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Ponder R, Chez L, Rosenthal CJ, Bravo K, Lluri G, Reardon L, Lin J, Levi DS, Aboulhosn JA. Clinical and invasively-measured predictors of high exercise capacity in Fontan patients. Int J Cardiol 2023; 388:131166. [PMID: 37433405 DOI: 10.1016/j.ijcard.2023.131166] [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: 05/14/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Fontan patients have variable exercise capacity. Contemporary understanding as to which factors predict high tolerance is limited. METHODS Records from the Ahmanson/University of California, Los Angeles Adult Congenital Heart Disease Center were reviewed for adult Fontan patients who underwent CPET. Patients were considered "high performers" if their maximum oxygen uptake (VO2 max/kg)-predicted was greater than 80%. Cross-sectional clinical, hemodynamic, and liver biopsy data was gathered. High-performers were compared to control patients across these parameters via associations and regression. RESULTS A total of 195 adult patients were included; 27 patients were considered "high performers". They had lower body mass indices (BMI, p < 0.001), mean Fontan pressures (p = 0.026), and cardiac outputs (p = 0.013). High performers also had higher activity levels (p < 0.001), serum albumin levels (p = 0.003), non-invasive and invasive systemic arterial oxygen saturations (p < 0.001 and p = 0.004), lower New York Heart Association (NYHA) heart failure class (p = 0.002), and were younger at Fontan completion (p = 0.011). High performers had less severe liver fibrosis (p = 0.015). Simple regression found Fontan pressure, non-invasive O2 saturation, albumin level, activity level, age at Fontan surgery, NYHA class, and BMI to predict significant changes in VO2 max/kg %-predicted. These associations persisted in multiple regression for non-invasive O2 saturation, NYHA class II, activity level, and BMI. CONCLUSIONS Thin Fontan patients who exercise more had better exercise capacity, Fontan hemodynamic profiles, and less liver fibrosis.
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Affiliation(s)
- Reid Ponder
- Department of Medicine, Tufts University School of Medicine, Boston, MA, United States of America; Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America.
| | - Luke Chez
- Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Carl J Rosenthal
- University of California-Los Angeles, Los Angeles, CA, United States of America
| | - Katia Bravo
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Gentian Lluri
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Leigh Reardon
- Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America; Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Jeannette Lin
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Daniel S Levi
- Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Jamil A Aboulhosn
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
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Ravndal M, Idorn L, Nielsen AKM, Kelly B, Nielsen KG, Nielsen DG, Hjortdal V. Exercise capacity in the Danish Fontan population remains stable after ten years of follow-up - is physical activity the key to success? Int J Cardiol 2023; 387:131137. [PMID: 37355241 DOI: 10.1016/j.ijcard.2023.131137] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/30/2023] [Accepted: 06/20/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Most Fontan patients have impaired exercise capacity, and a further decline in exercise capacity over time seems inevitable. However, few longitudinal studies exist, and there is a lack of data from newer eras. We aimed to describe the natural evolution of exercise capacity over a 10-year period in a contemporary, population-based cohort of Danish Fontan patients. METHODS The study was a nationwide, prospective study. A cardiopulmonary exercise test (CPET) was used to assess the exercise capacity. All Danish Fontan patients who participated in a national study in 2011 (CPET1), were invited to a follow-up visit in 2021 (CPET2). All patients who completed CPET1 and CPET2 with a respiratory exchange ratio over 1.0 were included. The main outcome was percent predicted VO2peak (%pred VO2peak). At the time of CPET2, patients filled out a questionnaire including questions regarding physical activity. RESULTS Seventy-seven patients completed both CPET1 and CPET2, and seventy patients completed the questionnaire. The time interval between the two CPETs was 10.4 ± 0.9 years. The median age was 15 years at CPET1 and 26 years at CPET2. The exercise capacity remained stable with a mean %pred VO2peak of 53.8 ± 11.3 at CPET1 and 55.6 ± 10.9 in CPET2 (p = 0.314). Higher levels of vigorous physical activity were associated with higher %pred VO2peak in CPET2 in a multivariate regression model. CONCLUSION The %pred VO2peak remained stable over a ten-year period in this population-based Fontan cohort. Higher levels of self-reported vigorous physical activity were associated with higher %pred VO2peak in the most recent CPET.
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Affiliation(s)
- Maren Ravndal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Lars Idorn
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Benjamin Kelly
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Kim Gjerum Nielsen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Rychik J, Goldberg DJ, Rand E, Mancilla EE, Heimall J, Seivert N, Campbell D, O'Malley S, Dodds KM. A Path FORWARD: Development of a Comprehensive Multidisciplinary Clinic to Create Health and Wellness for the Child and Adolescent with a Fontan Circulation. Pediatr Cardiol 2022; 43:1175-1192. [PMID: 35604474 PMCID: PMC9125546 DOI: 10.1007/s00246-022-02930-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/28/2022] [Indexed: 12/19/2022]
Abstract
Today, it is anticipated most individuals diagnosed with single-ventricle malformation will survive surgical reconstruction through a successful Fontan operation. As greater numbers of patients survive, so has the recognition that individuals with Fontan circulation face a variety of challenges. The goal of a normal quality and duration of life will not be reached by all. The hurdles fall into a variety of domains. From a cardiovascular perspective, the Fontan circulation is fundamentally flawed by its inherent nature of creating a state of chronically elevated venous pressure and congestion, accompanied by a relatively low cardiac output. Ventricular dysfunction, atrioventricular valve regurgitation, and arrhythmia may directly impact cardiac performance and can progress with time. Problems are not limited to the cardiovascular system. Fontan circulatory physiology impacts a multitude of biological processes and health parameters outside the heart. The lymphatic circulation is under strain manifesting as variable degrees of protein-rich lymph loss and immune system dysregulation. Organ system dysfunction develops through altered perfusion profiles. Liver fibrosis is ubiquitous, and a process of systemic fibrogenesis in response to circulatory stressors may affect other organs as well. Somatic growth and development can be delayed. Behavioral and mental health problems are common, presenting as clinically important levels of anxiety and depression. Most striking is the high variability in prevalence and magnitude of these complications within the population, indicating the likelihood of additional factors enhancing or mitigating their emergence. We propose that optimal care for the individual with single ventricle and a Fontan circulation is ideally offered in a comprehensive multidisciplinary manner, with attention to elements that are beyond cardiac management alone. In this report, we share the concepts, our experiences, and perspectives on development of a clinic model-the "Fontan rehabilitation, wellness and resilience development" or FORWARD program. We provide insights into the mechanics of our multidisciplinary model of care and the benefits offered serving our growing population of individuals with a Fontan circulation and their families.
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Affiliation(s)
- Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA.
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - David J Goldberg
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Elizabeth Rand
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Edna E Mancilla
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Jennifer Heimall
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Nicholas Seivert
- Department of Child and Adolescent Psychiatry, and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Danielle Campbell
- Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Shannon O'Malley
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Kathryn M Dodds
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Nursing at the University of Pennsylvania, Philadelphia, USA
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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