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van Hassel G, Rivrud SCS, Timmerman FJ, van der Meer P, Hoendermis ES, Liem ET, Berger RMF, van Melle JP. Iron deficiency in patients with a Fontan circulation and its impact on exercise capacity. Open Heart 2024; 11:e002693. [PMID: 38839367 PMCID: PMC11163596 DOI: 10.1136/openhrt-2024-002693] [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: 03/28/2024] [Accepted: 05/08/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Iron deficiency (ID) has been reported in patients with congenital heart disease. There is, however, a scarcity of data on its prevalence in patients with a Fontan circulation. The aim of this study is to investigate the prevalence of ID in Fontan patients and to investigate the association between ID and exercise capacity in this population. METHODS AND RESULTS Blood count and haematological parameters were determined in plasma of 61 Fontan patients (51% female, mean age 29±9 years). ID was defined as transferrin saturation (TSAT) ≤19.8%. The prevalence of ID was 36% (22/61 patients). Especially among women, the diagnosis of ID was highly prevalent (52%) despite normal haemoglobin levels (153.7±18.4 g/L). Mean ferritin levels were 98±80 µg/L and mean TSAT levels were 22%±12%. Cardiopulmonary exercise testing was performed in 46 patients (75%). Patients with ID had a lower peak oxygen uptake (V̇O2peak) (1397±477 vs 1692±530 mL/min; p=0.039), although this relationship was confounded by sex. The presence of ID increased the likelihood of not achieving a respiratory exchange ratio (RER) ≥1.1 by 5-fold (p=0.035). CONCLUSION ID is highly prevalent among patients with a Fontan circulation. V̇O2peak is lower in patients with ID. Fontan patients with ID are less likely to achieve an RER≥1.1 during cardiopulmonary exercise testing.
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Affiliation(s)
- Gaston van Hassel
- Center for Congential Heart Diseases, Department of Paediatric Cardiology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sean C S Rivrud
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank J Timmerman
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Elke S Hoendermis
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Eryn T Liem
- Center for Congential Heart Diseases, Department of Paediatric Cardiology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rolf M F Berger
- Center for Congential Heart Diseases, Department of Paediatric Cardiology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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2
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Carey PM, Yeh HW, Krzywda K, Teson KM, Watson JS, Goudar S, Forsha D, White DA. Moderators of peak respiratory exchange ratio during exercise testing in children and adolescents with Fontan physiology. Cardiol Young 2023; 33:2334-2341. [PMID: 36776115 DOI: 10.1017/s1047951123000227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
OBJECTIVES Many patients with Fontan physiology are unable to achieve the minimum criteria for peak effort during cardiopulmonary exercise testing. The purpose of this study is to determine the influence of physical activity and other clinical predictors related to achieving peak exercise criteria, signified by respiratory exchange ratio ≥ 1.1 in youth with Fontan physiology. METHODS Secondary analysis of a cross-sectional study of 8-18-year-olds with single ventricle post-Fontan palliation who underwent cardiopulmonary exercise testing (James cycle protocol) and completed a past-year physical activity survey. Bivariate associations were assessed by Wilcoxon rank-sum test and simple regression. Conditional inference forest algorithm was used to classify participants achieving respiratory exchange ratio > 1.1 and to predict peak respiratory exchange ratio. RESULTS Of the n = 43 participants, 65% were male, mean age was 14.0 ± 2.4 years, and 67.4% (n = 29) achieved respiratory exchange ratio ≥ 1.1. Despite some cardiopulmonary exercise stress test variables achieving statistical significance in bivariate associations with participants achieving respiratory exchange ratio > 1.1, the classification accuracy had area under the precision recall curve of 0.55. All variables together explained 21.4% of the variance in respiratory exchange ratio, with peak oxygen pulse being the most informative. CONCLUSION Demographic, physical activity, and cardiopulmonary exercise test measures could not classify meeting peak exercise criteria (respiratory exchange ratio ≥ 1.1) at a satisfactory accuracy. Correlations between respiratory exchange ratio and oxygen pulse suggest the augmentation of stroke volume with exercise may affect the Fontan patient's ability to sustain high-intensity exercise.
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Affiliation(s)
- Patricia M Carey
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | - Hung-Wen Yeh
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, USA
- Division of Health Services & Outcomes Research, Children's Mercy Research Institute, Kansas City, MO, USA
| | - Karoline Krzywda
- Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Kelli M Teson
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, USA
- Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Jessica S Watson
- Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Suma Goudar
- Children's National Heart Institute, Washington D.C., USA
| | - Daniel Forsha
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, USA
- Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA
| | - David A White
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, USA
- Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA
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3
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Illinger V, Materna O, Slabý K, Jičínská D, Kovanda J, Koubský K, Pokorný J, Procházka M, Antonová P, Hoskovec A, Radvanský J, Chaloupecký V, Janoušek J. Exercise capacity after total cavopulmonary anastomosis: a longitudinal paediatric and adult study. ESC Heart Fail 2021; 9:337-344. [PMID: 34894102 PMCID: PMC8788045 DOI: 10.1002/ehf2.13747] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/16/2021] [Accepted: 11/18/2021] [Indexed: 11/09/2022] Open
Abstract
AIMS Fontan palliation is a surgical strategy for patients with complex congenital heart disease, in whom biventricular circulation cannot be achieved. Long-term survival is negatively affected by the absence of sub-pulmonary ventricle and increased systemic venous pressure. Exercise capacity is a known predictor of overall survival and quality of life in congenital heart defects. We aim to track individual trends of peak oxygen uptake (V̇O2 peak) after total cavopulmonary connection (TCPC), identify predictors of deterioration, and derive a disease-specific reference V̇O2 peak dataset. METHODS AND RESULTS A retrospective study of serial cardiopulmonary exercise testing (CPET) data, gathered from all patients who underwent TCPC in the Czech Republic between 1992 and 2016. Of 354 consecutive patients with TCPC, 288 (81.4%) patients underwent one or more CPETs yielding 786 unique V̇O2 peak values used as a reference dataset. Longitudinal data were available in 206 (58.2%) patients, who underwent a median (inter-quartile range) of 3.0 (2.0-5.0) CPETs over a mean (standard deviation) of 8.9 (5.5) years. The decline of exercise capacity with age was linear and not faster than in healthy peers (P = 0.47), but relative values of V̇O2 peak in TCPC patients were 12.6 mL/min/kg lower. Single ventricular morphology and pulmonary artery size had no significant influence on the exercise capacity dynamics. V̇O2 peak decline correlated negatively with the trend of body mass index z-score (P = 0.006) and was faster in women than men (P = 0.008). CONCLUSIONS Total cavopulmonary connection patients have significantly reduced exercise capacity. The age-related decline paralleled the healthy population and correlated negatively with the body mass index trend. The presented V̇O2 peak reference dataset may help the clinicians to grade the severity of exercise capacity impairment in individual TCPC patients.
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Affiliation(s)
- Vojtěch Illinger
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague 5, 150 06, Czech Republic
| | - Ondřej Materna
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Kryštof Slabý
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague 5, 150 06, Czech Republic
| | - Denisa Jičínská
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Jan Kovanda
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Karel Koubský
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Jan Pokorný
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague 5, 150 06, Czech Republic
| | - Michal Procházka
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague 5, 150 06, Czech Republic
| | - Petra Antonová
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Antonín Hoskovec
- Department of Physics, Faculty of Nuclear Sciences and Physical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Jiří Radvanský
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague 5, 150 06, Czech Republic
| | - Václav Chaloupecký
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Jan Janoušek
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
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Harris KC, Mackie AS, Dallaire F, Khoury M, Singer J, Mahle WT, Klassen TP, McCrindle BW. Unique Challenges of Randomised Controlled Trials in Pediatric Cardiology. Can J Cardiol 2021; 37:1394-1403. [PMID: 34186112 DOI: 10.1016/j.cjca.2021.06.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 02/07/2023] Open
Abstract
Pediatric cardiology has evolved over time with reductions in childhood mortality due to congenital heart disease. Surgical innovation drove early changes in care. Increasingly, the need for more robust evidence provided by randomised controlled trials (RCTs) has been recognised. Although the number of RCTs has increased, there remains a relative paucity of truly impactful trials in the field. However, those trials that have changed practice have demonstrated the potential and importance of this work. Examples include the PRIMACORP trial, which established the safety and efficacy of milrinone after cardiac surgery, and the Single Ventricle Reconstruction trial, which was the first multicentre pediatric cardiac surgical RCT. The successful conduct and important findings emanating from these trials serve as beacons as clinicians strive to improve the evidence base in this field. The establishment of national and international networks such as the Pediatric Heart Network and the Canadian Pediatric Cardiology Research Network provide a strong foundation for future collaborative work. Despite this progress, there remain important challenges to designing and executing RCTs in pediatric cardiology. These include issues of greater disease and patient heterogeneity and increased costs. The use of innovative study designs and analytic methods and the establishment of core outcome measures have the potential to overcome some of the issues related to the smaller patient numbers compared with adult disciplines. As pediatric cardiologists look to the future, it is imperative that we work together to derive the maximum benefit from the considerable efforts directed toward conducting impactful clinical trials in pediatric cardiology.
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Affiliation(s)
- Kevin C Harris
- Children's Heart Centre, British Columbia Children's Hospital &-University of British Columbia, Vancouver, British Columbia, Canada.
| | - Andrew S Mackie
- Division of Pediatric Cardiology, Department of Pediatrics Stollery Children's Hospital. University of Alberta, Edmonton, Alberta, Canada
| | - Frederic Dallaire
- Division of Pediatric Cardiology, Department of Pediatrics, Sherbrooke University, Sherbrooke, Québec, Canada
| | - Michael Khoury
- Division of Pediatric Cardiology, Department of Pediatrics Stollery Children's Hospital. University of Alberta, Edmonton, Alberta, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - William T Mahle
- Division of Pediatric Cardiology, Emory University, Atlanta, Georgia, USA
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba and Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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5
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Is Neurodevelopment Related to Exercise Capacity in Single Ventricle Patients Who Have Undergone Fontan Palliation? Pediatr Cardiol 2021; 42:408-416. [PMID: 33190162 DOI: 10.1007/s00246-020-02497-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 11/07/2020] [Indexed: 10/23/2022]
Abstract
Survivors of palliative surgery for single ventricle heart disease (SVHD) are at risk of poor neurodevelopmental outcomes and reduced exercise capacity. In healthy populations, reduced exercise capacity is related to decreased cognition suggesting a possible relationship between exercise capacity and neurodevelopment. Using cardiopulmonary exercise testing (CPET) and neuropsychological testing (NPT) as indicators of exercise capacity and neurodevelopment, respectively, we hypothesized that in SVHD, higher CPET measures are related to better NPT performance. Patients were retrospectively identified. CPET variables included VO2max, anaerobic threshold, peak heart rate, ventilatory efficiency, and respiratory exchange ratio. NPT instruments were divided into domains measuring attention, executive functioning, adaptive functioning, and emotional functioning. Linear regression was used to test for associations between CPET and NPT. 23 subjects with SVHD met inclusion criteria. On both CPET and NPT, the cohort scored worse than healthy, age-matched subjects. Higher VO2max and anaerobic threshold were associated with better parent-rated overall adaptive functioning (p = 0.01 and p = 0.02, respectively). Higher peak heart rate was related to better sustained visual attention (p = 0.01). In SVHD, CPET measures indicating better exercise capacity were positively associated with a subset of scores on NPT. Larger, multisite studies implementing cardiorespiratory fitness intervention and incorporating cognitive outcome measures will be needed to better characterize the relationship between neurodevelopment and functional capacity in this population. Results may assist in providing anticipatory guidance and optimizing post-Fontan developmental trajectories.
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6
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Marshall KH, D'Udekem Y, Sholler GF, Opotowsky AR, Costa DSJ, Sharpe L, Celermajer DS, Winlaw DS, Newburger JW, Kasparian NA. Health-Related Quality of Life in Children, Adolescents, and Adults With a Fontan Circulation: A Meta-Analysis. J Am Heart Assoc 2020; 9:e014172. [PMID: 32172648 PMCID: PMC7335513 DOI: 10.1161/jaha.119.014172] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background People with a Fontan circulation experience a range of physical, psychosocial and neurodevelopmental challenges alongside, or caused by, their cardiac condition, with significant consequences for health‐related quality of life (HRQOL). We meta‐analyzed HRQOL outcomes reported by people with a Fontan circulation or their proxies and evaluated predictors of poorer HRQOL. Methods and Results Six electronic databases were searched for peer‐reviewed, English‐language articles published before March 2019. Standardized mean differences (SMD) were calculated using fixed and random‐effects models. Fifty articles reporting on 29 unique studies capturing HRQOL outcomes for 2793 people with a Fontan circulation and 1437 parent‐proxies were analyzed. HRQOL was lower in individuals with a Fontan circulation compared with healthy referents or normative samples (SMD, −0.92; 95% CI, −1.36 to −0.48; P<0.001). Lower scores were reported across all HRQOL domains, with the largest differences found for physical (SMD, −0.90; 95% CI, −1.13 to −0.67; P<0.001) and school/work functioning (SMD, −0.71; 95% CI, −0.90 to −0.52; P<0.001). Meta‐regression analyses found no significant predictors of self‐reported physical functioning, but older age at Fontan operation was associated with poorer emotional functioning (β=−0.124; P=0.004), and diagnosis of hypoplastic left heart was associated with poorer social functioning (β=−0.007; P=0.048). Sensitivity analyses showed use of the PedsQL Core Module was associated with lower HRQOL scores compared with the Short‐Form Health Survey‐36. Conclusions HRQOL outcomes for people with a Fontan circulation are lower than the general population. Optimal care acknowledges the lifelong impact of the Fontan circulation on HRQOL and offers targeted strategies to improve outcomes for this growing population.
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Affiliation(s)
- Kate H Marshall
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Discipline of Paediatrics School of Women's and Children's Health University of New South Wales Medicine The University of New South Wales Sydney New South Wales Australia
| | - Yves D'Udekem
- Heart Research Group Murdoch Children's Research Institute Melbourne Victoria Australia.,Department of Cardiac Surgery The Royal Children's Hospital Melbourne Victoria Australia
| | - Gary F Sholler
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Sydney Medical School The University of Sydney New South Wales Australia
| | - Alexander R Opotowsky
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio United States.,Cincinnati Adult Congenital Heart Disease Program Heart Institute Cincinnati Children's Hospital Cincinnati Ohio United States.,Department of Cardiology Boston Children's Hospital Boston Massachusetts United States.,Harvard Medical School Boston Massachusetts United States
| | - Daniel S J Costa
- Sydney Medical School The University of Sydney New South Wales Australia.,Pain Management Research Institute Royal North Shore Hospital Sydney New South Wales Australia
| | - Louise Sharpe
- School of Psychology The University of Sydney New South Wales Australia
| | - David S Celermajer
- Sydney Medical School The University of Sydney New South Wales Australia.,Department of Cardiology Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - David S Winlaw
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Sydney Medical School The University of Sydney New South Wales Australia
| | - Jane W Newburger
- Department of Cardiology Boston Children's Hospital Boston Massachusetts United States.,Harvard Medical School Boston Massachusetts United States
| | - Nadine A Kasparian
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Discipline of Paediatrics School of Women's and Children's Health University of New South Wales Medicine The University of New South Wales Sydney New South Wales Australia.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio United States.,Cincinnati Children's Center for Heart Disease and the Developing Mind Heart Institute and Division of Behavioral Medicine & Clinical Psychology Cincinnati Children's Hospital Cincinnati Ohio United States
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7
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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O’Byrne ML, McBride M, Paridon S, Goldmuntz E. Association of Habitual Activity and Body Mass Index in Survivors of Congenital Heart Surgery: A Study of Children and Adolescents With Tetralogy of Fallot, Transposition of the Great Arteries, and Fontan Palliation. World J Pediatr Congenit Heart Surg 2018; 9:177-184. [PMID: 29544424 PMCID: PMC6154798 DOI: 10.1177/2150135117752122] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Obesity is associated with increased lifelong morbidity and reduced life span and is increasingly prevalent in the congenital heart disease population. Habitual exercise is an important aspect of a healthy lifestyle and primary prevention of obesity in the general population. The association between habitual activity and body mass index (BMI) has not been studied in children with congenital heart disease. METHODS A cross-sectional analysis of two previously collected cohorts was performed, including participants 8 to 18 years old with tetralogy of Fallot, transposition of the great arteries, and single ventricle heart disease after a Fontan operation. The association between BMI and duration of habitual exercise (measured by questionnaire) was studied. Secondary analyses assessing the effect of other possible factors for BMI were performed. RESULTS In total, 172 participants were studied (45% Tetralogy of Fallot, 12% transposition of the great arteries, and 43% Fontan). Median BMI was 18.2, and 29% of the participants were obese or overweight. Median habitual exercise was 5.9 h/wk. Thirty-eight percent of participants reported having their activity restricted by their cardiologist. Increasing exercise duration was associated with lower BMI ( P = .01) in univariate analysis. In secondary analyses, restriction to mild exertion and participation in low-intensity exercise were both associated with increased BMI. CONCLUSION Increased habitual activity was associated with lower BMI, emphasizing the potential role of recreational sport in the health of children with congenital heart disease.
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Affiliation(s)
- Michael L O’Byrne
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia PA
- Leonard Davis Institute, The University of Pennsylvania, Philadelphia PA
| | - Michael McBride
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Stephen Paridon
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Elizabeth Goldmuntz
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
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9
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Bokma JP, Geva T, Sleeper LA, Babu Narayan SV, Wald R, Hickey K, Jansen K, Wassall R, Lu M, Gatzoulis MA, Mulder BJ, Valente AM. A propensity score-adjusted analysis of clinical outcomes after pulmonary valve replacement in tetralogy of Fallot. Heart 2017; 104:738-744. [PMID: 29092913 DOI: 10.1136/heartjnl-2017-312048] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/09/2017] [Accepted: 10/16/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To determine the association of pulmonary valve replacement (PVR) with death and sustained ventricular tachycardia (VT) in patients with repaired tetralogy of Fallot (rTOF). METHODS Subjects with rTOF and cardiac magnetic resonance from an international registry were included. A PVR propensity score was created to adjust for baseline differences. PVR consensus criteria were predefined as pulmonary regurgitation >25% and ≥2 of the following criteria: right ventricular (RV) end-diastolic volume >160 mL/m2, RV end-systolic volume >80 mL/m2, RV ejection fraction (EF) <47%, left ventricular EF <55% and QRS duration >160 ms. The primary outcome included (aborted) death and sustained VT. The secondary outcome included heart failure, non-sustained VT and sustained supraventricular tachycardia. RESULTS In 977 rTOF subjects (age 26±15 years, 45% PVR, follow-up 5.3±3.1 years), the primary and secondary outcomes occurred in 41 and 88 subjects, respectively. The HR for subjects with versus without PVR (time-varying covariate) was 0.65 (95% CI 0.31 to 1.36; P=0.25) for the primary outcome and 1.43 (95% CI 0.83 to 2.46; P=0.19) for the secondary outcome after adjusting for propensity and other factors. In subjects (n=426) not meeting consensus criteria, the HR for subjects with (n=132) versus without (n=294) PVR was 2.53 (95% CI 0.79 to 8.06; P=0.12) for the primary outcome and 2.31 (95% CI 1.07 to 4.97; P=0.03) for the secondary outcome. CONCLUSION In this large multicentre rTOF cohort, PVR was not associated with a reduced rate of death and sustained VT at an average follow-up of 5.3 years. Additionally, there were more events after PVR compared with no PVR in subjects not meeting consensus criteria.
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Affiliation(s)
- Jouke P Bokma
- Department of Cardiology, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands.,Netherlands Heart Institute, Utrecht, Netherlands
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sonya V Babu Narayan
- Department of Adult Congenital Heart Disease, Royal Brompton Hospital, London, UK
| | - Rachel Wald
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Kelsey Hickey
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Katrijn Jansen
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Rebecca Wassall
- Department of Adult Congenital Heart Disease, Royal Brompton Hospital, London, UK
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael A Gatzoulis
- Department of Adult Congenital Heart Disease, Royal Brompton Hospital, London, UK
| | - Barbara Jm Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands.,Netherlands Heart Institute, Utrecht, Netherlands
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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10
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Pediatric Exercise Testing: Value and Implications of Peak Oxygen Uptake. CHILDREN-BASEL 2017; 4:children4010006. [PMID: 28125022 PMCID: PMC5296667 DOI: 10.3390/children4010006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 12/15/2016] [Accepted: 01/17/2017] [Indexed: 01/26/2023]
Abstract
Peak oxygen uptake (peakV˙O2) measured by clinical exercise testing is the benchmark for aerobic fitness. Aerobic fitness, estimated from maximal treadmill exercise, is a predictor of mortality in adults. PeakV˙O2 was shown to predict longevity in patients aged 7–35 years with cystic fibrosis over 25 years ago. A surge of exercise studies in young adults with congenital heart disease over the past decade has revealed significant prognostic information. Three years ago, the first clinical trial in children with pulmonary arterial hypertension used peakV˙O2 as an endpoint that likewise delivered clinically relevant data. Cardiopulmonary exercise testing provides clinicians with biomarkers and clinical outcomes, and researchers with novel insights into fundamental biological mechanisms reflecting an integrated physiological response hidden at rest. Momentum from these pioneering observations in multiple disease states should impel clinicians to employ similar methods in other patient populations; e.g., sickle cell disease. Advances in pediatric exercise science will elucidate new pathways that may identify novel biomarkers. Our initial aim of this essay is to highlight the clinical relevance of exercise testing to determine peakV˙O2, and thereby convince clinicians of its merit, stimulating future clinical investigators to broaden the application of exercise testing in pediatrics.
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Ishigami S, Ohtsuki S, Eitoku T, Ousaka D, Kondo M, Kurita Y, Hirai K, Fukushima Y, Baba K, Goto T, Horio N, Kobayashi J, Kuroko Y, Kotani Y, Arai S, Iwasaki T, Sato S, Kasahara S, Sano S, Oh H. Intracoronary Cardiac Progenitor Cells in Single Ventricle Physiology: The PERSEUS (Cardiac Progenitor Cell Infusion to Treat Univentricular Heart Disease) Randomized Phase 2 Trial. Circ Res 2017; 120:1162-1173. [PMID: 28052915 DOI: 10.1161/circresaha.116.310253] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/29/2016] [Accepted: 01/03/2017] [Indexed: 12/15/2022]
Abstract
RATIONALE Patients with single ventricle physiology are at high risk of mortality resulting from ventricular dysfunction. The preliminary results of the phase 1 trial showed that cardiosphere-derived cells (CDCs) may be effective against congenital heart failure. OBJECTIVE To determine whether intracoronary delivery of autologous CDCs improves cardiac function in patients with single ventricle physiology. METHODS AND RESULTS We conducted a phase 2 randomized controlled study to assign in a 1:1 ratio 41 patients who had single ventricle physiology undergoing stage 2 or 3 palliation to receive intracoronary infusion of CDCs 4 to 9 weeks after surgery or staged reconstruction alone (study A). The primary outcome measure was to assess improvement in cardiac function at 3-month follow-up. Four months after palliation, controls had an alternative option to receive late CDC infusion on request (study B). Secondary outcomes included ventricular function, heart failure status, somatic growth, and health-related quality of life after a 12-month observation. At 3 months, the absolute changes in ventricular function were significantly greater in the CDC-treated group than in the controls (+6.4% [SD, 5.5] versus +1.3% [SD, 3.7]; P=0.003). In study B, a late CDC infusion in 17 controls increased the ventricular function at 3 months compared with that at baseline (38.8% [SD, 7.7] versus 34.8% [SD, 7.4]; P<0.0001). At 1 year, overall CDC infusion was associated with improved ventricular function (41.4% [SD, 6.6] versus 35.0% [SD, 8.2]; P<0.0001) and volumes (P<0.001), somatic growth (P<0.0001) with increased trophic factors production, such as insulin-like growth factor-1 and hepatocyte growth factor, and quality of life, along with a reduced heart failure status (P<0.0001) and cardiac fibrosis (P=0.014) relative to baseline. CONCLUSIONS Intracoronary infusion of CDCs after staged palliation favorably affected cardiac function by reverse remodeling in patients with single ventricle physiology. This impact may improve heart failure status, somatic growth, and quality of life in patients and reduce parenting stress for their families. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01829750.
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Affiliation(s)
- Shuta Ishigami
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Shinichi Ohtsuki
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Takahiro Eitoku
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Daiki Ousaka
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Maiko Kondo
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Yoshihiko Kurita
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Kenta Hirai
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Yosuke Fukushima
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Kenji Baba
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Takuya Goto
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Naohiro Horio
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Junko Kobayashi
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Yosuke Kuroko
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Yasuhiro Kotani
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Sadahiko Arai
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Tatsuo Iwasaki
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Shuhei Sato
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Shingo Kasahara
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Shunji Sano
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.)
| | - Hidemasa Oh
- From the Departments of Cardiovascular Surgery (S.I., D.O., T.G., N.H., J.K., Y. Kuroko, Y. Kotani, S.A., S.K., S. Sano), Pediatrics (S.O., T.E., M.K., Y. Kurita, K.H., Y.F., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S. Sato), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan; and Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital, Japan (H.O.).
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12
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Margossian R, Sleeper LA, Pearson GD, Barker PC, Mertens L, Quartermain MD, Su JT, Shirali G, Chen S, Colan SD. Assessment of Diastolic Function in Single-Ventricle Patients After the Fontan Procedure. J Am Soc Echocardiogr 2016; 29:1066-1073. [PMID: 27624592 PMCID: PMC5302850 DOI: 10.1016/j.echo.2016.07.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with functional single ventricles after the Fontan procedure have abnormal cardiac mechanics. The aims of this study were to determine factors that influence diastolic function and to describe associations of diastolic function with current clinical status. METHODS Echocardiograms were obtained as part of the Pediatric Heart Network Fontan Cross-Sectional Study. Diastolic function grade (DFG) was assessed as normal (grade 0), impaired relaxation (grade 1), pseudonymization (grade 2), or restrictive (grade 3). Studies were also classified dichotomously (restrictive pattern present or absent). Relationships between DFG and pre-Fontan variables (e.g., ventricular morphology, age at Fontan, history of volume-unloading surgery) and current status (e.g., systolic function, valvar regurgitation, exercise performance) were explored. RESULTS DFG was calculable in 326 of 546 subjects (60%) (mean age, 11.7 ± 3.3 years). Overall, 32% of patients had grade 0, 9% grade 1, 37% grade 2, and 22% grade 3 diastolic function. Although there was no association between ventricular morphology and DFG, there was an association between ventricular morphology and E', which was lowest in those with right ventricular morphology (P < .001); this association remained significant when using Z scores adjusted for age (P < .001). DFG was associated with achieving maximal effort on exercise testing (P = .004); the majority (64%) of those not achieving maximal effort had DFG 2 or 3. No additional significant associations of DFG with laboratory or clinical measures were identified. CONCLUSIONS Assessment of diastolic function by current algorithms results in a high percentage of patients with abnormal DFG, but few clinically or statistically significant associations were found. This may imply a lack of impact of abnormal diastolic function on clinical outcomes in this cohort, or it may indicate that the methodology may not be applicable to pediatric patients with functional single ventricles.
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Affiliation(s)
- Renee Margossian
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Lynn A Sleeper
- New England Research Institutes, Watertown, Massachusetts
| | - Gail D Pearson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Luc Mertens
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Jason T Su
- University of Utah, Salt Lake City, Utah
| | - Girish Shirali
- Medical University of South Carolina, Charleston, South Carolina
| | - Shan Chen
- New England Research Institutes, Watertown, Massachusetts
| | - Steven D Colan
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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13
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Knowles RL, Tadic V, Hogan A, Bull C, Rahi JS, Dezateux C. Self-Reported Health Experiences of Children Living with Congenital Heart Defects: Including Patient-Reported Outcomes in a National Cohort Study. PLoS One 2016; 11:e0159326. [PMID: 27487183 PMCID: PMC4972252 DOI: 10.1371/journal.pone.0159326] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 06/30/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Understanding children's views about living with congenital heart defects (CHDs) is fundamental to supporting their successful participation in daily life, school and peer relationships. As an adjunct to a health and quality of life outcomes questionnaire, we asked school-age children who survived infant heart procedures to describe their experiences of living with CHDs. METHODS In a UK-wide cohort study, children aged 10 to 14 years with CHDs self-completed postal questionnaires that included an open question about having a 'heart problem'. We compared the characteristics of children with more and less severe cardiac diagnoses and, through collaborative inductive content analysis, investigated the subjective experiences and coping strategies described by children in both clinical severity groups. RESULTS Text and/or drawings were returned by 436 children (246 boys [56%], mean age 12.1 years [SD 1.0; range 10-14]); 313 had less severe (LS) and 123 more severe (MS) cardiac diagnoses. At the most recent hospital visit, a higher proportion of the MS group were underweight (more than two standard deviations below the mean for age) or cyanosed (underweight: MS 20.0%, LS 9.9%; cyanosed: MS 26.2%, LS 3.5%). Children in the MS group described concerns about social isolation and feeling 'different', whereas children with less severe diagnoses often characterised their CHD as 'not a big thing'. Some coping strategies were common to both severity groups, including managing health information to avoid social exclusion, however only children in the LS group considered their CHD 'in the past' or experienced a sense of survivorship. CONCLUSIONS Children's reported experiences were not dependent on their cardiac diagnosis, although there were clear qualitative differences by clinical severity group. Children's concerns emphasised social participation and our findings imply a need to shift the clinical focus from monitoring cardiac function to optimising participation. We highlight the potential for informing and evaluating clinical practice and service provision through seeking patient-reported outcomes in paediatric care.
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Affiliation(s)
- Rachel Louise Knowles
- Life Course Epidemiology and Biostatistics Section, Population Policy and Practice Programme, UCL Institute of Child Health, University College London, London, United Kingdom
| | - Valerija Tadic
- Life Course Epidemiology and Biostatistics Section, Population Policy and Practice Programme, UCL Institute of Child Health, University College London, London, United Kingdom
| | - Ailbhe Hogan
- Life Course Epidemiology and Biostatistics Section, Population Policy and Practice Programme, UCL Institute of Child Health, University College London, London, United Kingdom
| | - Catherine Bull
- Cardiac Unit, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - Jugnoo Sangeeta Rahi
- Life Course Epidemiology and Biostatistics Section, Population Policy and Practice Programme, UCL Institute of Child Health, University College London, London, United Kingdom
| | - Carol Dezateux
- Life Course Epidemiology and Biostatistics Section, Population Policy and Practice Programme, UCL Institute of Child Health, University College London, London, United Kingdom
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Uzark K, Zak V, Shrader P, McCrindle BW, Radojewski E, Varni JW, Daniels K, Handisides J, Hill KD, Lambert LM, Margossian R, Pemberton VL, Lai WW, Atz AM. Assessment of Quality of Life in Young Patients with Single Ventricle after the Fontan Operation. J Pediatr 2016; 170:166-72.e1. [PMID: 26685073 PMCID: PMC4769899 DOI: 10.1016/j.jpeds.2015.11.016] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/12/2015] [Accepted: 11/05/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To assess self-reported quality of life (QOL) in a large multicenter cohort of adolescent and young adults surviving Fontan. STUDY DESIGN Cross-sectional. The Pediatric Quality of Life Inventory (PedsQL) was administered to 408 survivors of Fontan ages 13-25 years enrolled in the Pediatric Heart Network Fontan Follow-up Study. Subjects also completed either the Child Health Questionnaire (age <19 years) or Short Form Health Survey (age ≥ 19 years). PedsQL data were compared with matched controls without a chronic health condition. Correlations between the measures were examined. RESULTS Mean PedsQL scores for subjects receiving Fontan were significantly lower than those for the control group for physical and psychosocial QOL (P < .001). Overall, 45% of subjects receiving Fontan had scores in the clinically significant impaired range for physical QOL with 30% in the impaired range for psychosocial QOL. For each 1 year increase in age, the physical functioning score decreased by an average of 0.76 points (P = .004) and the emotional functioning score decreased by an average of 0.64 points (P = .03). Among subjects ≥19 years of age, the physical functioning score decreased by an average of 2 points for each year increase in age (P = .02). PedsQL scale scores were significantly correlated with conceptually related Child Health Questionnaire (P < .001) and Short Form Health Survey scores (P < .001). CONCLUSIONS Survivors of Fontan are at risk for significantly impaired QOL which may decline with advancing age. Routine assessment of QOL is essential to inform interventions to improve health outcomes. The PedsQL allowed QOL assessment from pediatrics to young adulthood. TRIAL REGISTRATION ClinicalTrials.gov: NCT00132782.
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Affiliation(s)
- Karen Uzark
- University of Michigan Mott Children's Hospital, Ann Arbor, MI.
| | - Victor Zak
- New England Research Institutes, Watertown, MA
| | | | - Brian W McCrindle
- University of Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | - Wyman W Lai
- Columbia University Medical Center, New York, NY
| | - Andrew M Atz
- Medical University of South Carolina, Charleston, SC
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Abstract
PURPOSE It is important to identify those children with a Fontan circulation who are at risk for impaired health-related quality of life. We aimed to determine the predictive value of functional health status - medical history and present medical status - on both physical and psychosocial domains of health-related quality of life, as reported by patients themselves and their parents. METHODS We carried out a prospective cross-sectional multi-centre study in Fontan patients aged between 8 and 15, who had undergone staged completion of total cavopulmonary connection according to a current technique before the age of 7 years. Functional health status was assessed as medical history - that is, age at Fontan, type of Fontan, ventricular dominance, and number of cardiac surgical procedures - and present medical status - assessed with magnetic resonance imaging, exercise testing, and rhythm assessment. Health-related quality of life was assessed with The TNO/AZL Child Questionnaire Child Form and Parent Form. RESULTS In multivariate prediction models, several medical history variables, such as more operations post-Fontan completion, lower age at Fontan completion, and dominant right ventricle, and present medical status variables, such as smaller end-diastolic volume, a higher score for ventilatory efficiency, and the presence of sinus node dysfunction, predicted worse outcomes on several parent-reported and self-reported physical as well as psychosocial health-related quality of life domains. CONCLUSIONS Medical history and worse present medical status not only predicted worse physical parent-reported and self-reported health-related quality of life but also worse psychosocial health-related quality of life and subjective cognitive functioning. These findings will help in identifying patients who are at risk for developing impaired health-related quality of life.
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Transcoronary infusion of cardiac progenitor cells in hypoplastic left heart syndrome: Three-year follow-up of the Transcoronary Infusion of Cardiac Progenitor Cells in Patients With Single-Ventricle Physiology (TICAP) trial. J Thorac Cardiovasc Surg 2015; 150:1198-1207, 1208.e1-2. [PMID: 26232942 DOI: 10.1016/j.jtcvs.2015.06.076] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/26/2015] [Accepted: 06/14/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Our aim was to assess midterm safety and clinical outcomes of intracoronary infusion of cardiosphere-derived cells (CDCs) after staged palliation in patients with hypoplastic left heart syndrome (HLHS). METHODS In this prospective, controlled study, 14 consecutive patients with HLHS who were undergoing 2- or 3-stage surgical palliations were assigned to receive intracoronary CDC infusion 1 month after cardiac surgery (n = 7), followed by 7 patients allocated to a control group with standard care alone. The primary end point was to assess procedural feasibility and safety; the secondary end point was to evaluate cardiac function and heart failure status through 36-month follow-up. RESULTS No complications, including tumor formation, were reported within 36 months after CDC infusion. Echocardiography showed significantly greater improvement in right ventricular ejection fraction (RVEF) in infants receiving CDCs than in controls at 36 months (+8.0% ± 4.7% vs +2.2% ± 4.3%; P = .03). These cardiac function improvements resulted in reduced brain natriuretic peptide levels (P = .04), lower incidence of unplanned catheter interventions (P = .04), and higher weight-for-age z score (P = .02) at 36 months relative to controls. As independent predictors of treatment responsiveness, absolute changes in RVEF at 36 months were negatively correlated with age, weight-for-age z score, and RVEF at CDC infusion. CONCLUSIONS Intracoronary CDC infusion after staged procedure in patients with HLHS is safe and improves RVEF, which persists during 36-month follow-up. This therapeutic strategy may enhance somatic growth and reduce incidence of heart failure.
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Ishigami S, Ohtsuki S, Tarui S, Ousaka D, Eitoku T, Kondo M, Okuyama M, Kobayashi J, Baba K, Arai S, Kawabata T, Yoshizumi K, Tateishi A, Kuroko Y, Iwasaki T, Sato S, Kasahara S, Sano S, Oh H. Intracoronary autologous cardiac progenitor cell transfer in patients with hypoplastic left heart syndrome: the TICAP prospective phase 1 controlled trial. Circ Res 2014; 116:653-64. [PMID: 25403163 DOI: 10.1161/circresaha.116.304671] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
RATIONALE Hypoplastic left heart syndrome (HLHS) remains a lethal congenital cardiac defect. Recent studies have suggested that intracoronary administration of autologous cardiosphere-derived cells (CDCs) may improve ventricular function. OBJECTIVE The aim of this study was to test whether intracoronary delivery of CDCs is feasible and safe in patients with hypoplastic left heart syndrome. METHODS AND RESULTS Between January 5, 2011, and January 16, 2012, 14 patients (1.8±1.5 years) were prospectively assigned to receive intracoronary infusion of autologous CDCs 33.4±8.1 days after staged procedures (n=7), followed by 7 controls with standard palliation alone. The primary end point was to assess the safety, and the secondary end point included the preliminary efficacy to verify the right ventricular ejection fraction improvements between baseline and 3 months. Manufacturing and intracoronary delivery of CDCs were feasible, and no serious adverse events were reported within the 18-month follow-up. Patients treated with CDCs showed right ventricular ejection fraction improvement from baseline to 3-month follow-up (46.9%±4.6% to 52.1%±2.4%; P=0.008). Compared with controls at 18 months, cardiac MRI analysis of CDC-treated patients showed a higher right ventricular ejection fraction (31.5%±6.8% versus 40.4%±7.6%; P=0.049), improved somatic growth (P=0.0005), reduced heart failure status (P=0.003), and lower incidence of coil occlusion for collaterals (P=0.007). CONCLUSIONS Intracoronary infusion of autologous CDCs seems to be feasible and safe in children with hypoplastic left heart syndrome after staged surgery. Large phase 2 trials are warranted to examine the potential effects of cardiac function improvements and the long-term benefits of clinical outcomes. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01273857.
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Affiliation(s)
- Shuta Ishigami
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Shinichi Ohtsuki
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Suguru Tarui
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Daiki Ousaka
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Takahiro Eitoku
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Maiko Kondo
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Michihiro Okuyama
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Junko Kobayashi
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Kenji Baba
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Sadahiko Arai
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Takuya Kawabata
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Ko Yoshizumi
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Atsushi Tateishi
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Yosuke Kuroko
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Tatsuo Iwasaki
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Shuhei Sato
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Shingo Kasahara
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Shunji Sano
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan
| | - Hidemasa Oh
- From the Departments of Cardiovascular Surgery (S.I., S.T., D.O., M.O., J.K., S.A., T.K., K.Y., A.T., Y.K., S.K., S.S.), Pediatrics (S.O., T.E., M.K., K.B.), Anesthesiology and Resuscitology (T.I.), and Radiology (S.S.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; and Department of Regenerative Medicine, Center for Innovative Clinical Medicine, Okayama University Hospital (H.O.), Okayama, Japan.
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Functional health status in children and adolescents after Fontan: comparison of generic and disease-specific assessments. Cardiol Young 2014; 24:469-77. [PMID: 23746330 PMCID: PMC4068336 DOI: 10.1017/s1047951113000632] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
PURPOSE The aim of this study was to compare associations between generic versus disease-specific functional health status assessments and patient and clinical characteristics for patients with severe congenital heart disease. METHODS This was a cross-sectional observational study involving 325 single ventricle patients, aged 10-18 years, after Fontan procedure. Enrolled patients underwent a medical history review, laboratory testing, and assessment of the functional health status by completion of the generic Child Report Child Health Questionnaire and the disease-specific Congenital Heart Adolescent and Teenage questionnaire. Correlated conceptually equivalent domains from both questionnaires were identified and their associations with patient and clinical variables were compared. RESULTS From the generic assessment, patients perceived marginally lower physical functioning (p = 0.05) but greater freedom from bodily pain compared with a normal population (p < 0.001). The equivalent physical functioning/limitations domain of the generic instrument, compared with the disease-specific instrument, had similar associations (higher multi-variable model R²) with medical history variables (R² = 0.14 versus R² = 0.12, respectively) and stronger associations with exercise testing variables (R² = 0.22 versus R² = 0.06). Similarly, the corresponding freedom from bodily pain/symptoms domains from both questionnaires showed a greater association for the generic instrument with medical history variables (R² = 0.15 versus R² = 0.09, respectively) and non-cardiac conditions (R² = 0.13 versus R² = 0.06). The associations of each questionnaire with echocardiographic results, cardiac magnetic resonance imaging results, and serum brain natriuretic peptide levels were uniformly weak (R² range <0.01 to 0.04). CONCLUSIONS Assessment of the physical functional health status using generic and disease-specific instruments yields few differences with regard to associations between conceptually similar domains and patient and clinical characteristics for adolescents after Fontan procedure.
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McCrindle BW, Zak V, Breitbart RE, Mahony L, Shrader P, Lai WW, Burns KM, Colan SD, Williams RV, Goldberg D, Hill KD, Khaikin S, Atz AM. The relationship of patient medical and laboratory characteristics to changes in functional health status in children and adolescents after the Fontan procedure. Pediatr Cardiol 2014; 35:632-40. [PMID: 24264999 PMCID: PMC3959245 DOI: 10.1007/s00246-013-0831-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 10/26/2013] [Indexed: 10/26/2022]
Abstract
Despite hypothesized concerns about deterioration beginning in adolescence, longitudinal data and associated factors regarding standardized assessment of physical functioning are not available for Fontan patients. Parents who participated in the Fontan Cross-Sectional Study completed the Child Health Questionnaire at 2 time points for 245 subjects ages 6-18 years. Associations between change in Physical Functioning Summary Score and baseline patient, medical, and laboratory characteristics (mean age 9.5 ± 1.7 years) and follow-up patient and medical characteristics (mean age 16.2 ± 1.6 years) were determined by regression analyses. During a mean of 6.7 ± 0.4 years, a small (not clinically important) but statistically significant decrease in score from 46.2 ± 11.7 to 44.5 ± 12.1 (p < 0.03) was noted. Subjects with higher baseline scores had a greater decrease in score (r = -0.48; p < 0.001). A multivariable model of patient and medical characteristics (R(2) = 0.11) showed that a greater decrease in score was significantly associated with interim development of asthma (n = 13; parameter estimate [PE] -6.6; p < 0.05) or other chronic respiratory, lung, or breathing problems (n = 13; PE -12.5; p < 0.001) and the presence of protein-losing enteropathy at any time (n = 12; PE -9.4; p = 0.006). Change in score was not significantly associated with baseline laboratory measures of exercise capacity and ventricular characteristics and function. Therefore, although physical functioning may be stable during adolescence for many Fontan patients, deterioration occurs in some in association with respiratory conditions and protein-losing enteropathy. Further longitudinal study is necessary to better understand the relationship between clinical morbidities and functional health status as these patients transition into adulthood.
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Affiliation(s)
| | - Victor Zak
- New England Research Institutes, Watertown, MA
| | | | - Lynn Mahony
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Wyman W. Lai
- Columbia University Medical Center, New York, NY
| | | | | | | | | | | | - Svetlana Khaikin
- University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Andrew M. Atz
- Medical University of South Carolina, Charleston, SC
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Rathod RH, Prakash A, Kim YY, Germanakis IE, Powell AJ, Gauvreau K, Geva T. Cardiac magnetic resonance parameters predict transplantation-free survival in patients with fontan circulation. Circ Cardiovasc Imaging 2014; 7:502-9. [PMID: 24619103 DOI: 10.1161/circimaging.113.001473] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Several clinical risk factors for death and heart transplantation have been identified in patients with Fontan circulation. It is unknown whether cardiac magnetic resonance (CMR) measurements of ventricular size and function are independently associated with these outcomes and further improve risk stratification. METHODS AND RESULTS Data on patients with Fontan circulation who had a CMR study from January 2002 to January 2011 were retrospectively reviewed. The end point was time to death or listing for heart transplantation after the CMR study. The median age of the 215 patients was 18.3 years (25th, 75th percentiles: 14, 26) with a median age at Fontan of 3.6 years (2.3, 7.1). During a median post-CMR follow-up period of 4.1 years (2.6, 6.2), 24 patients (11%) reached the end point: 20 deaths, 3 transplantations, and 1 transplantation listing. In a multivariable Cox regression model with clinical parameters only, protein-losing enteropathy was associated with death or listing for transplant. A multivariable model, including clinical and CMR parameters, showed that in addition to protein-losing enteropathy, ventricular indexed end-diastolic volume >125 mL/body surface area raised to the 1.3 power was associated with the endpoint. A likelihood-ratio test comparing the 2 models showed that the addition of indexed end-diastolic volume resulted in a significantly improved end point prediction (P<0.001)-C-index increased from 0.63 to 0.79. CONCLUSIONS CMR-derived ventricular indexed end-diastolic volume is an independent predictor of death or transplant in patients late after the Fontan operation and adds incremental value over clinical symptoms alone for risk stratification.
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Affiliation(s)
- Rahul H Rathod
- From the Department of Cardiology, Boston Children's Hospital, Boston, MA; and Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Ashwin Prakash
- From the Department of Cardiology, Boston Children's Hospital, Boston, MA; and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Yuli Y Kim
- From the Department of Cardiology, Boston Children's Hospital, Boston, MA; and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Ioannis E Germanakis
- From the Department of Cardiology, Boston Children's Hospital, Boston, MA; and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Andrew J Powell
- From the Department of Cardiology, Boston Children's Hospital, Boston, MA; and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- From the Department of Cardiology, Boston Children's Hospital, Boston, MA; and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Tal Geva
- From the Department of Cardiology, Boston Children's Hospital, Boston, MA; and Department of Pediatrics, Harvard Medical School, Boston, MA
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Buber J, Rhodes J. Exercise Physiology and Testing in Adult Patients with Congenital Heart Disease. Heart Fail Clin 2014; 10:23-33. [DOI: 10.1016/j.hfc.2013.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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CHEN CHUNAN, CHEN SSUYUAN, CHIU HSINHUI, WANG JOUKOU, CHANG CHUNGI, CHIU INGSH, CHEN YIHSHARNG, LU CHUNWEI, LIN MINGTAI, LUE HUNGCHI, HUA YUCHUAN, WU MEIHWAN. Prognostic Value of Submaximal Exercise Data for Cardiac Morbidity in Fontan Patients. Med Sci Sports Exerc 2014; 46:10-5. [DOI: 10.1249/mss.0b013e31829f8326] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Latus H, Gummel K, Diederichs T, Bauer A, Rupp S, Kerst G, Jux C, Akintuerk H, Schranz D, Apitz C. Aortopulmonary collateral flow is related to pulmonary artery size and affects ventricular dimensions in patients after the fontan procedure. PLoS One 2013; 8:e81684. [PMID: 24303064 PMCID: PMC3841134 DOI: 10.1371/journal.pone.0081684] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 10/15/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Aortopulmonary collaterals (APCs) are frequently found in patients with a single-ventricle (SV) circulation. However, knowledge about the clinical significance of the systemic-to-pulmonary shunt flow in patients after the modified Fontan procedure and its potential causes is limited. Accordingly, the aim of our study was to detect and quantify APC flow using cardiovascular magnetic resonance (CMR) and assess its impact on SV volume and function as well as to evaluate the role of the size of the pulmonary arteries in regard to the development of APCs. METHODS 60 patients (mean age 13.3 ± 6.8 years) after the Fontan procedure without patent tunnel fenestration underwent CMR as part of their routine clinical assessment that included ventricular functional analysis and flow measurements in the inferior vena cava (IVC), superior vena cava (SVC) and ascending aorta (Ao). APC flow was quantified using the systemic flow estimator: (Ao) - (IVC + SVC). Pulmonary artery index (Nakata index) was calculated as RPA + LPA area/body surface area using contrast enhanced MR angiography. The patient cohort was divided into two groups according to the median APC flow: group 1 < 0.495 l/min/m(2) and group 2 > 0.495 l/min/m(2). RESULTS Group 1 patients had significant smaller SV enddiastolic (71 ± 16 vs 87 ± 25 ml/m(2); p=0.004) and endsystolic volumes (29 ± 11 vs 40 ± 21 ml/m(2); p=0.02) whereas ejection fraction (59 ± 9 vs 56 ± 13%; p=0.38) differed not significantly. Interestingly, pulmonary artery size showed a significant inverse correlation with APC flow (r=-0.50, p=0.002). CONCLUSIONS Volume load due to APC flow in Fontan patients affected SV dimensions, but did not result in an impairment of SV function. APC flow was related to small pulmonary artery size, suggesting that small pulmonary arteries represent a potential stimulus for the development of APCs.
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Affiliation(s)
- Heiner Latus
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
- * E-mail:
| | - Kerstin Gummel
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Tristan Diederichs
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Anna Bauer
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Stefan Rupp
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Gunter Kerst
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Christian Jux
- Department of Pediatric Cardiology, University Children’s Hospital Muenster, Muenster, Germany
| | - Hakan Akintuerk
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Christian Apitz
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
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Idorn L, Juul K, Jensen A, Hanel B, Nielsen K, Andersen H, Reimers J, Sørensen K, Søndergaard L. Arrhythmia and exercise intolerance in Fontan patients: Current status and future burden. Int J Cardiol 2013; 168:1458-65. [DOI: 10.1016/j.ijcard.2012.12.055] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 12/01/2012] [Accepted: 12/24/2012] [Indexed: 10/27/2022]
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Dulfer K, Helbing WA, Duppen N, Utens EMWJ. Associations between exercise capacity, physical activity, and psychosocial functioning in children with congenital heart disease: a systematic review. Eur J Prev Cardiol 2013; 21:1200-15. [PMID: 23787793 DOI: 10.1177/2047487313494030] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Children and adolescents operated upon for congenital heart disease (ConHD) may show reduced exercise capacity and physical activity, possibly associated with lowered self-esteem and quality of life (QoL). The studies into associations between these parameters have not been reviewed before. OBJECTIVE Review of studies into associations between exercise capacity, physical activity, respectively exercise training, and psychosocial functioning of ConHD youngsters. DATA SOURCES PubMed, Embase and reference lists of related articles. STUDY SELECTION Articles published between January 2000 and December 2012 into exercise capacity and/or physical activity, and a measure of psychosocial functioning in children with ConHD. DATA EXTRACTION Two investigators independently reviewed the identified articles for eligibility, and one author extracted the data. RESULTS Although exercise capacity was strongly related to physical domains of parent-reported and self-reported QoL, it was almost never associated with psychosocial domains of QoL. Physical activity was rarely associated with physical or psychosocial domains of QoL. Remarkably, self-reported depressive symptoms were associated with both physical and psychosocial QoL. The few studies into exercise-training programmes showed promising results in QoL and emotional and behavioral problems, but they contained methodological flaws. CONCLUSIONS No clear relationships were found between exercise capacity, physical activity, and QoL in children and adolescents with ConHD. Therefore we recommend assessing QoL separately, preferably both self-reported and parent-reported. Since depressive symptoms were associated with reduced physical and psychosocial QoL, screening on these symptoms is also recommended.
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Affiliation(s)
- Karolijn Dulfer
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Willem A Helbing
- Department of Paediatrics, Division of Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nienke Duppen
- Department of Paediatrics, Division of Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elisabeth M W J Utens
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
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Atz AM, Travison TG, McCrindle BW, Mahony L, Glatz AC, Kaza AK, Breitbart RE, Colan SD, Kaltman JR, Margossian R, Pasquali SK, Wang Y, Gersony WM. Cardiac performance and quality of life in patients who have undergone the Fontan procedure with and without prior superior cavopulmonary connection. Cardiol Young 2013; 23:335-43. [PMID: 22824161 PMCID: PMC3578173 DOI: 10.1017/s1047951112001175] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND A superior cavopulmonary connection is commonly performed before the Fontan procedure in patients with a functionally univentricular heart. Data are limited regarding associations between a prior superior cavopulmonary connection and functional and ventricular performance late after the Fontan procedure. METHODS We compared characteristics of those with and without prior superior cavopulmonary connection among 546 subjects enrolled in the Pediatric Heart Network Fontan Cross-Sectional Study. We further compared different superior cavopulmonary connection techniques: bidirectional cavopulmonary anastomosis (n equals 229), bilateral bidirectional cavopulmonary anastomosis (n equals 39), and hemi-Fontan (n equals 114). RESULTS A prior superior cavopulmonary connection was performed in 408 subjects (75%); the proportion differed by year of Fontan surgery and centre (p-value less than 0.0001 for each). The average age at Fontan was similar, 3.5 years in those with superior cavopulmonary connection versus 3.2 years in those without (p-value equals 0.4). The type of superior cavopulmonary connection varied by site (p-value less than 0.001) and was related to the type of Fontan procedure. Exercise performance, echocardiographic variables, and predominant rhythm did not differ by superior cavopulmonary connection status or among superior cavopulmonary connection types. Using a test of interaction, findings did not vary according to an underlying diagnosis of hypoplastic left heart syndrome. CONCLUSIONS After controlling for subject and era factors, most long-term outcomes in subjects with a prior superior cavopulmonary connection did not differ substantially from those without this procedure. The type of superior cavopulmonary connection varied significantly by centre, but late outcomes were similar.
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Affiliation(s)
- Andrew M Atz
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Idorn L, Jensen AS, Juul K, Overgaard D, Nielsen NP, Sørensen K, Reimers JI, Søndergaard L. Quality of life and cognitive function in Fontan patients, a population-based study. Int J Cardiol 2013; 168:3230-5. [PMID: 23632112 DOI: 10.1016/j.ijcard.2013.04.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/22/2013] [Accepted: 04/04/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND After the Fontan procedure patients are at risk for reduced quality of life (QoL) and cognitive function. We aimed to assess these important factors in Danish Fontan patients and to compare the results with a group of healthy controls. METHODS All Fontan patients living in Denmark were identified and invited to participate. QoL was evaluated using the Pediatric Quality of Life Inventory (PedsQL) version 4.0 generic core module in patients <16 years and the Short Form 36 questionnaire (SF-36) in patients ≥16 years. Cognitive function was evaluated in all patients ≥6 years using the Quick Test of Cognitive Speed. To evaluate if QoL correlated with exercise capacity, patients performed a symptom-limited bicycle test. RESULTS 158 of 179 eligible patients (88%) consented to participate. Median age was 13.9 years (IQR: 10.2-19.3). PedsQL scores increased with age but were significantly lower among patients than among controls. SF-36 physical scores were significantly lower in patients compared to controls while psychosocial scores were similar. Cognitive speed was significantly reduced in patients at all ages compared to controls. No significant difference in PedsQL-/SF-36 scores or cognitive speed was found between hypoplastic left heart syndrome (HLHS) and non-HLHS Fontan patient. PedsQL-/SF-36 scores in patients ≥10 years correlated significantly to cognitive speed but not to peak exercise capacity. CONCLUSION QoL is reduced in Fontan children compared to their healthy counterparts whereas in patients ≥16 years only physical, but not psychosocial QoL is reduced. Cognitive speed was significantly lower in patients at all ages compared to controls.
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Affiliation(s)
- Lars Idorn
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
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Karamlou T, Poynter JA, Walters HL, Rhodes J, Bondarenko I, Pasquali SK, Fuller SM, Lambert LM, Blackstone EH, Jacobs ML, Duncan K, Caldarone CA, Williams WG, McCrindle BW. Long-term functional health status and exercise test variables for patients with pulmonary atresia with intact ventricular septum: a Congenital Heart Surgeons Society study. J Thorac Cardiovasc Surg 2013; 145:1018-1027.e3. [PMID: 23374986 DOI: 10.1016/j.jtcvs.2012.11.092] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 10/18/2012] [Accepted: 11/06/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND A bias favoring biventricular (BV) repair exists regarding choice of repair pathway for patients with pulmonary atresia with intact ventricular septum (PAIVS). We sought to determine the implications of moving borderline candidates down a BV route in terms of late functional health status (FHS) and exercise capacity (EC). METHODS Between 1987 and 1997, 448 neonates with PAIVS were enrolled in a multi-institutional study. Late EC and FHS were assessed following repair (mean 14 years) using standardized exercise testing and 3 validated FHS instruments. Relationships between FHS, EC, morphology, and 3 end states (ie, BV, univentricular [UV], or 1.5-ventricle repair [1.5V]) were evaluated. RESULTS One hundred two of 271 end state survivors participated (63 BV, 25 UV, and 14 1.5V). Participants had lower FHS scores in domains of physical functioning (P < .001) compared with age- and sex-matched normal controls, but scored significantly higher in nearly all psychosocial domains. EC was higher in 1.5V-repair patients (P = .02), whereas discrete FHS measures were higher in BV-repair patients. Peak oxygen consumption was low across all groups, and was positively correlated with larger initial tricuspid valve z-score (P < .001), with an enhanced effect within the BV-repair group. CONCLUSIONS Late patient-perceived physical FHS and measured EC are reduced, regardless of PAIVS repair pathway, with an important dichotomy whereby patients with PAIVS believe they are doing well despite important physical impediments. For those with smaller initial tricuspid valve z-score, achievement of survival with BV repair may be at a cost of late deficits in exercise capacity, emphasizing that better outcomes may be achieved for borderline patients with a 1.5V- or UV-repair strategy.
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Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif.
| | - Jeffrey A Poynter
- Division of Cardiovascular Surgery, The Hospital For Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Henry L Walters
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Mich
| | | | - Igor Bondarenko
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Mich
| | - Sara K Pasquali
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Mich
| | - Stephanie M Fuller
- Division of Cardiovascular Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Linda M Lambert
- Department of Pediatric Cardiovascular Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Eugene H Blackstone
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marshall L Jacobs
- Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kim Duncan
- Division of Cardiothoracic Surgery, Children's Hospital and Medical Center, Omaha, Neb
| | - Christopher A Caldarone
- Division of Cardiovascular Surgery, The Hospital For Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - William G Williams
- Division of Cardiovascular Surgery, The Hospital For Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Ehlert N, Hess J, Hager A. Shifts in Exercise Capacity Are Not Reported Adequately in Patients with Congenital Heart Disease. CONGENIT HEART DIS 2012; 7:448-54. [DOI: 10.1111/j.1747-0803.2012.00645.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Circulation: Cardiovascular Imaging
Editors' Picks. Circ Cardiovasc Imaging 2012. [DOI: 10.1161/circimaging.111.972174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The following articles are being highlighted as part of
Circulation: Cardiovascular Imaging
's Topic Review. This series will summarize the most important manuscripts, as selected by the editors, that have been published in the
Circulation
portfolio. The studies included in this article represent the most significant research in the area of congenital heart disease.
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Hövels-Gürich H. Psychomotorische Entwicklung von Kindern mit angeborenem Herzfehler. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2498-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Goldstein BH, Golbus JR, Sandelin AM, Warnke N, Gooding L, King KK, Donohue JE, Gurney JG, Goldberg CS, Rocchini AP, Charpie JR. Usefulness of peripheral vascular function to predict functional health status in patients with Fontan circulation. Am J Cardiol 2011; 108:428-34. [PMID: 21600541 DOI: 10.1016/j.amjcard.2011.03.064] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 03/18/2011] [Accepted: 03/18/2011] [Indexed: 11/30/2022]
Abstract
After the Fontan operation, patients are at a substantial risk of the development of impaired functional health status. Few early markers of suboptimal outcomes have been identified. We sought to assess the association between peripheral vascular function and functional health status in Fontan-palliated patients. Asymptomatic Fontan patients (n = 51) and age- and gender-matched healthy controls (n = 22) underwent endothelial pulse amplitude testing using a noninvasive fingertip peripheral arterial tonometry (PAT) device. Raw data were transformed into the PAT ratio, an established marker of vascular function. Cardiopulmonary exercise testing was performed using the Bruce protocol. In the Fontan cohort, 94% of patients were New York Heart Association functional class I and 88% had a B-type natriuretic peptide level of <50 pg/ml. The baseline pulse amplitude, a measure that reflects the arterial tone at rest, was greater in the Fontan patients than in the controls (median 2.74, interquartile range 1.96 to 4.13 vs median 1.86, interquartile range 1.14 to 2.79, p = 0.03). The PAT ratio, a measure of reactive hyperemia, was lower in Fontan patients (median 0.17, interquartile range -0.04 to 0.44, vs median 0.50, interquartile range 0.27 to 0.74, p = 0.002). The key parameters of exercise performance, including peak oxygen consumption (median 28.8 ml/kg/min, interquartile range 25.6 to 33.2 vs median 45.5 ml/kg/min, interquartile range 41.7 to 49.9, p <0.0001) and peak work (median 192 W, interquartile range 150 to 246 vs median 330, interquartile range 209 to 402 W, p <0.0001), were lower in Fontan patients than in the controls. The PAT ratio correlated with the peak oxygen consumption (r = 0.28, p = 0.02) and peak work (r = 0.26, p = 0.03). In conclusion, in an asymptomatic Fontan population, there is evidence of reduced basal peripheral arterial tone and vasodilator response, suggesting dysfunction of the endothelium-derived nitric oxide pathway. Vasodilator function appears to correlate with exercise performance.
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Affiliation(s)
- Bryan H Goldstein
- Division of Cardiology, Department of Pediatrics, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, USA.
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Li JS, Colan SD, Sleeper LA, Newburger JW, Pemberton VL, Atz AM, Cohen MS, Golding F, Klein GL, Lacro RV, Radojewski E, Richmond ME, Minich LL. Lessons learned from a pediatric clinical trial: the Pediatric Heart Network angiotensin-converting enzyme inhibition in mitral regurgitation study. Am Heart J 2011; 161:233-40. [PMID: 21315203 PMCID: PMC3053082 DOI: 10.1016/j.ahj.2010.10.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 10/19/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mitral regurgitation is the most common indication for reoperation in children following repair of atrioventricular septal defect (AVSD). We hypothesized that angiotensin-converting enzyme inhibitor therapy would decrease the severity of mitral regurgitation and limit left ventricular volume overload in children following AVSD repair. METHODS The Pediatric Heart Network designed a placebo-controlled randomized trial of enalapril in this population. The primary aim was to test the effect of enalapril on the change in left ventricular end-diastolic dimension body surface area-adjusted z score. Before the launch of the trial, a feasibility study was performed to estimate the number of patients with at least moderate mitral regurgitation following AVSD repair. TRIAL EXPERIENCE Seventeen months after the start of the study, 349 patients were screened, 8 were trial eligible, and only 5 were enrolled. The study was subsequently terminated because of low patient accrual. Several factors led to the problems with patient accrual, including (1) the use of criteria to assess disease severity in the feasibility study that were not identical to those used in the trial, (2) failure to achieve equipoise for the study among clinicians and referring physicians, (3) reliance on methodology developed in adult populations with different disease mechanisms, and (4) absence of adequate data to define the natural history of the disease process under study. Progress in the treatment of children with cardiovascular disease will depend on the future of multicenter collaborative clinical trials. The lessons learned from this study may contribute to improvements in this research.
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Rhodes J, Ubeda Tikkanen A, Jenkins KJ. Exercise Testing and Training in Children With Congenital Heart Disease. Circulation 2010; 122:1957-67. [DOI: 10.1161/circulationaha.110.958025] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jonathan Rhodes
- From the Department of Cardiology, Children's Hospital, Boston, Mass (J.R., K.J.J.) and the Departments of Rehabilitation and Pediatric Cardiology, Hospital Gregorio Marañón, Madrid, Spain (A.U.T.)
| | - Ana Ubeda Tikkanen
- From the Department of Cardiology, Children's Hospital, Boston, Mass (J.R., K.J.J.) and the Departments of Rehabilitation and Pediatric Cardiology, Hospital Gregorio Marañón, Madrid, Spain (A.U.T.)
| | - Kathy J. Jenkins
- From the Department of Cardiology, Children's Hospital, Boston, Mass (J.R., K.J.J.) and the Departments of Rehabilitation and Pediatric Cardiology, Hospital Gregorio Marañón, Madrid, Spain (A.U.T.)
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Abstract
PURPOSE OF REVIEW Heart failure is an important problem after surgical correction of congenital heart disease. Timely recognition may be difficult. Recent developments in exercise testing and stress-imaging may change the management of patients with congenital heart disease. RECENT FINDINGS Exercise tests are commonly used in the follow-up of patients with congenital heart disease. Maximal exercise studies are not always feasible in this patient population. Variables of submaximal exercise and ventilator efficiency have shown a good correlation with variables of maximal exercise and have been suggested to relate to long-term cardiac function.For evaluation of submaximal exercise, stress imaging may reveal abnormal responses unrecognized at rest. Both physical exercise as well as pharmacological stress may be used in combination with various imaging modalities. For practical reasons, dobutamine is most widely used to generate and mimic stress and is well tolerated in low doses. Particularly in lesions affecting the right ventricle and with single ventricular physiology after the Fontan operation, magnetic resonance stress imaging has provided additional insight into the cardiac function. SUMMARY The abnormal stress responses can potentially be used for risk assessment in the follow-up of patients with congenital cardiac disease. Further studies are required to provide common protocols for stress imaging.
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