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Mhd D, A H, P N, D Y, P B. Cardiopulmonary Exercise Testing in Children and Adolescents with Repaired Tetralogy of Fallot: Mechanisms of Exercise Intolerance and Clinical Implications. Pediatr Cardiol 2024:10.1007/s00246-024-03524-7. [PMID: 38940827 DOI: 10.1007/s00246-024-03524-7] [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] [Received: 03/02/2024] [Accepted: 05/12/2024] [Indexed: 06/29/2024]
Abstract
By comparison with adults, cardiopulmonary exercise testing in children with Tetralogy of Fallot is limited, and its clinical application less clarified. This study provides a comprehensive CPET profile in a child-adolescent population with repaired TOF, explores mechanisms underpinning exercise intolerance and associations with clinical outcome. Seventy-four CPETs were completed in 58 child-adolescents with rTOF (age 13.8 SD 2.4 years). CPET parameters were corrected for age, sex and body size. At follow-up (4.9 years, IQR 3.5-7.9) clinical status and re-intervention was evaluated and CPET indices predicting these outcomes determined. Cohort peak V̇O2 was within low-normal limits (% pred: 74.1% SD 15.4) with 15 patients (26%) displaying moderately severe reduction in V̇O2peak (< 65% pred). Oxygen uptake efficiency slope highly correlated with V̇O2peak (r = 0.94, p < 0.001) and was insensitive to exercise intensity. No significant change in CPET occurred in patients who underwent interval testing at 24 SD 14.5 months, although there was a variable response in V̇O2peak between individuals. Chronotropic response, lung vital capacity, heart rate-V̇O2 slope (indicator of stroke volume) predicted oxygen consumption: V̇O2peak (R2 = 50.91%, p < 0.001) and workload (R2 = 58.39%, p < 0.001). Adverse clinical status was associated with reduced workload (OR 0.97, p = 0.011). V̇E/V̇CO2 slope was steeper in those that died ((%pred:137.8 SD 60.5 vs. 108.4 SD 17.0, p < 0.019). RVOT reintervention post-CPET (24 patients, 43.8%) was associated with an increased gradient of HR-VO2 slope (OR 1.042, p = 0.004). In child-adolescents with TOF important reductions in cardiopulmonary functioning were apparent in 25% of patients. Exercise intolerance was related to reduced vital capacity, impaired chronotropic response and deficient stroke volume increment.
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Affiliation(s)
- Danton Mhd
- Department of Scottish, Pediatric Congenital Cardiac Services Royal Hospital for Children, Glasgow, G51 4TF, Scotland, UK.
- School of Cardiovascular and Metabolic, Health University of Glasgow, Glasgow, Scotland, UK.
| | - Hadjisoteriou A
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland, UK
| | - Noonan P
- Department of Scottish, Pediatric Congenital Cardiac Services Royal Hospital for Children, Glasgow, G51 4TF, Scotland, UK
| | - Young D
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, Scotland, UK
| | - Burns P
- Department Cardiopulmonary Physiology Royal Hospital for Children, Glasgow, Scotland, UK
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Leonardi B, Perrone M, Calcaterra G, Sabatino J, Leo I, Aversani M, Bassareo PP, Pozza A, Oreto L, Moscatelli S, Borrelli N, Bianco F, Di Salvo G. Repaired Tetralogy of Fallot: Have We Understood the Right Timing of PVR? J Clin Med 2024; 13:2682. [PMID: 38731211 PMCID: PMC11084704 DOI: 10.3390/jcm13092682] [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: 03/17/2024] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Despite many advances in surgical repair during the past few decades, the majority of tetralogy of Fallot patients continue to experience residual hemodynamic and electrophysiological abnormalities. The actual issue, which has yet to be solved, is understanding how this disease evolves in each individual patient and, as a result, who is truly at risk of sudden death, as well as the proper timing of pulmonary valve replacement (PVR). Our responsibility should be to select the most appropriate time for each patient, going above and beyond imaging criteria used up to now to make such a clinically crucial decision. Despite several studies on timing, indications, procedures, and outcomes of PVR, there is still much uncertainty about whether PVR reduces arrhythmia burden or improves survival in these patients and how to appropriately manage this population. This review summarizes the most recent research on the evolution of repaired tetralogy of Fallot (from adolescence onwards) and risk factor variables that may favor or delay PVR.
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Affiliation(s)
| | - Marco Perrone
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
- Division of Cardiology and CardioLab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | | | - Jolanda Sabatino
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Isabella Leo
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Martina Aversani
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Pier Paolo Bassareo
- School of Medicine, University College of Dublin, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland;
| | - Alice Pozza
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Lilia Oreto
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, 98122 Messina, Italy;
| | - Sara Moscatelli
- Institute of Cardiovascular Sciences University College London, London WC1E 6BT, UK and Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, AO Dei Colli, Monaldi Hospital, 80131 Naples, Italy;
| | - Francesco Bianco
- Cardiovascular Sciences Department, AOU “Ospedali Riuniti”, 60126 Ancona, Italy;
| | - Giovanni Di Salvo
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
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Leonardi B, Sollazzo F, Gentili F, Bianco M, Pomiato E, Kikina SS, Wald RM, Palmieri V, Secinaro A, Calcagni G, Butera G, Giordano U, Cafiero G, Drago F. Cardiopulmonary Exercise Testing after Surgical Repair of Tetralogy of Fallot-Does Modality Matter? J Clin Med 2024; 13:1192. [PMID: 38592039 PMCID: PMC10932302 DOI: 10.3390/jcm13051192] [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: 11/12/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Despite a successful repair of tetralogy of Fallot (rToF) in childhood, residual lesions are common and can contribute to impaired exercise capacity. Although both cycle ergometer and treadmill protocols are often used interchangeably these approaches have not been directly compared. In this study we examined cardiopulmonary exercise test (CPET) measurements in rToF. METHODS Inclusion criteria were clinically stable rToF patients able to perform a cardiac magnetic resonance imaging (CMR) and two CPET studies, one on the treadmill (incremental Bruce protocol) and one on the cycle ergometer (ramped protocol), within 12 months. Demographic, surgical and clinical data; functional class; QRS duration; CMR measures; CPET data and international physical activity questionnaire (IPAQ) scores of patients were collected. RESULTS Fifty-seven patients were enrolled (53% male, 20.5 ± 7.8 years at CPET). CMR measurements included a right ventricle (RV) end-diastolic volume index of 119 ± 22 mL/m2, a RV ejection fraction (EF) of 55 ± 6% and a left ventricular (LV) EF of 56 ± 5%. Peak oxygen consumption (VO2)/Kg (25.5 ± 5.5 vs. 31.7 ± 6.9; p < 0.0001), VO2 at anaerobic threshold (AT) (15.3 ± 3.9 vs. 22.0 ± 4.5; p < 0.0001), peak O2 pulse (10.6 ± 3.0 vs. 12.1± 3.4; p = 0.0061) and oxygen uptake efficiency slope (OUES) (1932.2 ± 623.6 vs. 2292.0 ± 639.4; p < 0.001) were significantly lower on the cycle ergometer compared with the treadmill, differently from ventilatory efficiency (VE/VCO2) max which was significantly higher on the cycle ergometer (32.2 ± 4.5 vs. 30.4 ± 5.4; p < 0.001). Only the VE/VCO2 slope at the respiratory compensation point (RCP) was similar between the two methodologies (p = 0.150). CONCLUSIONS The majority of CPET measurements differed according to the modality of testing, with the exception being the VE/VCO2 slope at RCP. Our data suggest that CPET parameters should be interpreted according to test type; however, these findings should be validated in larger populations and in a variety of institutions.
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Affiliation(s)
- Benedetta Leonardi
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.P.); (G.C.); (G.B.); (F.D.)
| | - Fabrizio Sollazzo
- Unità Operativa Complessa di Medicina dello Sport e Rieducazione Funzionale, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.S.); (M.B.); (V.P.)
| | - Federica Gentili
- Unit of Sport Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.G.); (U.G.); (G.C.)
| | - Massimiliano Bianco
- Unità Operativa Complessa di Medicina dello Sport e Rieducazione Funzionale, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.S.); (M.B.); (V.P.)
| | - Elettra Pomiato
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.P.); (G.C.); (G.B.); (F.D.)
| | - Stefani Silva Kikina
- Department of General Surgery, Southend University Hospital, Mid and South Essex NHS Foundation Trust, Westcliff-on-Sea SS0 0RY, UK;
| | - Rachel Maya Wald
- Toronto General Hospital Research Institute (TGHRI), Toronto, ON M5G 2N2, Canada;
| | - Vincenzo Palmieri
- Unità Operativa Complessa di Medicina dello Sport e Rieducazione Funzionale, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.S.); (M.B.); (V.P.)
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Department of Imaging, Bambino Gesù Children’s Hospital, IRCCS, 00168 Rome, Italy;
| | - Giulio Calcagni
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.P.); (G.C.); (G.B.); (F.D.)
| | - Gianfranco Butera
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.P.); (G.C.); (G.B.); (F.D.)
| | - Ugo Giordano
- Unit of Sport Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.G.); (U.G.); (G.C.)
| | - Giulia Cafiero
- Unit of Sport Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (F.G.); (U.G.); (G.C.)
| | - Fabrizio Drago
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (E.P.); (G.C.); (G.B.); (F.D.)
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Dallaire F, Grewal J, Mawad W, Wald RM. Challenges and Opportunities for Patients With Tetralogy of Fallot Across the Lifespan. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:253-255. [PMID: 38161677 PMCID: PMC10755820 DOI: 10.1016/j.cjcpc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/05/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Frédéric Dallaire
- Department of Pediatrics, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Jasmine Grewal
- Division of Cardiology, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wadi Mawad
- Division of Cardiology, Montreal Children’s Hospital, McGill University Health Center, Montreal, Québec, Canada
| | - Rachel M. Wald
- University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, University of Toronto, Toronto, Ontario, Canada
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