Serial Cardiopulmonary Exercise Testing in Patients after Extracardiac Conduit Total Cavopulmonary Connection for Single-Ventricle Hearts: An Observational Study

The Effects of Physical Activity and the Consequences of Physical Inactivity in Adult Patients with Congenital Heart Disease During the COVID-19 Pandemic

BACKGROUND

The ongoing COVID-19 pandemic has infected more than 500 million people worldwide. Several measures have been taken to reduce the spread of the virus and the saturation of intensive care units: among them, a lockdown (LD) was declared in Italy on 9 March 2020. As a result, gyms, public parks, sports fields, outdoor play areas, schools, and multiple commercial activities have been closed. The consequences of physical inactivity can be dramatic in adult patients with congenital heart disease (ACHD), in which the benefit of regular exercise is well known. In this study, we investigated the effects of reduced physical activity during the COVID-19 pandemic on ACHD's exercise capacity.

MATERIALS AND METHODS

Patients who performed exercise or cardiopulmonary exercise tests from October 2019 to February 2020 and one year after lockdown with the same protocol were retrospectively enrolled in our database.

INCLUSION CRITERIA

ACHD patients aged ≥ 18 years old under regular follow-up.

EXCLUSION CRITERIA

significant clinical and/or therapeutic changes between the two tests; significant illness occurred between the two tests, including COVID-19 infection; interruption of one of the tests for reasons other than muscle exhaustion.

RESULTS

Thirty-eight patients (55.6% males) met the inclusion criteria. Before the lockdown, 17 patients (group A) were engaged in regular physical activity (RPA), and 20 patients (group B) had a sedentary lifestyle. After LD, in group A, (a) the weekly amount of physical activity reduced with statistical significance from 115 ± 46 min/week to 91 ± 64 min/week (-21%, p = 0.03); (b) the BMI did not change; (c) the duration of exercise test and VO2 max at cardiopulmonary exercise test showed a significant reduction after the LD. In group B, BMI and exercise parameters did not show any difference.

CONCLUSIONS

The COVID-19 pandemic dramatically changed the habits of ACHD patients, significantly reducing their possibility to exercise. Our data analyzed in this extraordinary situation again demonstrated that physical inactivity in ACHD worsens functional capacity, as highlighted by VO2 max. Regular exercise should be encouraged in ACHD patients to preserve functional capacity.

Serial cardiopulmonary exercise testing in young patients after one-and-half ventricle repair and Fontan procedure: a comparative study

AIM

The Fontan procedure is a palliative surgical treatment for different congenital heart diseases with a univentricular heart, but it has been associated with decreased exercise capacity, cardiovascular morbidity, and premature mortality. The one-and-half ventricle repair (1.5VR) was introduced as an alternative to the Fontan procedure, specifically for selected patients with borderline hypoplastic right ventricle (HRV), aiming for a more physiological circulation. Despite these efforts, the benefit of 1.5VR over Fontan circulation comparison on clinical and functional outcomes remains unclear. The aim of this study was to investigate and compare young patients with HRV after 1.5VR with those with functional single right or left ventricles (FSRV or FSLV) after Fontan palliation over a 10-year follow-up period.

METHODS AND RESULTS

In this retrospective observational study, serial cardiopulmonary exercise tests (CPETs) performed in patients with 1.5VR and Fontan circulation between September 2002 and March 2024 have been analysed. Only patients with at least 10 years of follow-up were considered. A total of 43 patients were included (age at baseline 8.6 ± 2.6 years): 21 with FSLV, 12 with FSRV, and 10 with 1.5VR. No differences in cardiorespiratory fitness and efficiency were shown at the first CPET assessment among the three groups. At 10-year follow-up, 1.5VR had higher cardiorespiratory fitness and efficiency compared to FSLV and FSRV patients.

CONCLUSION

These findings suggest that the 1.5VR may provide superior long-term functional outcomes than the Fontan procedure in patients with borderline HRV. Further studies are needed to evaluate the impact on hard clinical endpoints.

Exercise Training for People Living with a Fontan Circulation: An Underutilized Intervention

Surgical repair for children born with single ventricle congenital heart disease, culminating in the Fontan operation, has resulted in dramatic improvements in survival; children born with these lesions are now typically expected to survive well into adulthood. Most, but not all, individuals with a Fontan circulation have reduced exercise capacity compared with the general population that in turn is associated with increased cardiovascular morbidity and mortality. The cause of reduced exercise capacity is multifactorial. A significant contributor is the absence of a subpulmonary ventricular pump, which limits preload and appropriate cardiac output augmentation to meet the increased metabolic demands that occur with exercise. While in its infancy relative to adults with acquired heart disease, the evidence to date suggests that exercise interventions to improve exercise capacity and Fontan physiology in children and adults with Fontan circulation are safe, effective and well tolerated. However, many knowledge gaps remain, including a detailed understanding of the unique physiological adaptations that occur, the optimal approach to exercise in this population and the effectiveness of home-based interventions utilizing telemedicine and remote physiologic monitoring technologies. Furthermore, the long-term impact of such interventions on the Fontan-cardiovascular system, physical activity levels, health-related quality of life, and late cardiovascular morbidity and mortality are not well characterized. In this review, we outline the factors associated with reduced exercise capacity in individuals with Fontan circulation, review the experience to date of dedicated interventions to improve exercise capacity, and highlight the current knowledge gaps in the field and priorities for further study.