Physical activity is associated with improved aerobic exercise capacity over time in adults with congenital heart disease

Remission from depression is associated with improved quality of life and preserved exercise capacity in adults with congenital heart disease

Aims

Improved long-term survival has widened the treatment goals for adults with congenital heart disease (ACHD) by addressing parameters that impact mental well-being and exercise capacity. Depression, a frequent co-morbidity in ACHD, is linked to both. Whether successful treatment of depression also affects cardiac parameters is a matter of debate.

Methods

This prospective, cross-sectional, longitudinal study included N = 150 ACHD (mean age 35.2 ± 11.3 years, 57% male) at baseline (t0) and N = 114 at follow-up (mean follow-up: 4.8 ± 0.6 years; t1). Patients were interviewed using a structured clinical interview, and severity of depression was assessed using the Montgomery-Asperg Depression Scale (MADRS). Additional testing was performed using self-rating questionnaires concerning depression, anxiety and quality of life (QoL). Exercise capacity (VO2max) was assessed by symptom limited exercise testing.

Results

Of N = 33 patients diagnosed with depression at t0, N = 18 patients remitted and N = 15 were non-remitters. Remitters displayed significantly decreased anxiety (P = 0.013), improved global QoL (P = 0.002), and preserved VO2max (P = 0.958) at t1 compared to t0. This was associated with favourable health behaviour at t1 and stable body-mass-index. Contrarily, non-remitters reported further increased anxiety (P = 0.021) and no significant improvement in QoL (P = 0.405). VO2max declined significantly (P = 0.006) and body-mass-index increased (P = 0.004). Never-depressed patients showed no significant changes in anxiety (P = 0.415) or QoL (P = 0.211). VO2max decreased significantly (P < 0.001).

Conclusion

In ACHD, remission from depression is associated with better physical functioning, mental health, and QoL. The assessment and treatment of depression in ACHD emerges as an important clinical goal that should be included in a comprehensive multimodal treatment plan.

The effects of telerehabilitation in adults with complex biventricular congenital heart conditions: protocol for a multi-centre, randomised controlled trial-CH-FIT

BACKGROUND

Accumulated evidence suggests that exercise training exerts beneficial effects on people with congenital heart conditions. These findings are predominantly derived from small, single-centre exercise trials conducted in outpatient rehabilitation facilities. In recent years, the delivery of exercise interventions remotely has increased through digital communications technology (telerehabilitation). However, very little research to date has been conducted into the efficacy of telerehabilitation in people with a congenital heart condition.

AIMS

To evaluate the effects of a telehealth-delivered exercise intervention in people with a history of a surgical biventricular repair due to a congenital heart condition.

METHODS

One hundred eligible adolescent (≥ 16 years) and adult participants living with a complex biventricular congenital heart condition will be recruited from four Australian sites and randomised to either (1) a 16-week telehealth-delivered combined (aerobic and resistance) exercise training programme of moderate-to-vigorous intensity or (2) usual care (control group), in a 1:1 allocation, with an 8-month follow-up.

OUTCOMES OF INTEREST

The primary outcome will be the change in aerobic capacity expressed as peak oxygen uptake (VO2peak). Secondary outcomes will include changes in vascular function, muscle oxygenation, metabolic profile, body composition and musculoskeletal fitness, neurohormonal activation, neurocognitive function, physical activity levels, dietary and nutritional status, and quality of life. Outcomes will be assessed at baseline, 16 weeks, and 12 months (to determine longer-term maintenance potential).

DISCUSSION

If found to be efficacious, telerehabilitation may be an alternative option for delivering exercise, improving health outcomes, and increasing accessibility to exercise programmes. Efficacy data is required to quantify the clinical significance of this delivery mode of exercise.

TRIAL REGISTRATION

ACTRN12622000050752 Trial registration date: 17 January 2022 Trial registration URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382635&showOriginal=true&isReview=true Trial registry name: Australian and New Zealand Clinical Trials Registry.

Core components of a rehabilitation program in pediatric cardiac disease

There is increasing effort in both the inpatient and outpatient setting to improve care, function, and quality of life for children with congenital heart disease, and to decrease complications. As the mortality rates of surgical procedures for congenital heart disease decrease, improvement in perioperative morbidity and quality of life have become key metrics of quality of care. Quality of life and function in patients with congenital heart disease can be affected by multiple factors: the underlying heart condition, cardiac surgery, complications, and medical treatment. Some of the functional areas affected are motor abilities, exercise capacity, feeding, speech, cognition, and psychosocial adjustment. Rehabilitation interventions aim to enhance and restore functional ability and quality of life for those with physical impairments or disabilities. Interventions such as exercise training have been extensively evaluated in adults with acquired heart disease, and rehabilitation interventions for pediatric patients with congenital heart disease have similar potential to improve perioperative morbidity and quality of life. However, literature regarding the pediatric population is limited. We have gathered a multidisciplinary team of experts from major institutions to create evidence- and practice-based guidelines for pediatric cardiac rehabilitation programs in both inpatient and outpatient settings. To improve the quality of life of pediatric patients with congenital heart disease, we propose the use of individualized multidisciplinary rehabilitation programs that include: medical management; neuropsychology; nursing care; rehabilitation equipment; physical, occupational, speech, and feeding therapies; and exercise training.

Move more - be happier? physical activity and health-related quality of life in children with congenital heart disease

OBJECTIVE

This cross-sectional study aimed to determine whether there is an association between objectively assessed physical activity (PA) and health-related quality of life (HRQoL) in children with CHD.

PATIENTS AND METHODS

From September 2017 to January 2021, 343 children with CHD (12.1 ± 3.3 years, 135 girls) provided valid PA data after a 7-day objective PA assessment. PA was evaluated as average daily steps and moderate-to-vigorous physical activity (MVPA) minutes assessed via wearable bracelet Garmin vivofit Jr. These children also completed the KINDL - a 24 Likert-scaled item questionnaires assessing HRQoL in the six dimensions physical well-being, emotional well-being, self-esteem, family, friends and everyday functioning.

RESULTS

Daily Steps (r = 0.166, P = .003) and daily MVPA minutes (r = 0.134, P = .017,) were both correlated to total KINDL score. Furthermore, both steps and MVPA were associated with the subscales physical well-being (steps: r = 0.165 p=.003; MVPA: r = 0.129, P = .022), friends (steps: r = 0.210, P < .001, MVPA: r = 0.179, P = .001), steps, and to everyday functioning (r = 0.142, P = .012). Logistic regression showed each MVPA minute increase conferred to a 1% increase in reporting better HRQoL (OR: 1.009 [95% CI: 1.002 - 1.017], P = .019).

CONCLUSIONS

PA was positively associated with HRQoL in children with CHD. Patients who move more are more likely to report better HRQoL. While the magnitude of this association needs to be further understood, continuous encouragement towards more PA seems to be crucial in a holistic approach to medical aftercare in children with CHD.

The Effects of Physical Inactivity and Exercise at Home in Young Patients with Congenital Heart Disease during the COVID-19 Pandemic

Background: The COVID-19 pandemic had a significant impact on the population’s ability to be physically active. Purpose: Evaluate the effect of the COVID-19 mitigation measures on exercise tolerance in patients with congenital heart disease (CHD). Materials and methods: All subjects (880, 6–18 years old) who performed a stress test at our hospital from October 2020 to February 2021 and had a similar test one year earlier were enrolled. A questionnaire on the degree of physical activity carried out in 2020 concerning the period prior to the pandemic was compiled. Exercise tolerance and the main anthropometric parameters between the first and second tests were compared. Results: 110 subjects (11.9 ± 4.1 years) were included in the study. The percentage of patients engaged in regular physical activity (RPA) decreased significantly during the pandemic (p < 0.001), and BMI increased significantly (p < 0.001), except among the subjects who began RPA during the lockdown, whereas test duration did not decrease significantly overall but increased in this last subgroup (p < 0.05) Conclusions: The COVID-19 lockdown led to a less active lifestyle with a significant increase in BMI in our group of CHD. These data could have negative effects on the risk profile of this population. RPA practiced at home seems to be effective in counteracting such effects.

Enablers and barriers for being physically active: experiences from adults with congenital heart disease

BACKGROUND

In general, adults with congenital heart disease have reduced exercise capacity and many do not reach the recommended level of physical activity. A physically active lifestyle is essential to maintain health and to counteract acquired cardiovascular disease, therefore enablers and barriers for being physically active are important to identify.

AIM

To describe what adults with complex congenital heart diseases consider as physical activity, and what they experience as enablers and barriers for being physically active.

METHODS

A qualitative study using semi-structured interviews in which 14 adults with complex congenital heart disease (seven women) participated. The interviews were analysed using qualitative content analysis.

RESULTS

The analysis revealed four categories considered enablers and barriers - encouragement, energy level, approach and environment. The following is exemplified by the category encouragement as an enabler: if one had experienced support and encouragement to be physically active as a child, they were more positive to be physically active as an adult. In contrast, as a barrier, if the child lacked support and encouragement from others, they had never had the opportunity to learn to be physically active.

CONCLUSION

It is important for adults with congenital heart disease to have the opportunity to identify barriers and enablers for being physically active. They need knowledge about their own exercise capacity and need to feel safe that physical activity is not harmful. This knowledge can be used by healthcare professionals to promote, support and eliminate misconceptions about physical activity. Barriers can potentially be transformed into enablers through increased knowledge about attitudes and prerequisites.

Cardiopulmonary Rehabilitation Improves Respiratory Muscle Function and Functional Capacity in Children with Congenital Heart Disease. A Prospective Cohort Study

Critical surgical and medical advances have shifted the focus of congenital heart disease (CHD) patients from survival to achievement of a greater health-related quality of life (HRQoL). HRQoL is influenced, amongst other factors, by aerobic capacity and respiratory muscle strength, both of which are reduced in CHD patients. This study evaluates the influence of a cardiopulmonary rehabilitation program (CPRP) on respiratory muscle strength and functional capacity. Fifteen CHD patients, ages 12 to 16, with reduced aerobic capacity in cardiopulmonary exercise testing (CPET) were enrolled in a CPRP involving strength and aerobic training for three months. Measurements for comparison were obtained at the start, end, and six months after the CPRP. A significant improvement of inspiratory muscle strength was evidenced (maximum inspiratory pressure 21 cm H₂O, 23%, p < 0.01). The six-minute walking test showed a statistically and clinically significant rise in walked distance (48 m, p < 0.01) and a reduction in muscle fatigue (1.7 out of 10 points, p = 0.017). These results suggest CPRP could potentially improve respiratory muscle function and functional capacity, with lasting results, in children with congenital heart disease, but additional clinical trials must be conducted to confirm this finding.

Diagnosis and treatment of adults with congenital heart disease

Approximately 50 million adults worldwide have known congenital heart disease (CHD). Among the most common types of CHD defects in adults are atrial septal defects and ventricular septal defects followed by complex congenital heart lesions such as tetralogy of Fallot. Adults with CHDs are more likely to have hypertension, cerebral vascular disease, diabetes and chronic kidney disease than age-matched controls without CHD. Moreover, by the age of 50, adults with CHD are at a greater than 10% risk of experiencing cardiac dysrhythmias and approximately 4% experience sudden death. Consequently, adults with CHD require healthcare that is two- to four-times greater than adults without CHD. This paper discusses the diagnosis and treatment of adults with atrial septal defects, ventricular septal defects and tetralogy of Fallot.

Effect of acupuncture in physiological parameters and endurance running performance

BACKGROUND

Few studies have examined the effect of acupuncture (AC) treatment in aerobic capacity and endurance performance in healthy adults. Thus, the aim of the present study was to evaluate the effects of AC on selected physiological parameters and 3 km running performance.

METHODS

Twenty-four healthy subjects with low to moderate aerobic capacity participated in the study and randomly assigned in two groups: AC group (ACG - N.=14) and control group (CG - N.=10). The subjects completed an incremental test to exhaustion and a 3 km race on a treadmill to evaluate their physiological responses and endurance running performance respectively, prior and after 4 weeks (8 sessions, twice a week) of acupuncture treatment.

RESULTS

AC treatment had a significant main effect in T3km [F(1, 21)=7.173, P=0.014, partial η2=0.255], as well as in VT [F(1, 21)=8.476, P=0.008, partial η2=0.288] and HRmax@3km [F(1, 21)=4.930, P=0.038, partial η2=0.190], after controlling for the effect of the pre-test, while no other significant main effects were detected.

CONCLUSIONS

Healthy physically active adults significantly improved their endurance running performance after 4 weeks of AC treatment. This is mainly due to the enhancement of the speed corresponding with VT, comparing with their baseline values.

Health-Related Physical Fitness and Quality of Life in Children and Adolescents With Isolated Left-to-Right Shunt

Objective: Atrial (ASD) and ventricular septal defects (VSD) represent the most common congenital heart defects (CHD) and are considered simple and curable. This study investigates long-term functional outcomes in children with such defects. Patients and Methods : We examined 147 patients (74 girls, 12.1 ± 3.5 years) with isolated shunts (ASD: 54%, VSD: 46%) for their Health-Related Physical Fitness (HRPF) and Health-Related Quality of Life (HRQoL). Native condition was present in 58 patients, interventional closure of the defect was performed in 42 and surgical closure in 47. For comparison, a healthy control group (CG) of 1,724 children (48.9% girls, 12.8 ± 2.8 years) was recruited within two recent school projects. Results: After adjustment for age and sex, children with ASD and VSD presented lower HRPF (z-score healthy peers: 0.02 ± 0.73, ASD: -0.41 ± 0.73, p < 0.001; VSD: -0.61 ± 0.73, p < 0.001) then healthy peers. Transferred into percentiles, VSD were on the 26th and ASD on the 34th percentile of the healthy peers. HRQoL did not differ between peers and CHD with isolated shunts (healthy peers: 76.1 ± 9.7, ASD: 76.2 ± 9.9, p = 0.999; VSD: 78.7 ± 9.7, p = 0.316). Regarding the surgical history of the shunts (native, percutaneously treated, surgically treated), there were also no difference in-between these three states, nor differed HRPF and HRQoL in-between gender. Conclusions: Children with ASD or VSD have impaired HRPF but normal HRQoL. Early childhood sports promotion could be a good measure to counteract these restrictions in HRPF at an early stage.

Predictors of Postoperative Rehabilitation Therapy Following Congenital Heart Surgery

Background

Patients with congenital heart disease are at risk of motor, cognitive, speech, and feeding difficulties after cardiac surgery. Rehabilitation therapy could improve functional outcomes in this population if applied in the acute postcardiac surgical in‐hospital stay. However, information on the types of acute postcardiac surgery therapy needs in children is scarce. Our goal was to describe rehabilitation therapy following congenital heart surgery and pre/intraoperative factors associated with need for therapy.

Methods and Results

This is a retrospective cohort study of patients <18 years undergoing heart surgery at our center from January 1, 2013 to January 31, 2015. Demographic, and pre‐, intra‐, and postoperative clinical and rehabilitation therapy (physical, occupational, speech, feeding therapy, and neurodevelopment intervention) data were collected. Need for rehabilitation therapy in the acute postoperative period, particularly following palliative repair, was the outcome variable in a multivariable logistic regression model to identify independent pre‐ and intraoperative factors associated with therapy. A total of 586 out of 1415 (41%) subjects received rehabilitation therapy postsurgery. Certain subgroups had increased rehabilitation therapy use such as neonates (80%). On multivariable analysis, palliative repair, prematurity, genetic syndrome, presurgical hospital stay of more than 1 day, and prolonged cardiopulmonary bypass time were independently associated with rehabilitation therapy.

Conclusions

Nearly half of patients who underwent post–congenital heart surgery received rehabilitation therapy. Frequency of use and types of therapy vary according to patient characteristics; however, certain pre‐ and intraoperative factors are associated with need for rehabilitation therapy, and may aid decision‐making for appropriate resource allocation.

A Randomized Trial Comparing Cardiac Rehabilitation to Standard of Care for Adults With Congenital Heart Disease

Background:

Cardiac rehabilitation (CR) improves exercise capacity and quality of life while reducing mortality in adults with acquired heart disease. Cardiac rehabilitation has not been extensively studied in adults with congenital heart disease (CHD).

Methods:

We performed a prospective, randomized controlled trial (NCT01822769) of a 12-week clinical CR program compared with standard of care (SOC). Participants were ≥16 years old, had moderate or severe CHD, had O2 saturation ≥92%, and had peak O2 consumption ([Formula: see text]) < 80% predicted. We assessed exercise capacity, physical activity, quality of life, self-reported health status, and other variables at baseline and after 12 weeks. The prespecified primary end point was change in [Formula: see text].

Results:

We analyzed data on 28 participants (aged 41.1 ± 12.1 years, 50% male), 13 randomized to CR and 15 to SOC. [Formula: see text] averaged 16.8 ± 3.8 mL/kg/min, peak work rate = 95 ± 28 W, and median Minnesota Living with Heart Failure Questionnaire (MLHFQ) score = 27 (interquartile range: 11-44). Cardiac rehabilitation participants were older (48 ± 9 years vs 36 ± 12 years; P = .01), but there were no significant between-group differences in other variables. There were no adverse events related to CR. [Formula: see text] increased in the CR group compared with SOC (+2.2 mL/kg/min, 95% confidence interval: 0.7-3.7; P = .002, age-adjusted +2.7 mL/kg/min; P = .004); there was a nonsignificant improvement in work rate (+8.1 W; P = .13). Among the 25 participants with baseline MLHFQ > 5, there was a clinically important >5-point improvement in 72.7% and 28.6% of CR and SOC participants, respectively ( P = .047). Cardiac rehabilitation was also associated with improved self-assessment of overall health ( P < .04).

Conclusions:

Cardiac rehabilitation is safe and is associated with improvement in aerobic capacity and self-reported health status compared with SOC in adults with CHD.

Effect of Meridian Acupressure on Aerobic Performance of Healthy Young Population: A Randomized Controlled Study

OBJECTIVES

An enhancement of aerobic capacity has always been in the scope of various exercise programs. Apart from traditional, like endurance training, methods to improve aerobic performance, there is growing interest to alternative bodywork techniques, like massage, yoga, and acupuncture. This study aimed to investigate the acupressure effect on maximal aerobic capacity (VO₂max) in healthy young adult males.

DESIGN

Forty young healthy participants were randomly divided into intervention (n = 20) and control (n = 20) groups. The inferred VO₂max level in groups was assessed by the 6-min Harvard step test twice: at baseline and after acupressure session.

INTERVENTION

Three-minute finger-tip point massage of Neiguan, Juque, and Xinshu acupoints covered by 1 cm² sticky capsaicin-dressed heat plasters was applied in the intervention group, whereas in the control group, placebo acupressure was utilized.

RESULTS

The inferred VO₂max in the intervention group increased from baseline 2.38 ± 0.48 L/min to 2.57 ± 0.6 L/min (p < 0.003), whereas inferred VO₂max of the control group remained unchanged (2.46 ± 0.5 L/min at baseline and 2.47 ± 0.4 L/min after placebo acupressure, p > 0.9).

CONCLUSIONS

The results of the study demonstrated that finger-tip acupressure increases aerobic performance of young healthy males on more than 10%. Acupressure probably decreased anxiety level, which allowed better utilization of available energy sources.

National Trends in Hospitalizations of Adults With Tetralogy of Fallot

The population of adults with tetralogy of Fallot (TOF) is growing, and it is not known how the changes in age distribution, treatment strategies, and prevalence of co-morbidities impact their interaction with the health care system. We sought to analyze the frequency and reasons for hospital admissions over the past decade. We extracted serial cross-sectional data from the United States Nationwide Inpatient Sample on hospitalizations including the diagnostic code for TOF from 2000 to 2011. From 2000 to 2011, there were 20,545 admissions for subjects with TOF, with a steady increase in annual number. The most common primary admission diagnoses were heart failure (HF; 17%), arrhythmias (atrial 10% and ventricular 6%), pneumonia (9%), and device complications (7%). The rates of co-morbidities increased significantly, particularly diabetes (4.5% to 8.1%), obesity (2.1% to 6.5%), hypertension, and renal disease. The number of pulmonic valve replacements increased (6.8% to 11.3% of TOF admissions, p <0.001), with an increase in median age at surgery from 16 to 19 years old (p = 0.036). The cost per TOF admission was more than double that of noncongenital HF admissions and rose significantly, reaching $21,800 ± 46,000 in 2011. In conclusion, hospitalized patients with TOF have become significantly more medically complex and are growing in number. The increase in the prevalence of obesity, hypertension, and diabetes in this young population supports the need for prevention efforts focused on modifiable risk factors, in addition to HF and arrhythmia treatment. The increase in cost of care calls for further analysis of areas in which efficiency can be increased to ensure high quality of care and lifelong follow-up of patients with TOF.

Voluntary stand-up physical activity enhances endurance exercise capacity in rats

Involuntary physical activity induced by the avoidance of electrical shock leads to improved endurance exercise capacity in animals. However, it remains unknown whether voluntary stand-up physical activity (SPA) without forced simulating factors improves endurance exercise capacity in animals. We examined the eff ects of SPA on body weight, cardiac function, and endurance exercise capacity for 12 weeks. Twelve male Sprague-Dawley rats (aged 8 weeks, n=6 per group) were randomly assigned to a control group (CON) or a voluntary SPA group. The rats were induced to perform voluntary SPA (lifting a load equal to their body weight), while the food height (18.0 cm) in cages was increased progressively by 3.5 every 4 weeks until it reached 28.5 cm for 12 weeks. The SPA group showed a lower body weight compared to the CON group, but voluntary SPA did not affect the skeletal muscle and heart weights, food intake, and echocardiography results. Although the SPA group showed higher grip strength, running time, and distance compared to the CON group, the level of irisin, corticosterone, genetic expression of mitochondrial biogenesis, and nuclei numbers were not affected. These findings show that voluntary SPA without any forced stimuli in rats can eff ectively reduce body weight and enhance endurance exercise capacity, suggesting that it may be an important alternative strategy to enhance endurance exercise capacity.

Overweight predicts poorer exercise capacity in congenital heart disease patients

Background

Overweight (OW) and obesity (OB) are endemic in the United States and affect adolescents and adults with congenital heart disease (ACHD). Defining the burden of excess weight on the cardiovascular system in ACHD is the goal of this study. Limitation of exercise capacity due to overweight or obesity might be reversible with weight loss and improve quality of life for ACHD adults.

Methods

Exercise tests performed using a Bruce protocol and measurement of maximum oxygen consumption were retrospectively reviewed on 418 CHD patients. OW and OB were defined as the 85–95 or > 95 percentile respectively for age and gender or by adult criteria. Severity of CHD was assigned based on criteria published in standard guidelines.

Results

63 patients had mild, 198 moderate, and 157 severe heart disease. Each ACHD group was 32 to 34% OW or OB. Measured exercise time (ET) of CHD patients with moderate or severe heart disease was less than that of controls in each weight categories. However, OB or OW people have shorter ET than their normal weight peers with CHD. Multiple regression using ET as the dependent variable finds that female sex, relative BMI, and VE/VCO2 at peak exercise are all associated with lesser ET with high significance. Peak heart rate is associated with greater ET, with borderline significance. Severity of heart disease is not independently associated with ET.

Conclusions

OW and OB are strongly associated with reduced ET in persons with congenital heart disease. Losing weight may improve exercise capacity in ACHD.

Growth and Obesity Among Older Single Ventricle Patients Presenting for Fontan Conversion

INTRODUCTION

Long-term growth outcomes and the prevalence of obesity among older single ventricle (SV) patients have not been well characterized. We investigated these parameters, as well as the impact of obesity on survival, in an older cohort of SV patients presenting for Fontan conversion.

METHODS

We analyzed preoperative height, weight, and body mass index (BMI) of patients who underwent Fontan conversion. Overweight and obese were defined as BMI ≥85 percentile and ≥95 percentile for patients <20 years and BMI 25 to 30 kg/m(2) and ≥30 kg/m(2) for patients ≥20 years, respectively. Postoperative transplant-free survival was assessed among obese, overweight, and normal weight patients.

RESULTS

We evaluated 139 patients presenting for Fontan conversion at a median age of 23.2 years. Patients had shorter stature compared to the normal population (mean Z score -0.6, P < .001). Younger patients had lower BMI compared to the normal population (<20 years: mean Z score -0.5, P = .02), while older patients had elevated BMI (≥20 years: mean Z score +0.4, P < .001). The mean BMI among older patients approached overweight at 24.6 kg/m(2). The prevalence of obesity increased with advancing age, with 36% overweight and 14% obese at >30 years. At a median of 8.2 years following Fontan conversion, obesity and overweight status were not associated with transplant-free survival.

CONCLUSION

Older SV patients presenting for Fontan conversion had shorter stature compared to the normal population as well as a high prevalence of overweight and obesity. Although there was no relationship between weight status and early postoperative survival, further investigation of long-term outcomes is warranted.

The impact of pulmonary insufficiency on the right ventricle: a comparison of isolated valvar pulmonary stenosis and tetralogy of fallot

Pulmonary insufficiency (PI) is associated with right ventricular (RV) dilation, dysfunction, and exercise intolerance in patients with tetralogy of fallot (TOF). We sought to compare RV function and exercise performance in patients with valvar pulmonary stenosis (VPS) following pulmonary balloon valvuloplasty to those with repaired TOF with similar degrees of PI. We performed a cross-sectional study of patients with VPS and TOF. Cardiac magnetic resonance (CMR) and exercise stress test were performed. Subjects were matched by time from initial procedure and severity of PI using propensity scores. After matching, there were 16 patients with VPS and 16 with TOF for comparison, with similar demographics. Time from initial procedure was 14 years (12-16), p = 0.92, and pulmonary regurgitant fraction was 19 % (6-31), p = 0.94, Patients with TOF had lower ejection fraction [58 % (53-66) vs. 65 % (60-69), p = 0.04] and more RV hypertrophy [69 g/m(2) (52-86) vs. 44 g/m(2) (32-66), p = 0.04] compared to those with VPS. Aerobic capacity was worse in patients with TOF [68 ± 19 % mVO2 (56-84) vs. 82 ± 9.2 % (74-89) in VPS, p = 0.01], with a trend for less habitual physical activity [0.9 (0-12) vs. 8 h/week (4-12), p = 0.056], respectively. With similar degrees of PI, patients with TOF demonstrate worse RV function and aerobic capacity as compared to patients with just VPS. Habitual exercise may in part explain differences in exercise performance and should be further explored.

Emerging hemodynamic signatures of the right heart (Third International Right Heart Failure Summit, part 2)

Despite the importance of preserved right ventricular structure and function with respect to outcome across the spectrum of lung, cardiac, and pulmonary vascular diseases, only recently have organized efforts developed to consider the pulmonary vascular-right ventricular apparatus as a specific unit within the larger context of cardiopulmonary pathophysiology. The Third International Right Heart Failure Summit (Boston, MA) was a multidisciplinary event dedicated to promoting a dialogue about the scientific and clinical basis of right heart disease. The current review provides a synopsis of key discussions presented during the section of the summit titled "Emerging Hemodynamic Signatures of the Right Heart." Specifically, topics emphasized in this element of the symposium included (1) the effects of pulmonary vascular dysfunction at rest or provoked by exercise on the right ventricular pressure-volume relationship, (2) the role of pressure-volume loop analysis as a method to characterize right ventricular inefficiency and predict right heart failure, and (3) the importance of a systems biology approach to identifying novel factors that contribute to pathophenotypes associated with pulmonary arterial hypertension and/or right ventricular dysfunction. Collectively, these concepts frame a forward-thinking paradigm shift in the approach to right heart disease by emphasizing factors that regulate the transition from adaptive to maladaptive right ventricular-pulmonary vascular (patho)physiology.

Long-term benefits of exercise training in patients with a systemic right ventricle

OBJECTIVES

The aim of the present study is to determine the long-term effects of a ten-week exercise training program in adult patients with a systemic right ventricle.

METHODS

All patients who participated in a 2009 randomized controlled trial were approached. At approximately three years of follow-up from initial baseline, patients underwent cardiopulmonary exercise testing, filled out two quality of life questionnaires, and NT proBNP levels were measured. All examinations were performed according to the protocols of the 2009 trial. In addition, patients were asked about their current sports habits.

RESULTS

Of the 54 patients who were randomized in the 2009-trial 40 participated in the current re-evaluation (male 50%, ccTGA 35%, age 36 ± 10 years, intervention group n=22, control group n=18). After three years, no persistent effect of exercise training on V'O₂peak training remained (-2% of predicted, 95% CI -3% to 5%; p=.56). However, patients who already participated in regular sports or exercise at baseline (n=23/40 (58%)) showed higher V'O₂peak of 13% of predicted (95% CI 4% to 23%; p>.01) and a decrease of 62% in plasma NT-proBNP (95% CI -115% to -10%; p>.03) during follow-up, when compared to patients who did not. Moreover, sports were associated with a lower incidence of clinical events (p=.032).

CONCLUSION

Short-term beneficial effects of exercise training did not persist over a three-year follow-up period. However, sports participation at baseline was associated with better exercise capacity, lower neurohormone levels, and increased event-free survival.