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Jang JY, Lee S, Kim DH, Song JM, Kang DH, Song JK. Variable Hemodynamic Responses during Diastolic Stress Echocardiography in Patients Who Have Relaxation Abnormality with Possible Elevated Filling Pressure. Korean Circ J 2018; 48:744-754. [PMID: 30073814 PMCID: PMC6072668 DOI: 10.4070/kcj.2018.0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/06/2018] [Accepted: 04/04/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The clinical characteristics of patients with diastolic dysfunction characterized by a relaxation abnormality with possible elevated filling pressure is remain to be determined. We sought to test whether diastolic stress echocardiography (DSE) is useful for characterization of these patients. METHODS A total of 120 patients (58 men, mean age of 64±7 years) with E/A ratio <1.0 (mean±SD, 0.7±0.1) and 10≤ E/e' <15 at rest echocardiography was enrolled prospectively for supine bicycle exercise up to 50 W. RESULTS During exercise, 47 patients (39%) showed high left ventricular filling pressure (E/e' >15, hLVFP) and 40 (30%) developed exercise-induced pulmonary hypertension (systolic pulomary arterial pressure >50 mmHg, EiPH) without hLVFP. The remaining 33 patients did not show hLVFP or EiPH. The incidence of EiPH with hLVFP was 21% (25/120). By multivariate analysis, age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.00-1.13; p=0.039) and systolic pulmonary artery pressure at rest (OR, 1.14; 95% CI, 1.02-1.27; p=0.02) were associated with EiPH, whereas late diastolic transmitral velocity (OR, 1.04; 95% CI, 1.00-1.08; p=0.03) and diastolic blood pressure (OR, 0.94; 95% CI, 0.90-0.99; p=0.02) were associated with hLVFP during exercise. CONCLUSIONS Patients with relaxation abnormality and possibly hLVFP showed markedly heterogeneous hemodynamic changes during low-level exercise and DSE was useful to characterize these patients.
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Affiliation(s)
- Jeong Yoon Jang
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
| | - Sahmin Lee
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Hee Kim
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Min Song
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk Hyun Kang
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Kwan Song
- Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Korea.
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Krieger EV, Leary PJ, Opotowsky AR. Pulmonary Hypertension in Congenital Heart Disease: Beyond Eisenmenger Syndrome. Cardiol Clin 2015; 33:599-609, ix. [PMID: 26471823 DOI: 10.1016/j.ccl.2015.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients with adult congenital heart disease have an increased risk of developing pulmonary hypertension. There are several mechanisms of pulmonary hypertension in patients with adult congenital heart disease, and understanding them requires a systematic approach to define the patient's hemodynamics and physiology. This article reviews the updated classification of pulmonary hypertension in patients with adult congenital heart disease with a focus on pathophysiology, diagnostics, and the evaluation of pulmonary hypertension in special adult congenital heart disease populations.
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Affiliation(s)
- Eric V Krieger
- Seattle Adult Congenital Heart Service, Division of Cardiology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
| | - Peter J Leary
- Pulmonary Vascular Disease Program, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Alexander R Opotowsky
- Boston Adult Congenital Heart and Pulmonary Hypertension Service, Department of Cardiology, Boston Children's Hospital and Brigham and Women's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Santos M, Systrom D, Epstein SE, John A, Ruiz G, Landzberg MJ, Opotowsky AR. Impaired exercise capacity following atrial septal defect closure: an invasive study of the right heart and pulmonary circulation. Pulm Circ 2015; 4:630-7. [PMID: 25610599 DOI: 10.1086/678509] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/16/2014] [Indexed: 11/03/2022] Open
Abstract
Patients with early repair of an isolated atrial septal defect (ASD) are expected to have unremarkable right ventricular (RV) and pulmonary circulation physiology. Some studies, however, suggest persistent functional impairment. We aimed to examine the role of abnormal RV and pulmonary vascular response to exercise in patients who had undergone ASD closure. Using a previously published data set, we reviewed invasive exercise cardiopulmonary testing with right-sided hemodynamic data for 12 asymptomatic patients who had undergone ASD closure. The 5 (42%) patients with impaired maximal oxygen uptake ([Formula: see text]) were older and exhibited a lower peak cardiac index (5.6 ± 0.8 vs. 9.0 ± 1.2 L/min/m(2); P = .005) because of abnormal stroke volume augmentation (+3.2 ± 3.9 vs. +17.4 ± 10.2 mL/m(2); P = .02). While all resting hemodynamic variables were similar, patients with low [Formula: see text] tended to have abnormal total pulmonary vascular resistance change during exercise (+11% ± 41% vs. -28% ± 26%; P = .06) and had a steeper relation between mean pulmonary arterial pressure and cardiac index (5.8 ± 0.6 vs. 2.2 ± 0.1 L/min/m(2); P = .02). The increase in peak mean RV power during exercise was also significantly lower in the impaired-[Formula: see text] patients (4.7 ± 1.6 vs. 7.6 ± 2.1 J/s; P = .04). As described in the original study, despite normal resting hemodynamics, a subset of asymptomatic patients with repaired ASD had diminished exercise capacity. Our analysis allows us to conclude that this is due to a combination of abnormal pulmonary vascular response to exercise and impaired RV function.
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Affiliation(s)
- Mário Santos
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - David Systrom
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stephen E Epstein
- MedStar Heart Institute, Washington Hospital Center, Washington, DC, USA
| | - Anitha John
- MedStar Heart Institute, Washington Hospital Center, Washington, DC, USA ; Department of Cardiology, Children's National Medical Center, Washington, DC, USA
| | - George Ruiz
- MedStar Heart Institute, Washington Hospital Center, Washington, DC, USA
| | - Michael J Landzberg
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA ; Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexander R Opotowsky
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA ; Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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Marsden AL, Reddy VM, Shadden SC, Chan FP, Taylor CA, Feinstein JA. A new multiparameter approach to computational simulation for Fontan assessment and redesign. CONGENIT HEART DIS 2010; 5:104-17. [PMID: 20412482 DOI: 10.1111/j.1747-0803.2010.00383.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite an abundance of prior Fontan simulation articles, there have been relatively few clinical advances that are a direct result of computational methods. We address a few key limitations of previous Fontan simulations as a step towards increasing clinical relevance. Previous simulations have been limited in scope because they have primarily focused on a single energy loss parameter. We present a multi-parameter approach to Fontan modeling that establishes a platform for clinical decision making and comprehensive evaluation of proposed interventions. METHODS Time-dependent, 3-D blood flow simulations were performed on six patient-specific Fontan models. Key modeling advances include detailed pulmonary anatomy, catheterization-derived pressures, and MRI-derived flow with respiration. The following performance parameters were used to rank patients at rest and simulated exercise from best to worst performing: energy efficiency, inferior and superior vena cava (IVC, SVC) pressures, wall shear stress, and IVC flow distribution. RESULTS Simulated pressures were well matched to catheterization data, but low Fontan pressure did not correlate with high efficiency. Efficiency varied from 74% to 96% at rest, and from 63% to 91% with exercise. Distribution of IVC flow ranged from 88%/12% (LPA/RPA) to 53%/47%. A "transcatheter" virtual intervention demonstrates the utility of computation in evaluating interventional strategies, and is shown to result in increased energy efficiency. CONCLUSIONS A multiparameter approach demonstrates that each parameter results in a different ranking of Fontan performance. Ranking patients using energy efficiency does not correlate with the ranking using other parameters of presumed clinical importance. As such, current simulation methods that evaluate energy dissipation alone are not sufficient for a comprehensive evaluation of new Fontan designs.
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Affiliation(s)
- Alison L Marsden
- Mechanical and Aerospace Engineering Department, University of California, San Diego, CA 92093-0411, USA.
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Tang BT, Fonte TA, Chan FP, Tsao PS, Feinstein JA, Taylor CA. Three-dimensional hemodynamics in the human pulmonary arteries under resting and exercise conditions. Ann Biomed Eng 2010; 39:347-58. [PMID: 20640512 DOI: 10.1007/s10439-010-0124-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 07/02/2010] [Indexed: 11/30/2022]
Abstract
The biomechanical forces associated with blood flow have been shown to play a role in pulmonary vascular cell health and disease. Therefore, the quantification of human pulmonary artery hemodynamic conditions under resting and exercise states can be useful in investigating the physiology of disease development and treatment outcomes. In this study, a combined magnetic resonance imaging and computational fluid dynamics approach was used to quantify pulsatile flow fields, wall shear stress (WSS), oscillations in WSS (OSI), and energy efficiency in six subject-specific models of the human pulmonary vasculature with high spatial and temporal resolution. Averaging over all subjects, WSS was found to increase from 19.8±4.0 to 51.8±6.7 dynes/cm2, and OSI was found to decrease from 0.094±0.016 to 0.081±0.015 in the proximal pulmonary arteries between rest and exercise conditions (p<0.05). These findings demonstrate the localized, biomechanical effects of exercise. Furthermore, an average decrease of 10% in energy efficiency was noted between rest and exercise. These data indicate the amount of energy dissipation that typically occurs with exercise and may be useful in future surgical planning applications.
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Affiliation(s)
- Beverly T Tang
- Department of Mechanical Engineering, Stanford University, Stanford, CA 94305-5431, USA
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Adatia I, Kothari SS, Feinstein JA. Pulmonary Hypertension Associated With Congenital Heart Disease. Chest 2010; 137:52S-61S. [DOI: 10.1378/chest.09-2861] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Singhal S, Yousuf MA, Weintraub NL, Shizukuda Y. Use of bicycle exercise echocardiography for unexplained exertional dyspnea. Clin Cardiol 2010; 32:302-6. [PMID: 19569067 DOI: 10.1002/clc.20593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Unexplained exertional dyspnea is a common and perplexing clinical problem. Myocardial ischemia and left ventricular systolic dysfunction are important cardiac causes, but are often not detected in these patients. Recently, exercise-induced left ventricular diastolic dysfunction and exercised-induced pulmonary hypertension have emerged as common alternative mechanisms. While conventional exercise treadmill echocardiography effectively diagnoses left ventricular systolic dysfunction and myocardial ischemia, it has limited ability to detect exercise-induced diastolic dysfunction or pulmonary hypertension. The latest advances in exercise echocardiography, including utilization of tissue Doppler imaging and harmonic imaging, make noninvasive evaluation of both conventional and alternative cardiac causes of exertional dyspnea possible. These advancements, when coupled with newly designed supine exercise platforms for bicycle exercise echocardiography (BE), facilitate the detection of exercise-induced diastolic dysfunction and pulmonary hypertension. Moreover, BE using supine ergometry additionally permits the dynamic evaluation of valvular function and interatrial shunting and detection of pulmonary arteriovenous fistula, uncommon but important causes of unexplained exertional dyspnea. Therefore, we propose that because of its superior diagnostic capabilities, BE should be included as part of a comprehensive cardiac evaluation of patients with unexplained exertional dyspnea.
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Affiliation(s)
- Shalabh Singhal
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio 45236, USA
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Kulik T, Mullen M, Adatia I. Pulmonary arterial hypertension associated with congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2009. [DOI: 10.1016/j.ppedcard.2009.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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9
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Marsden AL, Bernstein AJ, Reddy VM, Shadden SC, Spilker RL, Chan FP, Taylor CA, Feinstein JA. Evaluation of a novel Y-shaped extracardiac Fontan baffle using computational fluid dynamics. J Thorac Cardiovasc Surg 2009; 137:394-403.e2. [PMID: 19185159 DOI: 10.1016/j.jtcvs.2008.06.043] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 04/01/2008] [Accepted: 06/15/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The objective of this work is to evaluate the hemodynamic performance of a new Y-graft modification of the extracardiac conduit Fontan operation. The performance of the Y-graft design is compared to two designs used in current practice: a t-junction connection of the venae cavae and an offset between the inferior and superior venae cavae. METHODS The proposed design replaces the current tube grafts used to connect the inferior vena cava to the pulmonary arteries with a Y-shaped graft. Y-graft hemodynamics were evaluated at rest and during exercise with a patient-specific model from magnetic resonance imaging data together with computational fluid dynamics. Four clinically motivated performance measures were examined: Fontan pressures, energy efficiency, inferior vena cava flow distribution, and wall shear stress. Two variants of the Y-graft were evaluated: an "off-the-shelf" graft with 9-mm branches and an "area-preserving" graft with 12-mm branches. RESULTS Energy efficiency of the 12-mm Y-graft was higher than all other models at rest and during exercise, and the reduction in efficiency from rest to exercise was improved by 38%. Both Y-graft designs reduced superior vena cava pressures during exercise by as much as 5 mm Hg. The Y-graft more equally distributed the inferior vena cava flow to both lungs, whereas the offset design skewed 70% of the flow to the left lung. The 12-mm graft resulted in slightly larger regions of low wall shear stress than other models; however, minimum shear stress values were similar. CONCLUSIONS The area-preserving 12-mm Y-graft is a promising modification of the Fontan procedure that should be clinically evaluated. Further work is needed to correlate our performance metrics with clinical outcomes, including exercise intolerance, incidence of protein-losing enteropathy, and thrombus formation.
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Affiliation(s)
- Alison L Marsden
- Mechanical and Aerospace Engineering Department, University of California, San Diego, Calif, USA
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Remillard CV, Yuan JXJ. Characterization of Hemodynamics in Patients with Idiopathic and Thromboembolic Pulmonary Hypertension. CLINICAL MEDICINE. CIRCULATORY, RESPIRATORY AND PULMONARY MEDICINE 2008. [DOI: 10.4137/ccrpm.s696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Demographic and hemodynamic data from patients with idiopathic pulmonary arterial hypertension (IPAH) and chronic thromboembolic pulmonary hypertension (CTEPH) have not been systematically characterized to identify differences related to gender, age, race, disease severity, and drug response. Our goal was to define the distribution and relation of IPAH and CTEPH based on these criteria. Hemodynamic and demographic data from 242 IPAH patients and 90 CTEPH patients were collected and compared. IPAH incidence was greater in women, but men had a higher basal mean pulmonary arterial pressure (mPAP). mPAP was comparable among all IPAH ethnic groups. IPAH patients with no history of fenfluramine-phentermine use had a higher mPAP than users. Exercise-induced IPAH was apparent in 14.5% of IPAH patients. Only 9% of IPAH patients responded to inhaled nitric oxide with a ≥20% decrease in mPAP. Compared to CTEPH patients, mPAP was greater but average age of diagnosis was lower in IPAH patients. mPAP negatively correlated with age of diagnosis in IPAH patients only. These results indicate that elevated CO is not the main determinant of mPAP in both IPAH and CTEPH patients. However, the two patient groups differ in terms of their demographic and hemodynamic distributions, and according to the correlation between mPAP and other clinical hemodynamics and demographics.
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Affiliation(s)
- Carmelle V. Remillard
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA 92093-0725
| | - Jason X.-J. Yuan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA 92093-0725
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Marsden AL, Vignon-Clementel IE, Chan FP, Feinstein JA, Taylor CA. Effects of Exercise and Respiration on Hemodynamic Efficiency in CFD Simulations of the Total Cavopulmonary Connection. Ann Biomed Eng 2006; 35:250-63. [PMID: 17171509 DOI: 10.1007/s10439-006-9224-3] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 10/23/2006] [Indexed: 10/23/2022]
Abstract
Congenital heart defects with a single functional ventricle, such as hypoplastic left heart syndrome and tricuspid atresia, require a staged surgical approach to separate the systemic and pulmonary circulations. Ultimately, the venous or pulmonary side of the heart is bypassed by directly connecting the vena cava to the pulmonary arteries with a modified t-shaped junction. The Fontan procedure (total cavopulmonary connection, TCPC) completes this process of separation. To date, computational fluid dynamics (CFD) simulations in this low pressure, passive flow, intrathoracic system have neglected the presumed important effects of respiration on physiology and higher "stress" states such as with exercise have never been considered. We hypothesize that incorporating effects of respiration and exercise would provide more realistic estimates of TCPC performance. Time-dependent, 3D blood flow simulations are performed by a custom finite element solver for two patient-specific Fontan models with a novel respiration model, developed to generate physiologic time-varying flow conditions. Blood flow features, pressure, and energy efficiency are analyzed at rest and with increasing flow rates to simulate exercise conditions. The simulations produce realistic pressure and flow data, comparable to that measured by catheterization and echocardiography, and demonstrate substantial increases in energy dissipation (i.e. decreased performance) with exercise and respiration due to increasing intensity of small scale vortices in the flow. As would be expected, these changes are highly dependent on patient-specific anatomy and Fontan geometry. We propose that respiration and exercise should be incorporated into TCPC CFD simulations to provide increasingly realistic evaluations of TCPC performance.
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Affiliation(s)
- Alison L Marsden
- Pediatrics Department, Stanford University, Clark Center E350, Stanford, CA 94305, USA.
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PHYSICAL ACTIVITY AND CONGENITAL HEART DISEASE. Nurs Clin North Am 1994. [DOI: 10.1016/s0029-6465(22)02737-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Congenital heart defects arise in approximately 1% of all live births, independent of ethnic and geographical considerations. With the development of new surgical procedures and current technologies a large number of these heart lesions can be surgically corrected in infancy. In the majority of cases patients evaluated some 10 to 20 years after surgery are asymptomatic and can lead a normal life. Despite their satisfactory clinical outcome patients may, nevertheless, show an abnormal pattern of physiological responses when submitted to dynamic exercise. This paper reviews the scientific literature concerning the exercise capabilities and the cardiorespiratory adjustments to exercise in patients surgically corrected for 4 of the most common congenital heart lesions: isolated atrial septal defect, isolated ventricular septal defects, pulmonary stenosis and tetralogy of Fallot. The maximal exercise tolerance of postoperative congenital heart defect patients may usually be related to: (a) the age of the patients at the time of surgery; (b) the severity of the lesions remaining after surgery; and (c) the age of the patients at the time of investigation. Although normal maximal exercise capabilities may be found in a good number of patients operated for either of the 4 lesions considered, this does not imply normal exercise haemodynamics. A general observation made in these 4 groups of patients is that of a subnormal exercise cardiac output which may or may not be fully compensated by an increase in peripheral oxygen extraction. The limitation in exercising cardiac output may, in turn, be attributed to either a subnormal stroke volume or a limitation in the chronotropic response to exercise or a combination of both factors. Residual pulmonary stenosis, increased pulmonary vascular resistance, increased myocardial stiffness are all factors that may contribute to the cardiac output limitation. A thorough explanation of underlying causes for the abnormal haemodynamic response to exercise, however, still remains to be provided.
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Affiliation(s)
- H Perrault
- Department of Physical Education, McGill University, Montreal, Quebec, Canada
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Bush A, Busst C, Knight WB, Shinebourne EA. Modification of pulmonary hypertension secondary to congenital heart disease by prostacyclin therapy. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1987; 136:767-9. [PMID: 3307574 DOI: 10.1164/ajrccm/136.3.767] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We have shown that PGI2 is a powerful but not selective pulmonary vasodilator, and we believe that there is a role for PGI2 in pulmonary vascular disease secondary to congenital heart disease, but much work remains to be done, including comparisons of PGI2 with other vasodilators. The role of PGI2 in altering the cellular and chemical events producing pulmonary vascular disease secondary to congenital heart disease, and any role in long-term treatment, is largely unexplored.
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Abstract
Although there is widespread acceptance that some children with congenital or acquired heart disease need exercise proscription, there is little data on which to base recommendations. In this article, the author, after reviewing the hemodynamic burdens of the common cardiac anomalies in children, gives his personal recommendations for recreational and sports activities.
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