in their ability to participate. In this review, we apply self-efficacy as an overarching mediator of PA participation and explore trends and determinants of PA participation among individuals with ToF and its subsequent impact on exercise capacity, disease risk, and health-related quality of life. We outline the rationale and strategies aimed at improving PA in children and adults with ToF and highlight current knowledge gaps and future directions in the promotion of PA in the population with ToF.
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Affiliation(s)
- Mackenzie Buchanan
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher Spence
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Keir
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael Khoury
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Moscatelli S, Pergola V, Motta R, Fortuni F, Borrelli N, Sabatino J, Leo I, Avesani M, Montanaro C, Surkova E, Mapelli M, Perrone MA, di Salvo G. Multimodality Imaging Assessment of Tetralogy of Fallot: From Diagnosis to Long-Term Follow-Up. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1747. [PMID: 38002838 PMCID: PMC10670209 DOI: 10.3390/children10111747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023]
Abstract
Tetralogy of Fallot (TOF) is the most common complex congenital heart disease with long-term survivors, demanding serial monitoring of the possible complications that can be encountered from the diagnosis to long-term follow-up. Cardiovascular imaging is key in the diagnosis and serial assessment of TOF patients, guiding patients' management and providing prognostic information. Thorough knowledge of the pathophysiology and expected sequalae in TOF, as well as the advantages and limitations of different non-invasive imaging modalities that can be used for diagnosis and follow-up, is the key to ensuring optimal management of patients with TOF. The aim of this manuscript is to provide a comprehensive overview of the role of each modality and common protocols used in clinical practice in the assessment of TOF patients.
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Affiliation(s)
- Sara Moscatelli
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK
- Institute of Cardiovascular Sciences, University College London, London WC1E 6BT, UK
- Paediatric Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London SW3 5NP, UK
| | - Valeria Pergola
- Dipartimento di Scienze Cardio-Toraco-Vascolari e Sanità pubblica, University Hospital of Padua, 35128 Padua, Italy
| | - Raffaella Motta
- Dipartimento di Scienze Cardio-Toraco-Vascolari e Sanità pubblica, University Hospital of Padua, 35128 Padua, Italy
| | - Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, 06034 Foligno, Italy
- Department of Cardiology, Leiden University Medical Center, 2300 Leiden, The Netherlands
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Jolanda Sabatino
- Experimental and Clinical Medicine Department, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy
| | - Isabella Leo
- Experimental and Clinical Medicine Department, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy
| | - Martina Avesani
- Division of Paediatric Cardiology, Department of Women and Children's Health, University Hospital of Padua, 35128 Padua, Italy
| | - Claudia Montanaro
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St. Thomas's NHS Foundation Trust, London SW3 5NP, UK
- CMR Unit, Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London SW3 5NP, UK
- National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK
| | - Elena Surkova
- Department of Echocardiography, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London SW3 5NP, UK
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, 20122 Milan, Italy
| | - Marco Alfonso Perrone
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children's Hospital IRCCS, 00165 Rome, Italy
- Division of Cardiology and Cardio Lab, Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Giovanni di Salvo
- Division of Paediatric Cardiology, Department of Women and Children's Health, University Hospital of Padua, 35128 Padua, Italy
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Drastal MS, Layton AM, Fremed MA. Characterizing the Use of Exercise Testing in Repaired Tetralogy of Fallot Patients: A Multi-Institutional Survey. RESEARCH SQUARE 2023:rs.3.rs-3131080. [PMID: 37461658 PMCID: PMC10350203 DOI: 10.21203/rs.3.rs-3131080/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Long-term survival for repaired Tetralogy of Fallot (rTOF) is excellent. We achieve this by close clinical monitoring to stratify prognosis and guide clinical decision-making. Cardiopulmonary exercise stress testing (CPET) is used to help guide clinical decision making; however, there are no clear guidelines for its use in this population. We sought to describe practice variability with regards to exercise testing for rTOF patients and how exercise data is used to guide management. We distributed a survey to pediatric cardiologists via email. Analyses were performed using qualitative statistics, two-sample T-tests, and chi-squared analysis. One-hundred and three clinicians completed the survey with 83% reporting that they routinely send symptomatic rTOF patients for exercise testing and 59% for asymptomatic patients. Respondents who routinely test asymptomatic patients reported higher levels of perceived helpfulness of exercise testing (p = 0.04) and comfort with CPET interpretation (p = 0.03). Nearly all respondents (92%) reported changing management primarily based on exercise testing results, with 62% reporting "occasionally changing management" and 10% reporting "frequently changing management". Results indicated that exercise test results influenced clinical decisions, such as the timing of interventions, need for additional imaging, or the initiation of exercise interventions. There was a statistically significant relationship between the perceived helpfulness of exercise testing and the likelihood of management changes (p < 0.01). The variability in attitudes and practices highlights the need for evidence-based guidelines addressing exercise testing in rTOF, particularly for asymptomatic patients.
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Affiliation(s)
| | - Aimee M Layton
- Columbia University Vagelos College of Physicians and Surgeons and NewYork Presbyterian Morgan Stanley Children's Hospital
| | - Michael A Fremed
- Columbia University Vagelos College of Physicians and Surgeons and NewYork Presbyterian Morgan Stanley Children's Hospital
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6
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Mahendran AK, Katz D, Opotowsky AR, Lubert AM. Exercise Pathophysiology and Testing in Individuals With a Fontan Circulation. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:112-123. [PMID: 37969357 PMCID: PMC10642126 DOI: 10.1016/j.cjcpc.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/07/2023] [Indexed: 11/17/2023]
Abstract
The Fontan circulation, a surgical palliation for single-ventricle congenital heart disease, profoundly impacts the cardiopulmonary response to exercise. Reliant on passive pulmonary blood flow, the Fontan circulation has limited capacity to augment cardiac output as necessary to supply working muscles during exercise. Cardiopulmonary exercise testing (CPET) objectively assesses cardiorespiratory fitness and provides insight into the etiology of exercise intolerance. Furthermore, CPET variables, such as peak oxygen consumption and submaximal variables, have prognostic value and may be used as meaningful endpoints in research studies. CPET is also useful in clinical research applications to assess the effect of pharmacologic or other interventions. Medical therapies to improve exercise tolerance in individuals with a Fontan circulation, such as pulmonary vasodilators, may modestly improve peak oxygen consumption. Exercise training focused on aerobic fitness and lower extremity strength may have a more consistent and larger impact on these measures of aerobic fitness. CPET is a valuable diagnostic and prognostic tool for those with a Fontan circulation. Newer ancillary assessments, such as noninvasive peripheral venous pressure monitoring and cardiac output measurements, hold promise to provide a more nuanced insight into the underlying pathophysiology.
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Affiliation(s)
- Arjun K. Mahendran
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David Katz
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alexander R. Opotowsky
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Adam M. Lubert
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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7
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Griffith G, Liem RI, Carr M, Corson T, Ward K. Development of a Pediatric Cardiology Cardiopulmonary Exercise Testing Database. Pediatr Cardiol 2023:10.1007/s00246-023-03112-1. [PMID: 36757429 DOI: 10.1007/s00246-023-03112-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/23/2023] [Indexed: 02/10/2023]
Abstract
Cardiopulmonary exercise testing (CPET) provides clinicians with information vital to the management of pediatric cardiology patients. CPET can also be used to measure cardiorespiratory fitness (CRF) in these patients. CRF is a robust marker of overall health in children. However, a complete understanding of CRF in pediatric cardiology patients is limited by lack of large, standardized CPET databases. Our purpose was to develop a standardized CPET database, describe available data at our institution, and discuss challenges and opportunities associated with this project. CPETs performed from 1993 to present in an urban pediatric hospital were collected and compiled into a research database. Historical data included demographic and clinical variables and CPET outcomes, and additional variables were calculated and coded to facilitate analyses in these cohorts. Patient diagnoses were coded to facilitate sub-analyses of specific cohorts. Quality assurance protocols were established to ensure future database contributions and promote inter-institutional collaborations. This database includes 10,319 CPETs (56.1% male), predominantly using the Bruce Protocol. Patients ranging from ages 6 to 18 years comprise 86.8% of available CPETs. Diagnosis classification scheme includes patients with structurally normal hearts (n = 3,454), congenital heart disease (n = 3,614), electrophysiological abnormalities (n = 2,082), heart transplant or cardiomyopathy (n = 833), and other diagnoses (n = 336). Historically, clinicians were provided with suboptimal interpretive resources for CPET, often generalizing inferences from these resources to non-representative clinical populations. This database supports representative CRF comparisons and establishes a framework for future CRF-based registries in pediatric patients referred for CPET, ultimately improving clinical decision-making regarding fitness in these populations.
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Affiliation(s)
- Garett Griffith
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave., Suite 1100, Chicago, IL, 60611, USA.
| | - Robert I Liem
- Division of Hematology, Oncology, and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Michael Carr
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Tyler Corson
- Rush University College of Health Sciences, Chicago, IL, USA
| | - Kendra Ward
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Feinberg School of Medicine, Northwestern University, Chicago, USA
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8
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Cardiopulmonary Exercise Testing Characterizes Silent Cardiovascular Abnormalities in Asymptomatic Pediatric Cancer Survivors. Pediatr Cardiol 2023; 44:344-353. [PMID: 36076098 DOI: 10.1007/s00246-022-02995-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
Late-onset cardiovascular complications are serious concerns for pediatric cancer survivors (PCS) including those who are asymptomatic. We investigated whether cardiopulmonary exercise testing (CPET) can delineate the underlying pathophysiology of preclinical cardiovascular abnormalities in PCS. We examined CPET data via cycle ergometer in asymptomatic PCS with normal echocardiogram and age-matched controls. Peak and submaximal parameters were analyzed. Fifty-three PCS and 60 controls were studied. Peak oxygen consumption (VO2), peak work rate (WR), and ventilatory anaerobic threshold (VAT) were significantly lower in PCS than controls (1.86 ± 0.53 vs. 2.23 ± 0.61 L/min, 125 ± 45 vs. 154 ± 46 W, and 1.20 ± 0.35 vs. 1.42 ± 0.43 L/min, respectively; all p < 0.01), whereas peak heart rate (HR) and ventilatory efficiency (a slope of minute ventilation over CO2 production or ∆VE/∆VCO2) were comparable. Peak respiratory exchange ratio (RER) was significantly higher in PCS (p = 0.0006). Stroke volume (SV) reserve was decreased in PCS, indicated by simultaneous higher dependency on HR (higher ∆HR/∆WR) and lower peak oxygen pulse (OP). Twelve PCS with high peak RER (≥ 1.3) revealed lower pVO2 and VAT than the rest of PCS despite higher ventilatory efficiency (lower ∆VE/∆VCO2), suggesting fundamental deficiency in oxygen utilization in some PCS. Poor exercise performance in PCS may be mainly attributed to limited stroke volume reserve, but the underlying pathophysiology is multifactorial. Combined assessment of peak and submaximal CPET parameters provided critical information in delineating underlying exercise physiology of PCS.
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Cleveland JD, Wells WJ. The Surgical Approach to Pulmonary Valve Replacement. Semin Thorac Cardiovasc Surg 2022; 34:1256-1261. [PMID: 35584775 DOI: 10.1053/j.semtcvs.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 11/11/2022]
Affiliation(s)
- John D Cleveland
- Division of Cardiac Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | - Winfield J Wells
- Division of Cardiac Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA.
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Cardiopulmonary Exercise Testing in Repaired Tetralogy of Fallot: Multiparametric Overview and Correlation with Cardiac Magnetic Resonance and Physical Activity Level. J Cardiovasc Dev Dis 2022; 9:jcdd9010026. [PMID: 35050237 PMCID: PMC8778451 DOI: 10.3390/jcdd9010026] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with repaired Tetralogy of Fallot (rToF) typically report having preserved subjective exercise tolerance. Chronic pulmonary regurgitation (PR) with varying degrees of right ventricular (RV) dilation as assessed by cardiac magnetic resonance imaging (MRI) is prevalent in rToF and may contribute to clinical compromise. Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity, and the International Physical Activity Questionnaire (IPAQ) can provide additional data on physical activity (PA) achieved. Our aim was to assess the association between CPET values, IPAQ measures, and MRI parameters. All rToF patients who had both an MRI and CPET performed within one year between March 2019 and June 2021 were selected. Clinical data were extracted from electronic records (including demographic, surgical history, New York Heart Association (NYHA) functional class, QRS duration, arrhythmia, MRI parameters, and CPET data). PA level, based on the IPAQ, was assessed at the time of CPET. Eighty-four patients (22.8 ± 8.4 years) showed a reduction in exercise capacity (median peak VO2 30 mL/kg/min (range 25–33); median percent predicted peak VO2 68% (range 61–78)). Peak VO2, correlated with biventricular stroke volumes (RVSV: β = 6.11 (95%CI, 2.38 to 9.85), p = 0.002; LVSV: β = 15.69 (95% CI 10.16 to 21.21), p < 0.0001) and LVEDVi (β = 8.74 (95%CI, 0.66 to 16.83), p = 0.04) on multivariate analysis adjusted for age, gender, and PA level. Other parameters which correlated with stroke volumes included oxygen uptake efficiency slope (OUES) (RVSV: β = 6.88 (95%CI, 1.93 to 11.84), p = 0.008; LVSV: β = 17.86 (95% CI 10.31 to 25.42), p < 0.0001) and peak O2 pulse (RVSV: β = 0.03 (95%CI, 0.01 to 0.05), p = 0.007; LVSV: β = 0.08 (95% CI 0.05 to 0.11), p < 0.0001). On multivariate analysis adjusted for age and gender, PA level correlated significantly with peak VO2/kg (β = 0.02, 95% CI 0.003 to 0.04; p = 0.019). We observed a reduction in objective exercise tolerance in rToF patients. Biventricular stroke volumes and LVEDVi were associated with peak VO2 irrespective of RV size. OUES and peak O2 pulse were also associated with biventricular stroke volumes. While PA level was associated with peak VO2, the incremental value of this parameter should be the focus of future studies.
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Delise P, Mos L, Sciarra L, Basso C, Biffi A, Cecchi F, Colivicchi F, Corrado D, D'Andrea A, Di Cesare E, Di Lenarda A, Gervasi S, Giada F, Guiducci V, Inama G, Leoni L, Palamà Z, Patrizi G, Pelliccia A, Penco M, Robles AG, Romano S, Romeo F, Sarto P, Sarubbi B, Sinagra G, Zeppilli P. Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in athletes with heart disease: update 2020. J Cardiovasc Med (Hagerstown) 2021; 22:874-891. [PMID: 33882535 DOI: 10.2459/jcm.0000000000001186] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since 1989, SIC Sport and a FMSI, in partnership with leading Italian Cardiological Scientific Associations (ANCE, ANMCO and SIC) have produced Cardiological Guidelines for Completive Sports Eligibility for athletes with heart disease (COCIS -- 1989, 1995, 2003, 2009 and 2017). The English version of the Italian Cardiological Guidelines for Competitive Sports Eligibility for athletes with heart disease was published in 2013 in this Journal. This publication is an update with respect to the document previously published in English in 2013. It includes the principal innovations that have emerged over recent years, and is divided into five main chapters: arrhythmias, ion channel disorders, congenital heart diseases, acquired valve diseases, cardiomyopathies, myocarditis and pericarditis and ischemic heart disease. Wherever no new data have been introduced with respect to the 2013 publication, please refer to the previous version. This document is intended to complement recent European and American guidelines but an important difference should be noted. The European and American guidelines indicate good practice for people engaging in physical activity at various levels, not only at the competitive level. In contrast, the COCIS guidelines refer specifically to competitive athletes in various sports including those with high cardiovascular stress. This explains why Italian guidelines are more restrictive than European and USA ones. COCIS guidelines address 'sports doctors' who, in Italy, must certify fitness to participate in competitive sports. In Italy, this certificate is essential for participating in any competition.
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Affiliation(s)
- Pietro Delise
- Division of Cardiology, Hospital 'P. Pederzoli', Peschiera del Garda, VR
| | - Lucio Mos
- San Antonio Hospital, San Daniele del Friuli, UD
| | | | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua
| | | | - Franco Cecchi
- Referral Center for Cardiomyopathies, Careggi University Hospital, Florence
| | | | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua
| | - Antonello D'Andrea
- Department of Cardiothoracic Sciences, Monaldi Hospital, Second University of Naples, Naples
| | - Ernesto Di Cesare
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila
| | | | - Salvatore Gervasi
- Sports Medicine Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome
| | - Franco Giada
- Sports Medicine and Cardiovascular Rehabilitation Unit, Cardiovascular Department, PF Calvi Hospital, Noale, Venice
| | - Vincenzo Guiducci
- Interventional Cardiology Unit, S. Maria Nuova Hospital, Reggio Emilia
| | | | - Loira Leoni
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua
| | | | | | | | - Maria Penco
- Cardiology, Department of Life, Health and Environmental Sciences|, University of L'Aquila, L'Aquila
| | | | - Silvio Romano
- Cardiology, Department of Life, Health and Environmental Sciences|, University of L'Aquila, L'Aquila
| | - Francesco Romeo
- Department of Cardiology, University of Rome 'Tor Vergata', Rome
| | | | - Berardo Sarubbi
- Unit of Grown-up Congenital Heart Disease, Monaldi Hospital, Naples
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Integrata, University of Trieste (ASUITS), Trieste, Italy
| | - Paolo Zeppilli
- Sports Medicine Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome
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Sandström A, Wikner A, Rinnström D, Sandberg C, Christersson C, Dellborg M, Nielsen NE, Sörensson P, Thilén U, Johansson B. Exercise capacity in adult patients with tetralogy of Fallot. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Better preoperative exercise function is associated with shorter hospital stay after paediatric pulmonary valve replacement or conduit revision. Cardiol Young 2021; 31:1636-1643. [PMID: 33658103 DOI: 10.1017/s1047951121000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Exercise capacity is a modifiable factor in patients with CHD that has been related to surgical outcomes in adults. We hypothesised that this was true for children undergoing surgical pulmonary valve replacement; therefore, the relationship of preoperative percent predicted peak oxygen consumption to surgical outcomes as measured by total hospital length of stay was explored. METHODS Single centre retrospective cohort study of patients aged 8-18 years who underwent surgical pulmonary valve replacement. The primary predictor was preoperative percent predicted peak oxygen consumption, and primary outcome was total hospital length of stay. Clinical, imaging, and cardiopulmonary exercise test data were reviewed and compared to total hospital length of stay. Cox proportional hazards regression was used to examine the association between total hospital length of stay and percent predicted peak oxygen consumption. RESULTS Three-hundred and seventy patients undergoing pulmonary valve replacement/conduit change between 2003 and 2017 at Boston Children's Hospital were identified. Ninety had preoperative cardiopulmonary exercise tests within 6 months of surgery. Exclusion for inadequate exercise data (n = 3) and imaging data (n = 1) left 86 patients for review. Patients with percent predicted peak oxygen consumption ≥ 70% (n = 46, 53%) had shorter total hospital length of stay (4.4 days) than the 40 with percent predicted peak oxygen consumption <70% (5.4 days, p = 0.007). Median percent predicted peak oxygen consumption increased over sequential surgical eras (p < 0.001), but total hospital length of stay did not correlate with surgical era, preoperative left ventricular function, or preoperative right ventricular dilation. CONCLUSION Children undergoing surgical pulmonary valve replacement with better preoperative exercise capacity had shorter total hospital length of stay. Exercise capacity is a potentially modifiable factor prior to and after pulmonary valve replacement. Until more patients systematically undergo cardiopulmonary exercise tests, the full impact of optimisation of exercise capacity will not be known.
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Mano TB, Gonçalves AV, Agapito AF, Rosa SA, Rio P, Monteiro A, Rito T, Silva AS, Pinto F, Ferreira RC, de Sousa L. Cardiopulmonary exercise testing in adults with congenital heart disease: Prognostic role in cyanotic patients. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Bicycle spiroergometry: comparison of standardized examination protocols for adolescents: is it necessary to define own standard values for each protocol? Eur J Appl Physiol 2021; 121:1783-1794. [PMID: 33712869 PMCID: PMC8144119 DOI: 10.1007/s00421-021-04601-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/10/2021] [Indexed: 11/10/2022]
Abstract
Purpose To compare performance data of adolescents collected with five different bicycle spiroergometry protocols and to assess the necessity for establishing standard values for each protocol. Methods One-hundred-twenty adolescents completed two bicycle spiroergometries within 14 days. One of the two tests was performed based on our institutional weight-adapted protocol (P0). The other test was performed based on one out of four exercise protocols widely used for children and adolescents (P1, 2, 3 or 4) with 30 persons each. The two tests were performed in a random order. Routine parameters of cardiopulmonary exercise tests (CPET) such as VO2peak, maximum power, O2 pulse, OUES, VE/VCO2 slope as well as ventilatory and lactate thresholds were investigated. Agreement between protocols was evaluated by Bland–Altman analysis, coefficients of variation (CV) and intra-class correlation coefficients (ICC). Results None of the CPET parameters were significantly different between P0 and P1, 2, 3 or 4. For most of the parameters, low biases between P0 and P1–P4 were found and 95% confidence intervalls were narrow. CV and ICC values largely corresponded to well-defined analytical goals (CV < 10% and ICC > 0.9). Only maximal power (Pmax) showed differences in size and drift of the bias depending on the length of the step duration of the protocols. Conclusion Comparability between examination protocols has been shown for CPET parameters independent on step duration. Protocol-dependent standard values do not appear to be necessary. Only Pmax is dependent on the step duration, but in most cases, this has no significant influence on the fitness assessment.
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Lin MT, Chen CA, Chen SJ, Chiu SN, Lu CW, Wu MH, Wang JK. Prognostic markers in patients undergoing transcatheter implantation of Venus P-valve: Experience in Taiwan. J Formos Med Assoc 2020; 120:1202-1211. [PMID: 33158698 DOI: 10.1016/j.jfma.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/09/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND/PURPOSE Prognostic factors remain unclear in patients undergoing transcatheter implantation of Venus P-valve for their severe pulmonary regurgitation associated with native right ventricular (RV) outflow tract. METHOD Between January 2017 and October 2018, we prospectively collected data of patient characteristics, cardiac magnetic resonance imaging, cardiopulmonary exercise testing, and levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) before and 6-12 months after valve graft implantation. RESULTS Fifteen patients (male: 8, median age: 24.8 years) were enrolled. The procedure success rate was 100%. The median follow-up was 16.3 months without any dysfunction of the valve graft. The cohort demonstrated a significant improvement in cardiac index (from 3.3 to 3.9 L/min/m2) and increase of percentage of New York Heart Association functional class I (P < 10-3), reduction in RV end-diastolic volume index (P = 0.008), and reductions in NT-proBNP levels (from 78.9 to 45.8 pg/mL, P = 0.040). However, the peak oxygen consumption (VO2) dropped from 50.2% to 48.5% of the predicted value. Interestingly, we determined that patients with NT-proBNP levels below 70 pg/mL and left ventricular end-diastolic pressure (LVEDP) below 11 mmHg had a significantly higher chance of exhibiting improvement in peak VO2 compared with those without (3/4 vs 1/10, P = 0.041). CONCLUSION In the small cohort with severe pulmonary regurgitation, implantation of a Venus P-valve led to promising reductions in RV volume. However, no definite improvement in cardiopulmonary exercise capacity or RV ejection fraction was achieved. Levels of NT-proBNP and LVEDP may be helpful for refining the indications of the Venus P-valve implantation.
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Affiliation(s)
- Ming-Tai Lin
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Chun-An Chen
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Shyh-Jye Chen
- Department of Radiology, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Shuenn-Nan Chiu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan.
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Ta HT, Critser PJ, Alsaied T, Germann J, Powell AW, Redington AN, Tretter JT. Modified Ventricular Global Function Index Correlates With Exercise Capacity in Repaired Tetralogy of Fallot. J Am Heart Assoc 2020; 9:e016308. [PMID: 32633206 PMCID: PMC7660707 DOI: 10.1161/jaha.120.016308] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Cardiac MRI (CMR) derived ventricular global function index (GFI), a ratio of stroke volume to the sum of mean ventricular cavity and myocardial volumes, has demonstrated improved prediction of clinical outcomes in adults with atherosclerotic disease over ejection fraction. We sought to assess CMR derived GFI and a novel modification that accounts for unique loading conditions in patients with repaired tetralogy of Fallot (rTOF) and determine its correlation with exercise performance. Methods and Results Seventy‐five patients with rTOF who underwent CMR were identified. Clinical variables were recorded and biventricular GFI calculated. A right ventricular (RV) effective GFI (eGFI) was derived by incorporating effective stroke volume. Thirty‐five pediatric patients were matched with 29 age‐matched healthy controls. Twenty‐five patients completed cardiopulmonary exercise tests within 6 months of CMR. Stepwise regression models were used to determine univariate and multivariable predictors of indexed and percent predicted peak VO2. Median age at CMR was 20 years (interquartile range, 13–28). Pediatric rTOF patients had lower RV eGFI (P < 0.001), RV ejection fraction (P=0.002), but higher indexed RV end‐diastolic and end‐systolic volumes (P < 0.001, P < 0.001) compared with controls. Univariate analysis demonstrated a correlation between indexed peak VO2 with RV eGFI (R2=0.32, P=0.004), but with neither RVGFI, RV ejection fraction, indexed RV volumes nor RV mass. RV eGFI remained significantly associated with indexed peak VO2 during multivariable modeling. Conclusions Reduced RV eGFI was associated with reduced exercise capacity in rTOF patients, while RV GFI, RV ejection fraction, indexed RV volumes and mass were not. Our modification of the GFI, RV eGFI, may be a valuable non‐invasive marker of cardiac function in rTOF.
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Affiliation(s)
- Hieu T Ta
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Paul J Critser
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Tarek Alsaied
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Joshua Germann
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Adam W Powell
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Andrew N Redington
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Justin T Tretter
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
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Akam-Venkata J, Sriram C, French M, Smith R, Aggarwal S. Does Restrictive Lung Function Affect the Exercise Capacity in Patients with Repaired Tetralogy of Fallot? Pediatr Cardiol 2019; 40:1688-1695. [PMID: 31529227 DOI: 10.1007/s00246-019-02205-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/04/2019] [Indexed: 12/01/2022]
Abstract
Patients with repaired Tetralogy of Fallot (rTOF) have decreased exercise capacity (XC) and restrictive lung function (RLF). Our objective was to determine the association between RLF and impaired XC in patients with rTOF. This was a single center retrospective review of patients with rTOF who underwent a cardiopulmonary treadmill exercise testing and spirometry from 2005 to 2015. Patients with a respiratory exchange ratio ≥ 1.05 and peak heart rate > 90% of predicted value were included. Forced vital capacity (FVC) and Forced expiratory volume in 1st second of forceful expiration (FEV1) were used to classify the lung function. Exercise parameters such as peak oxygen uptake (VO2), % of predicted VO2 (%VO2), Metabolic equivalents (METS), and exercise time (ET) were compared between the two groups (i) compared patients with normal lung function (normal FEV1, FVC, and FEV1/FVC > 80%) (ii) RLF (FVC < 80%, normal or increased FEV1/FVC > 80%). In our cohort (n = 151, 52% male, mean age ± SD of 22.3 ± 9.1 years), patients with RLF (n = 73) compared to those with normal lung function (n = 86) had a lower peak VO2 (30.8 ± 8.6 vs. 36.6 ± 9.8 mL/kg/min; p < 0.001) and shorter exercise time (9:23 ± 1:78 vs. 10:23 ± 1:62 min, p < 0.001). On multivariate regression analysis, RLF was independently associated with reduced XC (VO2%) (β-coefficient - 0.182, p < 0.02) after controlling for age and gender. RLF is common in patients with rTOF and is associated with decreased XC. The contribution of RLF to reduced XC in this population should be considered prior to therapeutic decisions.
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Affiliation(s)
- Jyothsna Akam-Venkata
- Division of Cardiology, Department of Pediatrics, The Carman and Ann Adams, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, USA.
| | - Chenni Sriram
- Division of Cardiology, Department of Pediatrics, The Carman and Ann Adams, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, USA
| | - Michelle French
- Division of Cardiology, Department of Pediatrics, The Carman and Ann Adams, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, USA
| | - Roxann Smith
- Division of Cardiology, Department of Pediatrics, The Carman and Ann Adams, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, USA
| | - Sanjeev Aggarwal
- Division of Cardiology, Department of Pediatrics, The Carman and Ann Adams, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, USA
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Goldberg DJ, Zak V, Goldstein BH, Schumacher KR, Rhodes J, Penny DJ, Petit CJ, Ginde S, Menon SC, Kim SH, Kim GB, Nowlen TT, DiMaria MV, Frischhertz BP, Wagner JB, McHugh KE, McCrindle BW, Shillingford AJ, Sabati AA, Yetman AT, John AS, Richmond ME, Files MD, Payne RM, Mackie AS, Davis CK, Shahanavaz S, Hill KD, Garg R, Jacobs JP, Hamstra MS, Woyciechowski S, Rathge KA, McBride MG, Frommelt PC, Russell MW, Urbina EM, Yeager JL, Pemberton VL, Stylianou MP, Pearson GD, Paridon SM. Results of the FUEL Trial. Circulation 2019; 141:641-651. [PMID: 31736357 DOI: 10.1161/circulationaha.119.044352] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Fontan operation creates a total cavopulmonary connection, a circulation in which the importance of pulmonary vascular resistance is magnified. Over time, this circulation leads to deterioration of cardiovascular efficiency associated with a decline in exercise performance. Rigorous clinical trials aimed at improving physiology and guiding pharmacotherapy are lacking. METHODS The FUEL trial (Fontan Udenafil Exercise Longitudinal) was a phase III clinical trial conducted at 30 centers. Participants were randomly assigned udenafil, 87.5 mg twice daily, or placebo in a 1:1 ratio. The primary outcome was the between-group difference in change in oxygen consumption at peak exercise. Secondary outcomes included between-group differences in changes in submaximal exercise at the ventilatory anaerobic threshold, the myocardial performance index, the natural log of the reactive hyperemia index, and serum brain-type natriuretic peptide. RESULTS Between 2017 and 2019, 30 clinical sites in North America and the Republic of Korea randomly assigned 400 participants with Fontan physiology. The mean age at randomization was 15.5±2 years; 60% of participants were male, and 81% were white. All 400 participants were included in the primary analysis with imputation of the 26-week end point for 21 participants with missing data (11 randomly assigned to udenafil and 10 to placebo). Among randomly assigned participants, peak oxygen consumption increased by 44±245 mL/min (2.8%) in the udenafil group and declined by 3.7±228 mL/min (-0.2%) in the placebo group (P=0.071). Analysis at ventilatory anaerobic threshold demonstrated improvements in the udenafil group versus the placebo group in oxygen consumption (+33±185 [3.2%] versus -9±193 [-0.9%] mL/min, P=0.012), ventilatory equivalents of carbon dioxide (-0.8 versus -0.06, P=0.014), and work rate (+3.8 versus +0.34 W, P=0.021). There was no difference in change of myocardial performance index, the natural log of the reactive hyperemia index, or serum brain-type natriuretic peptide level. CONCLUSIONS In the FUEL trial, treatment with udenafil (87.5 mg twice daily) was not associated with an improvement in oxygen consumption at peak exercise but was associated with improvements in multiple measures of exercise performance at the ventilatory anaerobic threshold. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02741115.
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Affiliation(s)
- David J Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, PA (D.J.G., S.W., M.G.M., S.M.P.)
| | - Victor Zak
- New England Research Institutes, Watertown, MA (V.Z.)
| | - Bryan H Goldstein
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, OH (B.H.G., M.S.H., K.A.R., E.M.U.)
| | - Kurt R Schumacher
- Division of Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI (K.R.S., M.W.R.)
| | - Jonathan Rhodes
- Department of Cardiology, Children's Hospital Boston, MA (J.R.)
| | - Daniel J Penny
- Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX (D.J.P.)
| | - Christopher J Petit
- Emory University School of Medicine, Children's Healthcare of Atlanta, GA (C.J.P.)
| | - Salil Ginde
- Division of Cardiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee (S.G., P.C.F.)
| | - Shaji C Menon
- Division of Pediatric Cardiology, University of Utah, Salt Lake City (S.C.M.)
| | - Seong-Ho Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon-Si, South Korea (S.-H.K.)
| | - Gi Beom Kim
- Seoul National University School of Medicine, Seoul National University Children's Hospital, South Korea (G.B.K.)
| | - Todd T Nowlen
- Heart Center, Phoenix Children's Hospital, AZ (T.T.N.)
| | - Michael V DiMaria
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (M.V.D.)
| | - Benjamin P Frischhertz
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN (B.P.F.)
| | - Jonathan B Wagner
- Divisions of Cardiology and Clinical Pharmacology, Children's Mercy Kansas City, MO (J.B.W.)
| | - Kimberly E McHugh
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston (K.E.M.)
| | - Brian W McCrindle
- Division of Cardiology, The Hospital for Sick Children, University of Toronto, Ontario (B.W.M.)
| | - Amanda J Shillingford
- Nemours Cardiac Center, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE (A.J.S.)
| | - Arash A Sabati
- Los Angeles Children's Hospital, Division of Cardiology, CA (A.A.S.)
| | - Anji T Yetman
- Children's Hospital and Medical Center, University of Nebraska, Omaha (A.T.Y.)
| | - Anitha S John
- Division of Cardiology, Children's National Health System, Washington, DC (A.S.J.)
| | - Marc E Richmond
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY (M.E.R.)
| | - Matthew D Files
- Division of Cardiology, Seattle Children's Hospital, WA (M.D.F.)
| | - R Mark Payne
- Division of Cardiology, Riley Hospital for Children, Indianapolis, IN (R.M.P.)
| | - Andrew S Mackie
- Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada (A.S.M.)
| | | | | | - Kevin D Hill
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC (K.D.H.)
| | - Ruchira Garg
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (R.G.)
| | - Jeffrey P Jacobs
- Johns Hopkins All Children's Hospital, Department of Surgery, St Petersburg, FL (J.P.J.)
| | - Michelle S Hamstra
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, OH (B.H.G., M.S.H., K.A.R., E.M.U.)
| | - Stacy Woyciechowski
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, PA (D.J.G., S.W., M.G.M., S.M.P.)
| | - Kathleen A Rathge
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, OH (B.H.G., M.S.H., K.A.R., E.M.U.)
| | - Michael G McBride
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, PA (D.J.G., S.W., M.G.M., S.M.P.)
| | - Peter C Frommelt
- Division of Cardiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee (S.G., P.C.F.)
| | - Mark W Russell
- Division of Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI (K.R.S., M.W.R.)
| | - Elaine M Urbina
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, OH (B.H.G., M.S.H., K.A.R., E.M.U.)
| | - James L Yeager
- Consultant to Mezzion Pharma Co Ltd, Mezzion Pharma Co Ltd, Seoul, South Korea (J.L.Y.)
| | - Victoria L Pemberton
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (V.L.P., M.P.S., G.D.P.)
| | - Mario P Stylianou
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (V.L.P., M.P.S., G.D.P.)
| | - Gail D Pearson
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (V.L.P., M.P.S., G.D.P.)
| | - Stephen M Paridon
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, PA (D.J.G., S.W., M.G.M., S.M.P.)
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Functional Capacity Is Affected by Younger Age of Repair in Tetralogy of Fallot Patients But Not by Era of Repair. World J Pediatr Congenit Heart Surg 2019; 10:715-721. [DOI: 10.1177/2150135119878034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background:Cardiopulmonary exercise testing is widely used to assess functional capacity in patients with tetralogy of Fallot after surgical repair. Little is known regarding the impact of age at the time of primary complete repair and surgical era effect on exercise capacity.Methods:A retrospective, single-center chart review was done from 1976 to 2016 on pediatric patients with tetralogy of Fallot who underwent cardiopulmonary exercise testing with cycle ergometry utilizing the James protocol and were then sorted by repair before/after 1990 and by age of complete repair before/after one year. Exclusion criteria included submaximal tests, incomplete data, previous pulmonary valve replacement, and surgery prior to complete repair (ie, Blalock-Taussig shunt placement).Results:When comparing the groups who underwent primary complete repair before (N = 39) and after (N = 26) one year of age, the younger group demonstrated a higher percentage of predicted peak oxygen consumption ([Formula: see text] o2peak; 83.1% ± 11.8% vs 73.1% ± 16.1%; P = .005) despite having worse pulmonary insufficiency at the time of exercise testing. There were no differences in heart rate and blood pressure response. Age of repair was independently associated with [Formula: see text] o2peak. Data were statistically similar to the study eras (repair before 1990, N = 23; repair after 1990, N = 65): percentage of predicted [Formula: see text] o2peak (81.4% ± 13.6% vs 79.1% ± 14.4%, P = .5), maximal systolic blood pressure (155.1 ± 22.4 mm Hg vs 153.9 ± 17 mm Hg, P = .8), and percentage of predicted maximal heart rate (89.8% ± 9% vs 92% ± 7.1%, P = .3).Conclusions:Older age at primary repair appears to negatively impact [Formula: see text] o2peak; however, era effect does not appear to influence cardiopulmonary exercise testing outcomes.
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21
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Edelson JB, Burstein DS, Paridon S, Stephens P. Exercise stress testing: A valuable tool to predict risk and prognosis. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.101130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Runte K, Brosien K, Salcher-Konrad M, Schubert C, Goubergrits L, Kelle S, Schubert S, Berger F, Kuehne T, Kelm M. Hemodynamic Changes During Physiological and Pharmacological Stress Testing in Healthy Subjects, Aortic Stenosis and Aortic Coarctation Patients-A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2019; 6:43. [PMID: 31024935 PMCID: PMC6467940 DOI: 10.3389/fcvm.2019.00043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/22/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction: Exercise testing has become a diagnostic standard in the evaluation and management of heart disease. While different methods of exercise and pharmacological stress testing exist, only little is known about their comparability. We aimed to assess hemodynamic changes during dynamic exercise, isometric exercise, and dobutamine stress testing at different stress intensities in healthy subjects and patients with aortic stenosis (AS) and aortic coarctation (CoA). Methods: A systematic literature search (PROSPERO 2017:CRD42017078608) in MEDLINE of interventional trials was conducted to identify eligible studies providing evidence of changes in hemodynamic parameters under different stress conditions acquired by MRI or echocardiography. A random effects model was used to estimate pooled mean changes in hemodynamics. Results: One hundred and twenty-eight study arms with a total of 3,139 stress-examinations were included. In healthy subjects/(where available) in AS, pooled mean changes (95% CIs) during light dynamic stress were 31.78 (27.82–35.74) bpm in heart rate (HR) and 6.59 (2.58–10.61) ml in stroke volume (SV). Changes during light pharmacological stress were 13.71 (7.87–19.56)/14.0 (9.82–18.18) bpm in HR, and 5.47 (0.3–10.63)/8.0 (3.82–12.18) ml in SV. Changes during light isometric stress were 18.44 (10.74–26.14)/5.0 (−1.17–11.17) bpm in HR and −4.17 (−14.37–6.03)/−4.0 (−16.43–8.43) ml in SV. Changes during moderate dynamic stress were 49.57 (40.03–59.1)/46.45 (42.63–50.27) bpm in HR and 11.64 (5.87–17.42) ml in SV. During moderate pharmacological stress, changes in HR were 42.83 (36.94–48.72)/18.66 (2.38–34.93) bpm and in SV 6.29 (−2.0–14.58)/13.11 (7.99–18.23) ml. During high intensity dynamic stress changes in HR were 89.31 (81.46–97.17)/55.32 (47.31–63.33) bpm and in SV 21.31 (13.42–29.21)/−0.96 (−5.27–3.35) ml. During high pharmacological stress, changes in HR were 53.58 (36.53–70.64)/42.52 (32.77–52.28) bpm, and in SV 0.98 (−9.32–11.27)/14.06 (−1.62–29.74) ml. HR increase and age were inversely correlated at high stress intensities. In CoA, evidence was limited to single studies. Conclusion: This systematic review and meta-analysis presents pooled hemodynamic changes under light, moderate and high intensity exercise and pharmacological stress, while considering the potential influence of age. Despite limited availability of comparative studies, the reference values presented in this review allow estimation of the expected individual range of a circulatory response in healthy individuals and patients with AS and may contribute to future study planning and patient-specific models even when stress testing is contraindicated.
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Affiliation(s)
- Kilian Runte
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Kay Brosien
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Salcher-Konrad
- Personal Social Services Research Unit, London School of Economics and Political Science, London, United Kingdom.,LSE Health, London School of Economics and Political Science, London, United Kingdom
| | - Charlotte Schubert
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Leonid Goubergrits
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Kelle
- Department of Internal Medicine/Cardiology, German Heart Center Berlin, Berlin, Germany.,Department of Internal Medicine/Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Stephan Schubert
- Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Titus Kuehne
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Marcus Kelm
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
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23
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Blanchard J, Blais S, Chetaille P, Bisson M, Counil FP, Huard-Girard T, Berbari J, Boulay P, Dallaire F. New Reference Values for Cardiopulmonary Exercise Testing in Children. Med Sci Sports Exerc 2019; 50:1125-1133. [PMID: 29346167 PMCID: PMC6023574 DOI: 10.1249/mss.0000000000001559] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Cardiopulmonary exercise testing is an essential tool to assess cardiorespiratory fitness (CRF) in children. There is a paucity of adequate pediatric reference values that are independent of body size and pubertal stage. The purpose of this study is to provide Z score equations for several maximal and submaximal CRF parameters derived from a prospectively recruited sample of healthy children. METHODS In this cross-sectional multicenter study, we prospectively recruited 228 healthy children 12 to 17 yr old in local schools. We performed a symptom-limited cardiopulmonary exercise testing progressive ramp protocol on an electronically braked cycle ergometer. Eighteen CRF parameters were analyzed. We tested several regression models to obtain prediction curves that minimized residual association with age, body size, and pubertal stage. Both the predicted mean and the predicted SD were modeled to account for heteroscedasticity. RESULTS We identified nonlinear association of CRF parameters with body size and significant heteroscedasticity. To normalize CRF parameters, the use of a single body size variable was not sufficient. We therefore used multivariable models with various combination of height, corrected body mass, and age. Final prediction models yielded adjusted CRF parameters that were independent of age, sex, body mass, height, body mass index, and Tanner stages. CONCLUSIONS We present Z score equations for several CRF parameters derived from a healthy pediatric population. These reference values provide updated predicted means and range of normality that are independent of sex and body size. Further testing is needed to assess if these reference values increase sensitivity and specificity to identify abnormal cardiorespiratory response in children with chronic diseases.
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Affiliation(s)
- Joel Blanchard
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, and Sherbrooke University Hospital Research Center, Sherbrooke, CANADA.,Faculty of Physical Activity Sciences, University of Sherbrooke, Sherbrooke, CANADA
| | - Samuel Blais
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, and Sherbrooke University Hospital Research Center, Sherbrooke, CANADA
| | - Philippe Chetaille
- Department of Pediatrics, Mother-Child Sun Center, CHU of Quebec City, and Research Center of the Quebec City Hospital Center, Laval University, Quebec City, CANADA
| | - Michele Bisson
- Department of Pediatrics, Mother-Child Sun Center, CHU of Quebec City, and Research Center of the Quebec City Hospital Center, Laval University, Quebec City, CANADA
| | - François P Counil
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, and Sherbrooke University Hospital Research Center, Sherbrooke, CANADA
| | - Thelma Huard-Girard
- Department of Pediatrics, Mother-Child Sun Center, CHU of Quebec City, and Research Center of the Quebec City Hospital Center, Laval University, Quebec City, CANADA
| | - Jade Berbari
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, and Sherbrooke University Hospital Research Center, Sherbrooke, CANADA
| | - Pierre Boulay
- Faculty of Physical Activity Sciences, University of Sherbrooke, Sherbrooke, CANADA
| | - Frederic Dallaire
- Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Sherbrooke, and Sherbrooke University Hospital Research Center, Sherbrooke, CANADA
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24
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Priromprintr B, Silka MJ, Rhodes J, Batra AS. A prospective 5-year study of exercise performance following Melody valve implant. Am Heart J 2019; 209:47-53. [PMID: 30682562 DOI: 10.1016/j.ahj.2018.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 12/15/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The long-term benefits of Melody valve implant for right ventricular outflow tract conduit obstruction or insufficiency on exercise capacity are undefined. METHODS As part of the Melody valve clinical trial, 136 patients with congenital heart disease underwent serial cardiopulmonary exercise testing prior to, 6 months after, and annually for up to 5 years postimplant. RESULTS Mean age at Melody valve implantation was 22.4 ± 0.9 years (range 7-53 years). The 95 patients who completed the study protocol provide the basis of this report. An initial improvement in % predicted workload was present at 6 months postimplant; however, at the final (5 year) follow-up, sustained or further improvements in workload were not demonstrated for the entire cohort compared to baseline. By subgroup analysis, age <17 years at implant and pulmonary regurgitation as the primary lesion were variables associated with sustained improvement in exercise performance. There were sustained improvements in the ventilatory equivalents for O2 (minute ventilation/O2 intake, P = .01) and CO2 (minute ventilation/CO2 output, P < .01) at the ventilatory anaerobic threshold at the study conclusion. Improvements in forced vital capacity were also observed during the study but not sustained at the final follow-up. CONCLUSIONS A cautious appraisal of the cardiovascular benefits of Melody valve implant on sustained improvements in exercise performance appears warranted. Although the observed changes in pulmonary function suggest improved restrictive lung physiology and more efficient gas exchange, after an initial increase in % predicted performance, neither sustained nor further improvements in exercise performance were observed, except in specific patient subgroups.
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Affiliation(s)
- Bryant Priromprintr
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA; Lucile Packard Children's Hospital at Stanford, Stanford University Medical Center, Palo Alto, CA.
| | - Michael J Silka
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA.
| | | | - Anjan S Batra
- Children's Hospital of Orange County, University of California, Irvine, CA.
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25
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de Torres-Alba F, Kaleschke G, Baumgartner H. Impacto del implante percutáneo de válvula pulmonar en cuanto al momento de reintervenir por disfunción del tracto de salida del ventrículo derecho. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Management of Heart Failure in Adult Congenital Heart Disease. Prog Cardiovasc Dis 2018; 61:308-313. [DOI: 10.1016/j.pcad.2018.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/09/2018] [Indexed: 12/14/2022]
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27
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Areias JC. The role of cardiopulmonary exercise testing in decision-making in adults with congenital heart disease. Rev Port Cardiol 2018; 37:407-408. [PMID: 29773284 DOI: 10.1016/j.repc.2018.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- José Carlos Areias
- Serviço de Cardiologia Pediátrica e Centro de Referência de Cardiopatias Congénitas, Centro Hospitalar de S. João, CHSJ, Porto, Portugal.
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28
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de Torres-Alba F, Kaleschke G, Baumgartner H. Impact of Percutaneous Pulmonary Valve Implantation on the Timing of Reintervention for Right Ventricular Outflow Tract Dysfunction. ACTA ACUST UNITED AC 2018; 71:838-846. [PMID: 29859895 DOI: 10.1016/j.rec.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect. Early surgical repair has dramatically improved the outcome of this condition. However, despite the success of contemporary approaches with early complete repair, these are far from being curative and late complications are frequent. The most common complication is right ventricle outflow tract (RVOT) dysfunction, affecting most patients in the form of pulmonary regurgitation, pulmonary stenosis, or both, and can lead to development of symptoms of exercise intolerance, arrhythmias, and sudden cardiac death. Optimal timing of restoration of RVOT functionality in asymptomatic patients with RVOT dysfunction after TOF repair is still a matter of debate. Percutaneous pulmonary valve implantation, introduced almost 2 decades ago, has become a major game-changer in the treatment of RVOT dysfunction. In this article we review the pathophysiology, the current indications, and treatment options for RVOT dysfunction in patients after TOF repair with a focus on the role of percutaneous pulmonary valve implantation in the therapeutic approach to these patients.
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Affiliation(s)
- Fernando de Torres-Alba
- Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany.
| | - Gerrit Kaleschke
- Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Helmut Baumgartner
- Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
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29
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Areias JC. The role of cardiopulmonary exercise testing in decision-making in adults with congenital heart disease. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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