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Clode M, Tran D, Majumdar A, Ayer J, Ferrie S, Cordina R. Nutritional considerations for people living with a Fontan circulation: a narrative review. Cardiol Young 2024; 34:238-249. [PMID: 38258459 DOI: 10.1017/s1047951123004389] [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] [Indexed: 01/24/2024]
Abstract
The population of people living with a Fontan circulation are highly heterogenous, including both children and adults, who have complex health issues and comorbidities associated with their unique physiology throughout life. Research focused on nutritional considerations and interventions in the Fontan population is extremely limited beyond childhood. This review article discusses the current literature examining nutritional considerations in the setting of Fontan physiology and provides an overview of the available evidence to support nutritional management strategies and future research directions. Protein-losing enteropathy, growth deficits, bone mineral loss, and malabsorption are well-recognised nutritional concerns within this population, but increased adiposity, altered glucose metabolism, and skeletal muscle deficiency are also more recently identified issues. Emergencing evidence suggets that abnormal body composition is associated with poor circulatory function and health outcomes. Many nutrition-related issues, including the impact of congenital heart disease on nutritional status, factors contributing to altered body composition and comorbidities, as well as the role of the microbiome and metabolomics, remain poodly understood.
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Affiliation(s)
- Melanie Clode
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Derek Tran
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Heart Research Institute, Newtown, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Avik Majumdar
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
| | - Julian Ayer
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- The Heart Centre for Children, The Sydney Children's Hospital Network, Westmead, NSW, Australia
| | - Suzie Ferrie
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Rachael Cordina
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Heart Research Institute, Newtown, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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2
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Scheffers LE, Helbing WA, Pereira T, Walet S, Utens EMWJ, Dulfer K, van den Berg LE. A 12-week lifestyle intervention: effects on fatigue, fear, and nutritional status in children with a Fontan circulation. Front Pediatr 2023; 11:1154015. [PMID: 38027302 PMCID: PMC10657862 DOI: 10.3389/fped.2023.1154015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 07/26/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Children and adolescents with a Fontan circulation are less physically active compared to healthy peers. In the current study, effects of a 12-week lifestyle intervention on fatigue, fears regarding exercise, caloric intake, rest energy expenditure (REE), and body composition were measured in children with a Fontan circulation. Methods This study was a semi-cross-over randomized controlled trial. The lifestyle intervention consisted of a 12-week high-weight resistance training (three supervised training sessions a week) supported by high-protein diet (>2 g/kg) and tailored recommended caloric intake. Fatigue (measured by the validated PedsQol Multidimensional Fatigue Scale), fears regarding exercise (measured on a fear thermometer), REE (measured using indirect calorimetry), caloric intake and body composition using air displacement plethysmography, and four-skinfold method were measured before and after the intervention and control period. Results Twenty-seven pediatric Fontan patients, median age 12.9 years (IQR: 10.5-16.2), of the included 28 patients successfully completed the program. Before training, both child- and parent-reported levels of fatigue were significantly worse on all domains (general, sleep/rest, and cognitive fatigue) compared to healthy peers. After training, parent-reported fatigue significantly improved on the general and cognitive fatigue domains [effect size +16 points (7-25), p < 0.001, and +10 points (2-17), p = 0.015, compared to the control period]. Before training, fear regarding exercise scored on the fear thermometer was low for both children and parents (median score 1 and 2, respectively, on a scale of 0-8). After training, child-reported fear decreased further compared to the control period [effect size -1.4 points (-2.3 to -0.6), p = 0.001]. At baseline, children had increased REE +12% compared to reference values, which did not change after exercise. Children ate an average of 637 calories below recommended intake based on REE, caloric deficit became smaller after the intervention, and protein intake increased compared to the control period [-388 calories (-674 to -102), p = 0.008, and +15 g (0.4-30), p = 0.044]. Body fat percentage did not change significantly. Conclusion A 12-week lifestyle intervention improved parent-reported fatigue symptoms in the children, further decreased child-reported fears, and increased caloric and protein intake.
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Affiliation(s)
- L. E. Scheffers
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
- Department of Paediatrics, Division of Gastroenterology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
- Respiratory Medicine and Allergology, Department of Paediatrics, University Medical Center, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
- Department of Paediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Rotterdam, Netherlands
| | - W. A. Helbing
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
| | - T. Pereira
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
| | - S. Walet
- Division of Dietetics, Department of Internal Medicine, Erasmus MC, Rotterdam, Netherlands
| | - E. M. W. J. Utens
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
- Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, Netherlands
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center/Levvel, Amsterdam, Netherlands
| | - K. Dulfer
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre Sophia Children’s Hospital, Rotterdam, Netherlands
| | - L. E. van den Berg
- Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, Netherlands
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Aronoff EB, Chin C, Opotowsky AR, Mays WA, Knecht SK, Goessling J, Rice M, Shertzer J, Wittekind SG, Powell AW. Facility-Based and Virtual Cardiac Rehabilitation in Young Patients with Heart Disease During the COVID-19 Era. Pediatr Cardiol 2023:10.1007/s00246-023-03202-0. [PMID: 37294337 DOI: 10.1007/s00246-023-03202-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/30/2023] [Indexed: 06/10/2023]
Abstract
Cardiac rehabilitation (CR) is an important tool for improving fitness and quality of life in those with heart disease (HD). Few pediatric centers use CR to care for these patients, and virtual CR is rarely used. In addition, it is unclear how the COVID-19 era has changed CR outcomes. This study assessed fitness improvements in young HD patients participating in both facility-based and virtual CR during the COVID-19 pandemic. This retrospective single-center cohort study included new patients who completed CR from March 2020 through July 2022. CR outcomes included physical, performance, and psychosocial measures. Comparison between serial testing was performed with a paired t test with P < 0.05 was considered significant. Data are reported as mean ± standard deviation. There were 47 patients (19 ± 7.3 years old; 49% male) who completed CR. Improvements were seen in peak oxygen consumption (VO2, 62.3 ± 16.1 v 71 ± 18.2% of predicted, p = 0.0007), 6-min walk (6 MW) distance (401 ± 163.8 v 480.7 ± 119.2 m, p = < 0.0001), sit to stand (16.2 ± 4.9 v 22.1 ± 6.6 repetitions; p = < 0.0001), Patient Health Questionnaire-9 (PHQ-9) (5.9 ± 4.3 v 4.4 ± 4.2; p = 0.002), and Physical Component Score (39.9 ± 10.1 v 44.9 ± 8.8; p = 0.002). Facility-based CR enrollees were less likely to complete CR than virtual patients (60%, 33/55 v 80%, 12/15; p = 0.005). Increases in peak VO2 (60 ± 15.3 v 70.2 ± 17.8% of predicted; p = 0.002) were seen among those that completed facility-based CR; this was not observed in the virtual group. Both groups demonstrated improvement in 6 MW distance, sit-to-stand repetitions, and sit-and-reach distance. Completion of a CR program resulted in fitness improvements during the COVID-19 era regardless of location, although peak VO2 improved more for the in-person group.
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Affiliation(s)
- Elizabeth B Aronoff
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Clifford Chin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, MLC 2003, Cincinnati, OH, 45229-3026, USA
| | - Alexander R Opotowsky
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, MLC 2003, Cincinnati, OH, 45229-3026, USA
| | - Wayne A Mays
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, MLC 2003, Cincinnati, OH, 45229-3026, USA
| | - Sandra K Knecht
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, MLC 2003, Cincinnati, OH, 45229-3026, USA
| | - Jennah Goessling
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, MLC 2003, Cincinnati, OH, 45229-3026, USA
| | - Malloree Rice
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, MLC 2003, Cincinnati, OH, 45229-3026, USA
| | - Justine Shertzer
- Department of Pediatric Cardiology, The Heart, Vascular, and Thoracic Institute, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Samuel G Wittekind
- Department of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Adam W Powell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, MLC 2003, Cincinnati, OH, 45229-3026, USA.
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Tekerlek H, Saglam M, Kucukdagli AC, Aykan HH, Vardar-Yagli N, Calik-Kutukcu E, Inal-Ince D, Karagoz T. Assessment of exercise capacity using field walking tests in patients after the Fontan procedure: A case-control study. Heart Lung 2023; 60:66-73. [PMID: 36924606 DOI: 10.1016/j.hrtlng.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Despite the frequent use of the 6-minute walk test (6MWT), exercise capacity has not been assessed with the incremental shuttle walk test (ISWT) in patients who have undergone the Fontan procedure. It is unclear whether these tests cause clinically relevant cardiorespiratory responses in these patients. OBJECTIVES We aimed to assess cardiorespiratory responses to the 6MWT and ISWT in Fontan patients, compare the responses with those in the controls, and examine the agreement between the two field tests. METHODS Submaximal exercise capacity was assessed using the 6MWT, maximal exercise capacity using the ISWT, quadriceps isometric muscle strength with a hand dynamometer, and body composition using a bioelectrical impedance device. RESULTS Twenty-one Fontan patients (16.42±6.63 years, 5F/16M) and 21 controls (16.57±4.30 years, 7F/14M) were included. While body composition was similar between the groups (p>0.05), quadriceps isometric muscle strength and 6MWT and ISWT distance were lower in the Fontan patients than in the controls (p<0.05). In both the 6MWT and ISWT, pre- and post-test heart rate (HR), oxygen saturation (SpO2), dyspnea, and leg fatigue differed significantly between the Fontan patients and the controls (p<0.05). In addition, the ISWT resulted in a more significant change in HR, SpO2, and leg fatigue than the 6MWT in the Fontan patients (p<0.05). Bland-Altman plots for the 6MWT vs. the ISWT indicated agreement between the two tests. CONCLUSION There were remarkable changes in HR, SpO2, dyspnea, and leg fatigue in both tests. With similar safety to the 6MWT but with more caution applied for adverse events, the ISWT can also be performed as a field test to evaluate exercise capacity and identify more pronounced exercise-induced responses (especially oxygen desaturation) in Fontan patients.
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Affiliation(s)
- Haluk Tekerlek
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey.
| | - Melda Saglam
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey
| | - Ali Cem Kucukdagli
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Ankara, Turkey
| | - Hayrettin Hakan Aykan
- Hacettepe University, Faculty of Medicine, Department of Pediatric Cardiology, Ankara, Turkey; Hacettepe University, Life Support Center, Ankara, Turkey
| | - Naciye Vardar-Yagli
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey
| | - Ebru Calik-Kutukcu
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey
| | - Deniz Inal-Ince
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey
| | - Tevfik Karagoz
- Hacettepe University, Faculty of Medicine, Department of Pediatric Cardiology, Ankara, Turkey
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Van den Eynde J, Bartelse S, Rijnberg FM, Kutty S, Jongbloed MRM, de Bruin C, Hazekamp MG, Le Cessie S, Roest AAW. Somatic growth in single ventricle patients: A systematic review and meta-analysis. Acta Paediatr 2023; 112:186-199. [PMID: 36200280 PMCID: PMC10092582 DOI: 10.1111/apa.16562] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/17/2022] [Accepted: 10/05/2022] [Indexed: 01/13/2023]
Abstract
AIM To map somatic growth patterns throughout Fontan palliation and summarise evidence on its key modifiers. METHODS Databases were searched for relevant articles published from January 2000 to December 2021. Height and weight z scores at each time point (birth, Glenn procedure, Fontan procedure and >5 years after Fontan completion) were pooled using a random effects meta-analysis. A random effects meta-regression model was fitted to model the trend in z scores over time. RESULTS Nineteen studies fulfilled eligibility criteria, yielding a total of 2006 participants. The z scores for height and weight were markedly reduced from birth to the interstage period, but recovered by about 50% following the Glenn procedure. At >10 years after the Fontan procedure, the z scores for weight seemed to normalise despite persistent lower height, resulting in increased body mass index. The review revealed a number of modifiers of somatic growth, including aggressive nutritional management, timing of Glenn/Fontan, prompt resolution of complications and obesity prevention programmes in adolescence and adulthood. CONCLUSION This review mapped the somatic growth of single ventricle patients and summarised key modifiers that may be amendable to improvement. These data provide guidance on strategies to further optimise somatic growth in this population and may serve as a benchmark for clinical follow-up.
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Affiliation(s)
- Jef Van den Eynde
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiovascular Diseases, KU Leuven, Leuven, Belgium.,Helen B. Taussig Heart Center, Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland, USA
| | - Simone Bartelse
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Shelby Kutty
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Christiaan de Bruin
- Division of Paediatric Endocrinology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Saskia Le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Biomedical Data sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Powell AW, Mays WA, Hill GD. Effects of a zero-gravity treadmill on body composition and cardiorespiratory fitness after Achilles surgery in a Masters runner. SAGE Open Med Case Rep 2023; 11:2050313X231168753. [PMID: 37122426 PMCID: PMC10134111 DOI: 10.1177/2050313x231168753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Zero-gravity treadmills allow alterations in training load. Data are lacking on the utilization of this strategy to allow injured Masters-level athletes to return to activity and regain their fitness. A 6-week training program was designed for a 39-year-old male runner recovering from Achilles surgery using a zero-gravity treadmill. Three training sessions per week were performed with gradually increasing loads. Cardiopulmonary exercise testing and bioelectrical impedance analysis were performed before and after program completion. Following the training program, the athlete was able to return to full weight-bearing running. On cardiopulmonary exercise testing, there were improvements in peak oxygen consumption (42.9 vs 47.3 mL/min/kg; 118.6% vs 130.5% of predicted). On bioelectrical impedance analysis, there were small improvements in total weight, skeletal muscle mass, and adiposity felt to be within the standard of error for bioelectrical impedance analysis. In conclusion, load-altering exercise may be helpful for the Masters-level athlete recovering from Achilles tendon surgery.
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Affiliation(s)
- Adam W Powell
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Adam W Powell, The Heart Institute, Cincinnati Children’s Hospital Medical Center, 3333 Burnett Ave., MLC 2003, Cincinnati, OH 45229-3026, USA.
| | - Wayne A Mays
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Garick D Hill
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Powell AW, Mays WA, Wittekind SG, Chin C, Knecht SK, Lang SM, Opotowsky AR. Stable fitness during COVID-19: Results of serial testing in a cohort of youth with heart disease. Front Pediatr 2023; 11:1088972. [PMID: 36891230 PMCID: PMC9986439 DOI: 10.3389/fped.2023.1088972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/02/2023] [Indexed: 02/22/2023] Open
Abstract
Background Little is known about how sport and school restrictions early during the novel coronavirus 2019 (COVID-19) pandemic impacted exercise performance and body composition in youth with heart disease (HD). Methods A retrospective chart review was performed on all patients with HD who had serial exercise testing and body composition via bioimpedance analysis performed within 12 months before and during the COVID-19 pandemic. Formal activity restriction was noted as present or absent. Analysis was performed with a paired t-test. Results There were 33 patients (mean age 15.3 ± 3.4 years; 46% male) with serial testing completed (18 electrophysiologic diagnosis, 15 congenital HD). There was an increase in skeletal muscle mass (SMM) (24.1 ± 9.2-25.9 ± 9.1 kg, p < 0.0001), weight (58.7 ± 21.5-63.9 ± 22 kg, p < 0.0001), and body fat percentage (22.7 ± 9.4-24.7 ± 10.4%, p = 0.04). The results were similar when stratified by age <18 years old (n = 27) or by sex (male 16, female 17), consistent with typical pubertal changes in this predominantly adolescent population. Absolute peak VO2 increased, but this was due to somatic growth and aging as evidenced by no change in % of predicted peak VO2. There remained no difference in predicted peak VO2 when excluding patients with pre-existing activity restrictions (n = 12). Review of similar serial testing in 65 patients in the 3 years before the pandemic demonstrated equivalent findings. Conclusions The COVID-19 pandemic and related lifestyle changes do not appear to have had substantial negative impacts on aerobic fitness or body composition in children and young adults with HD.
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Affiliation(s)
- Adam W Powell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Wayne A Mays
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Samuel G Wittekind
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Clifford Chin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Sandra K Knecht
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Sean M Lang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Alexander R Opotowsky
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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Wadey CA, Barker AR, Stuart G, Tran DL, Laohachai K, Ayer J, Cordina R, Williams CA. Scaling Peak Oxygen Consumption for Body Size and Composition in People With a Fontan Circulation. J Am Heart Assoc 2022; 11:e026181. [PMID: 36515232 PMCID: PMC9798799 DOI: 10.1161/jaha.122.026181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Peak oxygen consumption (peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$) is traditionally divided ("ratio-scaled") by body mass (BM) for clinical interpretation. Yet, it is unknown whether ratio-scaling to BM can produce a valid size-independent expression of peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$ in people with a Fontan circulation. Furthermore, people with a Fontan circulation have deficits in lean mass, and it is unexplored whether using different measures of body composition may improve scaling validity. The objective was to assess the validity of different scaling denominators (BM, stature, body surface area, fat-free mass, lean mass, and appendicular lean mass using ratio and allometric scaling). Methods and Results Eighty-nine participants (age: 23.3±6.7 years; 53% female) with a Fontan circulation had their cardiorespiratory fitness and body composition measured by cardiopulmonary exercise testing and dual-energy x-ray absorptiometry. Ratio and allometric (log-linear regression) scaling was performed and Pearson correlations assessed scaling validity. Scaling denominators BM (r=-0.25, P=0.02), stature (r=0.46, P<0.001), and body surface area (0.23, P=0.03) were significantly correlated with their respective ratio-scaled expressions of peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$, but fat-free mass, lean mass, or appendicular lean mass were not (r≤0.11; R2=1%). Allometrically expressed peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$ resulted in no significant correlation with any scaling denominator (r=≤0.23; R2=≤4%). Conclusions The traditional and accepted method of ratio-scaling to BM is invalid because it fails to create a size-independent expression of peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$ in people with a Fontan circulation. However, ratio-scaling to measures of body composition (fat-free mass, lean mass, and appendicular lean mass) and allometric techniques can produce size-independent expressions of peak V̇O2$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$ in people with a Fontan circulation.
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Affiliation(s)
- Curtis A. Wadey
- Children’s Health & Exercise Research Centre (CHERC)Public Health and Sport Science, Faculty of Health and Life Sciences, University of ExeterExeterUnited Kingdom
| | - Alan R. Barker
- Children’s Health & Exercise Research Centre (CHERC)Public Health and Sport Science, Faculty of Health and Life Sciences, University of ExeterExeterUnited Kingdom
| | - Graham Stuart
- Bristol Congenital Heart Centre, The Bristol Heart Institute, University Hospitals Bristol NHS Foundation TrustBristolUnited Kingdom
| | - Derek L. Tran
- Central Clinical School, The University of SydneyCamperdownNew South Wales,Department of CardiologyRoyal Prince Alfred HospitalCamperdownNew South Wales,Heart Research Institute, Charles Perkins Centre, The University of SydneyCamperdownNew South Wales
| | - Karina Laohachai
- Central Clinical School, The University of SydneyCamperdownNew South Wales,Department of CardiologyRoyal Prince Alfred HospitalCamperdownNew South Wales,Heart Research Institute, Charles Perkins Centre, The University of SydneyCamperdownNew South Wales
| | - Julian Ayer
- Central Clinical School, The University of SydneyCamperdownNew South Wales,Department of CardiologyRoyal Prince Alfred HospitalCamperdownNew South Wales,Heart Research Institute, Charles Perkins Centre, The University of SydneyCamperdownNew South Wales
| | - Rachael Cordina
- Central Clinical School, The University of SydneyCamperdownNew South Wales,Department of CardiologyRoyal Prince Alfred HospitalCamperdownNew South Wales,Heart Research Institute, Charles Perkins Centre, The University of SydneyCamperdownNew South Wales
| | - Craig A. Williams
- Children’s Health & Exercise Research Centre (CHERC)Public Health and Sport Science, Faculty of Health and Life Sciences, University of ExeterExeterUnited Kingdom
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Avitabile CM, McBride MG, Zhang X, Ampah S, Goldstein BH, Alsaied T, Wittekind SG, Whitehead KK, Zemel BS, Paridon SM. Peak Work Rate Increases With Lower Extremity-Focused Exercise Training in Adolescents With Fontan Circulation. J Am Heart Assoc 2022; 11:e027464. [PMID: 36515264 PMCID: PMC9798796 DOI: 10.1161/jaha.122.027464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Skeletal muscle deficits are associated with worse exercise performance in the Fontan circulation and may be improved by exercise training. We aimed to assess the change in leg lean mass (a marker of skeletal muscle), exercise performance, and functional health status after a lower extremity-focused exercise intervention in adolescents with Fontan circulation. Methods and Results Densitometry for measurement of leg lean mass, cardiopulmonary exercise test, exercise cardiac magnetic resonance, peripheral vascular testing, physical activity questionnaire, and quality of life assessment were performed at baseline and after a 24-week, hybrid center- and home-based training program. Leg lean mass Z-scores were generated, and exercise parameters were expressed as percentage expected based on reference data. The effect of training was assessed by paired t-tests and simple linear regression. Twenty participants (15.6±1.7 years, 50% male) demonstrated low baseline leg lean mass Z-scores with no significant improvement with training (-1.38±1.02 pre versus -1.31±1.06 post, P=0.33). Maximum and percent predicted work increased from 121.9±29.8 (0.66±0.12) to 131.3±35.1 (0.70±0.15) watts (P=0.02). Peak respiratory exchange ratio increased (1.19±0.02 versus 1.25±0.01, P=0.02) but percent predicted oxygen consumption was unchanged, suggesting higher anaerobic activity after training. Physical activity questionnaire score positively associated with peak work at baseline (ß=18.13 [95% CI, 0.83-35.44], R2=0.21; P=0.04) but physical activity questionnaire, quality of life scores, exercise cardiac magnetic resonance performance, and peripheral vascular function were unchanged with training. Conclusions Peak work rate and anaerobic activity increased with lower extremity-focused training in adolescents with Fontan circulation. Larger studies should test the impact of these changes on functional status and quality of life.
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Affiliation(s)
- Catherine M. Avitabile
- Department of PediatricsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA,Division of Cardiology, Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Michael G. McBride
- Division of Cardiology, Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Xuemei Zhang
- Division of Cardiology, Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Steve Ampah
- Division of Cardiology, Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Bryan H. Goldstein
- Department of Pediatrics, Division of CardiologyUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Tarek Alsaied
- Department of Pediatrics, Division of CardiologyUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Samuel G. Wittekind
- Department of Pediatrics, Division of Cardiology, Cincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Kevin K. Whitehead
- Department of PediatricsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA,Division of Cardiology, Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Babette S. Zemel
- Department of PediatricsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA,Division of Gastroenterology, Hepatology, and NutritionChildren’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Stephen M. Paridon
- Department of PediatricsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA,Division of Cardiology, Children’s Hospital of PhiladelphiaPhiladelphiaPA
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10
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Anderson CAJ, Suna JM, Keating SE, Cordina R, Tran DL, Ayer J, Coombes JS. Safety and efficacy of exercise training in children and adolescents with congenital heart disease: A systematic review and descriptive analysis. Am Heart J 2022; 253:1-19. [PMID: 35768047 DOI: 10.1016/j.ahj.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/01/2022] [Accepted: 06/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND While exercise training is beneficial in the prevention and management of many chronic diseases, the role of exercise training in children and adolescents with congenital heart disease is less understood. We sought to determine the safety and efficacy of exercise training in children and adolescents with congenital heart disease. METHODS We conducted a systematic search of the following databases: PubMed, CINAHL, EMBASE, Web of Science and SportDiscus. We included randomised controlled trials that incorporated an exercise intervention compared with a non-exercising comparator group and examined safety and efficacy in children and adolescents with congenital heart disease. A descriptive analysis of the included trials was then conducted. RESULTS A total of 9 articles from 6 trials (642 participants with varying conditions and disease severity) were included. Significant variability of study participants and outcomes were observed across the trials. No adverse events linked to the exercise interventions were stated. The articles reported numerous positive changes to clinically relevant fitness measures. Exercise capacity improved with exercise training in 3 of 4 trials in which it was measured. Cardiorespiratory fitness showed improvements in 3 of 4 trials. Neuromuscular fitness increased in 1 of 2 trials. Physiological and metabolic parameters were improved, and negative changes were not observed to several clinically important measures (e.g. muscular oxygenation, cardiac measures) in 2 of 2 trials. Physical activity increased in 1 of 3 trials. No articles reported on changes in measures of body composition. Outcomes are varied with little consensus on measurements or assessment methods. CONCLUSIONS Exercise training appears to be safe and efficacious for improving physical fitness in children and adolescents with congenital heart disease who have been appropriately screened by their medical team. However, the certainty of the evidence for these findings is low to moderate.
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Affiliation(s)
- Christopher A J Anderson
- Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia.
| | - Jessica M Suna
- Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia; Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Shelley E Keating
- Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia; Heart Research Institute, Sydney, New South Wales, Australia
| | - Derek L Tran
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia; Heart Research Institute, Sydney, New South Wales, Australia
| | - Julian Ayer
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia; The Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jeff S Coombes
- Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
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11
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Baldini L, Librandi K, D’Eusebio C, Lezo A. Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood. Nutrients 2022; 14:nu14194055. [PMID: 36235705 PMCID: PMC9572747 DOI: 10.3390/nu14194055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022] Open
Abstract
Fontan circulation (FC) is a surgically achieved palliation state offered to patients affected by a wide variety of congenital heart defects (CHDs) that are grouped under the name of univentricular heart. The procedure includes three different surgical stages. Malnutrition is a matter of concern in any phase of life for these children, often leading to longer hospital stays, higher mortality rates, and a higher risk of adverse neurodevelopmental and growth outcomes. Notwithstanding the relevance of proper nutrition for this subset of patients, specific guidelines on the matter are lacking. In this review, we aim to analyze the role of an adequate form of nutritional support in patients with FC throughout the different stages of their lives, in order to provide a practical approach to appropriate nutritional management. Firstly, the burden of faltering growth in patients with univentricular heart is analyzed, focusing on the pathogenesis of malnutrition, its detection and evaluation. Secondly, we summarize the nutritional issues of each life phase of a Fontan patient from birth to adulthood. Finally, we highlight the challenges of nutritional management in patients with failing Fontan.
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Affiliation(s)
- Letizia Baldini
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
- Pediatria Specialistica, Ospedale Infantile Regina Margherita, Piazza Polonia 94, 10126 Torino, Italy
- Correspondence:
| | - Katia Librandi
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
| | - Chiara D’Eusebio
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
| | - Antonella Lezo
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
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12
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Weigelt A, Fritsch R, Rottermann K, Wällisch W, Moosmann J, Dittrich S, Purbojo A, Schöffl I. Fitter Fontans for future—Impact of physical exercise on cardiopulmonary function in Fontan patients. Front Cardiovasc Med 2022; 9:972652. [PMID: 36172584 PMCID: PMC9510659 DOI: 10.3389/fcvm.2022.972652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn Fontans, exercise tolerance is poorer compared to their healthy peers. Higher V˙O2peak represents a strong predictor for mortality and morbidity in these patients. Cardiac rehabilitation programs have been shown to improve cardiopulmonary function in Fontans. More habitual physical activity should therefore lead to a better exercise tolerance.MethodsWe performed cardiopulmonary exercise testing in 24 Fontan patients who had engaged in physical activity for a minimum of 3 h per week over their lifetime. As a control we performed cardiopulmonary exercise testing in 20 Fontan patients who had undertaken no physical activity or <3 h per week in the past.ResultsA total of 44 Fontan patients was included (mean age 18.1 years). The mean parameters measured at peak exercise differed significantly between the active and inactive group (peak oxygen uptake [V˙O2peak] of 34.0 vs. 25.0 ml/min/kg, peak heart rate (HR) of 169.8/min vs. 139.8/min). Even though the O2pulse and the EF did not differ significantly between both groups, N-Terminal-Pro-B-Type Natriuretic Peptide (NT-pro BNP) was significantly higher in the inactive group. The two groups did not differ with respect to their cardiac function determined by magnetic resonance imaging (MRI). V˙O2peak was positively correlated with hours of sports performed by Fontans.ConclusionsV˙O2peak and maximum HR were significantly higher in Fontans who had been physically active compared to those who had been inactive. The values reported in this study were higher than in other studies and reached normal values for V˙O2peak for most Fontans in the physically active group. The positive correlation between V˙O2peak and physical activity is an indicator of the importance of incorporating physical exercise programs into the treatment of Fontan patients.
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Affiliation(s)
- Annika Weigelt
- Department of Pediatric Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Annika Weigelt
| | - Regina Fritsch
- Department of Pediatric Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Kathrin Rottermann
- Department of Pediatric Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Wolfgang Wällisch
- Department of Pediatric Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Julia Moosmann
- Department of Pediatric Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ariawan Purbojo
- Department of Pediatric Heart Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Isabelle Schöffl
- Department of Pediatric Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, United Kingdom
- *Correspondence: Isabelle Schöffl ;
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13
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Body mass index and age are associated with ventricular end-diastolic pressure in adults with a Fontan circulation. Cardiol Young 2022; 32:1296-1301. [PMID: 34617506 DOI: 10.1017/s1047951121004091] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Systemic ventricular end-diastolic pressure is an important haemodynamic variable in adult patients with Fontan circulation. Risk factors associated with elevated end-diastolic pressure have not been clearly identified in this population. METHODS All patients > 18 years with Fontan circulation who underwent cardiac catheterisation at our centre between 1/08 and 3/19 were included. Relevant patient variables were extracted. Univariate and multivariate general linear models were analysed to identify variables associated with end-diastolic pressure. RESULTS Forty-two patients were included. Median age was 24.0 years (20.9-29.0) with a body mass index of 23.7 kg/m2 (21.5-29.7). 10 (23.8%) patients had a systemic right ventricle. The median (Interquartile range) and mean pulmonary artery pressure were 11.0 mmHg (9.0-12.0) and 16.0 mmHg (13.0-18.0), respectively. On univariate analysis, end-diastolic pressure was positively associated with body mass index (p < 0.01), age > 25 years (p = 0.04), symptoms of heart failure (p < 0.01), systemic ventricular systolic pressure (p = 0.03), pulmonary artery mean pressure (p < 0.01), and taking diuretics (p < 0.01) or sildenafil (p < 0.01). End-diastolic pressure was negatively associated with aortic saturation (p < 0.01). On multivariate analysis, end-diastolic pressure was positively associated with age ≥ 25 years (p < 0.01), and body mass index (p = 0.04). CONCLUSIONS In a cohort of adult patients with Fontan circulation undergoing catheterisation, end-diastolic pressure was positively associated with age ≥ 25 years and body mass index on multivariate analysis. Maintaining a healthy body mass index may offer haemodynamic benefit in adults with Fontan physiology.
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14
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Ritmeester E, Veger VA, van der Ven JPG, van Tussenbroek GMJW, van Capelle CI, Udink ten Cate FEA, Helbing WA. Fontan Circulation Associated Organ Abnormalities Beyond the Heart, Lungs, Liver, and Gut: A Systematic Review. Front Cardiovasc Med 2022; 9:826096. [PMID: 35391839 PMCID: PMC8981209 DOI: 10.3389/fcvm.2022.826096] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/17/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction Patients with a Fontan circulation are at risk for sequelae of Fontan physiology during follow-up. Fontan physiology affects all organ systems and an overview of end-organ damage is needed. Methods We performed a systematic review of abnormalities in multiple organ systems for patients with a longstanding Fontan circulation. We searched online databases for articles describing abnormalities in multiple organ systems. Cardio-pulmonary abnormalities, protein losing enteropathy, and Fontan associated liver disease have already extensively been described and were excluded from this systematic review. Results Our search returned 5,704 unique articles. After screening, we found 111 articles relating to multiple organ systems. We found abnormalities in, among others, the nervous system, pituitary, kidneys, and musculoskeletal system. Pituitary edema—relating to the unique pituitary vasculature- may affect the thyroid axis. Renal dysfunction is common. Creatinine based renal function estimates may be inappropriate due to myopenia. Both lean muscle mass and bone mineral density are decreased. These abnormalities in multiple organ systems may be related to Fontan physiology, cyanosis, iatrogenic factors, or lifestyle. Conclusions Health care providers should be vigilant for hypothyroidism, visual or hearing deficits, and sleep disordered breathing in Fontan patients. We recommend including cystatin C for assessment of renal function. This review may aid health care providers and guide future research. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021232461, PROSPERO, identifier: CRD42021232461.
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Affiliation(s)
- Evi Ritmeester
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Veerle A. Veger
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jelle P. G. van der Ven
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
- Netherlands Heart Institute, Utrecht, Netherlands
| | | | - Carine I. van Capelle
- Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Floris E. A. Udink ten Cate
- Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem A. Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Willem A. Helbing
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15
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Invasive Hemodynamic Evaluation of the Fontan Circulation: Current Day Practice and Limitations. Curr Cardiol Rep 2022; 24:587-596. [PMID: 35230616 DOI: 10.1007/s11886-022-01679-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Establishing the Fontan circulation has led to improved survival in patients born with complex congenital heart diseases. Despite early success, the long-term course of Fontan patients is complicated by multi-organ dysfunction, mainly due to a combination of low resting and blunted exercise-augmented cardiac output as well as elevated central venous (Fontan) pressure. Similarly, despite absolute hemodynamic differences compared to the normal population with biventricular circulation, the "normal" ranges of hemodynamic parameters specific to age-appropriate Fontan circulation have not been well defined. With the ever-increasing population of patients requiring Fontan correction, it is of utmost importance that an acceptable range of hemodynamics in this highly complex patient cohort is better defined. RECENT FINDINGS Multiple publications have described hemodynamic limitations and potential management options in patients with Fontan circulation; however, an acceptable range of hemodynamic parameters in this patient population has not been well defined. Identification of "normal" hemodynamic parameters among patients with Fontan circulation will allow physicians to more objectively define indications for intervention, which is a necessary first step to eliminate institutional and regional heterogeneity in Fontan management and potentially improve long-term clinical outcomes.
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16
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Villa C, Greenberg JW, Morales DL. Mechanical Support for the Failing Single Ventricle After Fontan. JTCVS Tech 2022; 13:174-181. [PMID: 35713590 PMCID: PMC9195612 DOI: 10.1016/j.xjtc.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/04/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - David L.S. Morales
- Address for reprints: David L. S. Morales, MD, Pediatric Cardiothoracic Surgery, The Heart Institute, Cincinnati Children's Hospital Medical Center, The University of Cincinnati College of Medicine, 3333 Burnet Ave – MLC 2004, Cincinnati, OH 45229.
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17
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Khoury M, Cordina R. Exercise Training for People Living with a Fontan Circulation: An Underutilized Intervention. Can J Cardiol 2022; 38:1012-1023. [PMID: 35041931 DOI: 10.1016/j.cjca.2022.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/31/2021] [Accepted: 01/08/2022] [Indexed: 12/17/2022] Open
Abstract
Surgical repair for children born with single ventricle congenital heart disease, culminating in the Fontan operation, has resulted in dramatic improvements in survival; children born with these lesions are now typically expected to survive well into adulthood. Most, but not all, individuals with a Fontan circulation have reduced exercise capacity compared with the general population that in turn is associated with increased cardiovascular morbidity and mortality. The cause of reduced exercise capacity is multifactorial. A significant contributor is the absence of a subpulmonary ventricular pump, which limits preload and appropriate cardiac output augmentation to meet the increased metabolic demands that occur with exercise. While in its infancy relative to adults with acquired heart disease, the evidence to date suggests that exercise interventions to improve exercise capacity and Fontan physiology in children and adults with Fontan circulation are safe, effective and well tolerated. However, many knowledge gaps remain, including a detailed understanding of the unique physiological adaptations that occur, the optimal approach to exercise in this population and the effectiveness of home-based interventions utilizing telemedicine and remote physiologic monitoring technologies. Furthermore, the long-term impact of such interventions on the Fontan-cardiovascular system, physical activity levels, health-related quality of life, and late cardiovascular morbidity and mortality are not well characterized. In this review, we outline the factors associated with reduced exercise capacity in individuals with Fontan circulation, review the experience to date of dedicated interventions to improve exercise capacity, and highlight the current knowledge gaps in the field and priorities for further study.
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Affiliation(s)
- Michael Khoury
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Rachael Cordina
- Sydney Medical School, University of Sydney, Sidney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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18
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Abstract
PURPOSE OF REVIEW Historically, children with congenital heart disease have been restricted from exercise, contributing to a sedentary lifestyle as well as increased cardiovascular risk factors. Given the large benefits and small risks of exercise in this population, guidelines have recently shifted towards exercise promotion. However, these recommendations have yet not gained traction and children with congenital heart disease continue to live sedentary lives. The purpose of this review is to summarize the current literature on exercise and exercise promotion in this population. RECENT FINDINGS New literature reinforces the importance of recommending exercise and improving exercise capacity both in congenital heart disease in general and for specific lesions. Exercise recommendations should be individualized based on functional parameters using a structured methodology to approach the evaluation, risk classification, and prescriptions of exercise and physical activity. SUMMARY Regular exercise is essential for children with congenital heart disease and providers must take an active role in providing exercise recommendations for their patients. Exercise promotion remains a challenge, necessitating novel approaches to promote exercise. Further studies are needed to improve the risk stratification of patients with congenital heart disease, assess the long-term outcomes of specific exercise interventions, and inform individualized recommendations to encourage children with congenital heart disease to safely engage in exercise and establish healthy lifelong habits that will decrease their cardiovascular risk.
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Affiliation(s)
- Katherine Hansen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, 94304, USA
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19
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Exercise Prescription Enhances Maximal Oxygen Uptake and Anaerobic Threshold in Young Single Ventricle Patients with Fontan Circulation. Pediatr Cardiol 2022; 43:969-976. [PMID: 35106621 PMCID: PMC9098606 DOI: 10.1007/s00246-021-02806-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/17/2021] [Indexed: 11/08/2022]
Abstract
A modified Fontan procedure is performed to palliate single ventricle malformations. This hemodynamic arrangement sets systemic venous pressure unphysiologically high which predisposes the patient to severe long-term complications. As a means of self-care, exercise may ease transpulmonary flow. We investigated the effects of 6-month exercise prescription on pediatric Fontan patients. Eighteen stable Fontan patients (14 ± 2.6 years, 160.4 ± 11.3 cm, and 51.4 ± 14.4 kg) were recruited. Baseline fitness was assessed by physical activity questionnaire, body composition, cardiorespiratory performance, and muscle fitness tests. Exercise prescription was individually tailored for a 6-month training period at home. At entrance to the study, Fontan patients had lower than normal maximal oxygen uptake (VO2max) of 28. ± 5.9 ml/kg/min (61 ± 11% of normal). VO2max significantly correlated with weekly amount of habitual exercise and muscle mass of the lower limbs (p < 0.001 for both). After 6 months of training, the patients had improved their anaerobic threshold of 18 ± 3.5 vs 20 ± 4.8 ml/kg/min, p = 0.007, and workload tolerance of 119 ± 39 vs 132.4 ± 44 W, p = 0.001. At EUROFIT tests, the patient muscle fitness was below age-matched reference, but correlations existed between VO2max and lower limb muscle tests. Our patients with Fontan hemodynamics were able to positively respond to an exercise program by enhancing submaximal performance which should be beneficial for getting through daily activities. Future studies should correlate whether hemodynamic findings at Fontan completion influence physical activity and exercise reserves, and whether these predict predisposition to chronic complications.
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20
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Overweight and Obesity in Patients with Congenital Heart Disease: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189931. [PMID: 34574853 PMCID: PMC8466650 DOI: 10.3390/ijerph18189931] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022]
Abstract
Background: Overweight and obesity have become a major public health concern in recent decades, particularly in patients with chronic health conditions like congenital heart disease (CHD). This systematic review elaborates on the prevalence and the longitudinal development of overweight and obesity in children and adults with CHD. Methods: A systematic literature search was conducted in PubMed, Cochrane, and Scopus from January 2010 to December 2020 on overweight and obesity prevalence in children and adults with CHD. Results: Of 30 included studies, 15 studies evaluated 5680 pediatric patients with CHD, 9 studies evaluated 6657 adults with CHD (ACHD) and 6 studies examined 9273 both pediatric patients and ACHD. Fifteen studies received the quality rating “good”, nine studies “fair”, and six studies “poor”. In children with CHD, overweight prevalence was between 9.5–31.5%, and obesity prevalence was between 9.5–26%; in ACHD, overweight prevalence was between 22–53%, and obesity was between 7–26%. The prevalence of overweight and obesity was thereby similar to the general population. Overweight and obesity have been shown to increase with age. Conclusion: The prevalence of overweight and obesity in children and adults with CHD is similar to the general population, demonstrating that the growing obesity pandemic is also affecting the CHD population.
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21
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Tran DL, Gibson H, Maiorana AJ, Verrall CE, Baker DW, Clode M, Lubans DR, Zannino D, Bullock A, Ferrie S, Briody J, Simm P, Wijesekera V, D'Almeida M, Gosbell SE, Davis GM, Weintraub R, Keech AC, Puranik R, Ugander M, Justo R, Zentner D, Majumdar A, Grigg L, Coombes JS, d'Udekem Y, Morris NR, Ayer J, Celermajer DS, Cordina R. Exercise Intolerance, Benefits, and Prescription for People Living With a Fontan Circulation: The Fontan Fitness Intervention Trial (F-FIT)-Rationale and Design. Front Pediatr 2021; 9:799125. [PMID: 35071139 PMCID: PMC8771702 DOI: 10.3389/fped.2021.799125] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/07/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Despite developments in surgical techniques and medical care, people with a Fontan circulation still experience long-term complications; non-invasive therapies to optimize the circulation have not been established. Exercise intolerance affects the majority of the population and is associated with worse prognosis. Historically, people living with a Fontan circulation were advised to avoid physical activity, but a small number of heterogenous, predominantly uncontrolled studies have shown that exercise training is safe-and for unique reasons, may even be of heightened importance in the setting of Fontan physiology. The mechanisms underlying improvements in aerobic exercise capacity and the effects of exercise training on circulatory and end-organ function remain incompletely understood. Furthermore, the optimal methods of exercise prescription are poorly characterized. This highlights the need for large, well-designed, multi-center, randomized, controlled trials. Aims and Methods: The Fontan Fitness Intervention Trial (F-FIT)-a phase III clinical trial-aims to optimize exercise prescription and delivery in people with a Fontan circulation. In this multi-center, randomized, controlled study, eligible Fontan participants will be randomized to either a 4-month supervised aerobic and resistance exercise training program of moderate-to-vigorous intensity followed by an 8-month maintenance phase; or usual care (control group). Adolescent and adult (≥16 years) Fontan participants will be randomized to either traditional face-to-face exercise training, telehealth exercise training, or usual care in a three-arm trial with an allocation of 2:2:1 (traditional:telehealth:control). Children (<16 years) will be randomized to either a physical activity and exercise program of moderate-to-vigorous intensity or usual care in a two-arm trial with a 1:1 allocation. The primary outcome is a change in aerobic exercise capacity (peak oxygen uptake) at 4-months. Secondary outcomes include safety, and changes in cardiopulmonary exercise testing measures, peripheral venous pressure, respiratory muscle and lung function, body composition, liver stiffness, neuropsychological and neurocognitive function, physical activity levels, dietary and nutritional status, vascular function, neurohormonal activation, metabolites, cardiac function, quality of life, musculoskeletal fitness, and health care utilization. Outcome measures will be assessed at baseline, 4-months, and 12-months. This manuscript will describe the pathophysiology of exercise intolerance in the Fontan circulation and the rationale and protocol for the F-FIT.
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Affiliation(s)
- Derek L Tran
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Hannah Gibson
- Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Andrew J Maiorana
- School of Allied Health, Curtin University, Perth, WA, Australia.,Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Charlotte E Verrall
- The University of Sydney Westmead Clinical School, Sydney, NSW, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David W Baker
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Melanie Clode
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - David R Lubans
- School of Education, Priority Research Centre for Physical Activity and Nutrition, The University of Newcastle, Newcastle, NSW, Australia
| | - Diana Zannino
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Andrew Bullock
- Paediatric and Adult Congenital Cardiology, Perth Children's Hospital, Perth, WA, Australia
| | - Suzie Ferrie
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Julie Briody
- Department of Nuclear Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Peter Simm
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Vishva Wijesekera
- Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Michelle D'Almeida
- Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Sally E Gosbell
- Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Glen M Davis
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Robert Weintraub
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Anthony C Keech
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Martin Ugander
- Royal North Shore Hospital, The Kolling Institute, Sydney, NSW, Australia
| | - Robert Justo
- Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Dominica Zentner
- The University of Melbourne Medical School, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Avik Majumdar
- Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Australian National Liver Transplant Unit, AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Leeanne Grigg
- The University of Melbourne Medical School, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Sciences, Centre for Research on Exercise, Physical Activity, and Health, The University of Queensland, Brisbane, QLD, Australia
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, United States
| | - Norman R Morris
- Allied Health Collaborative and Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast, QLD, Australia
| | - Julian Ayer
- The University of Sydney Westmead Clinical School, Sydney, NSW, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
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Powell AW, Wittekind SG, Alsaied T, Lubert AM, Chin C, Veldtman GR, Cordina R, Katz DA, Mays WA, Knecht SK, Opotowsky AR. Body Composition and Exercise Performance in Youth With a Fontan Circulation: A Bio-Impedance Based Study. J Am Heart Assoc 2020; 9:e018345. [PMID: 33289459 PMCID: PMC7955362 DOI: 10.1161/jaha.120.018345] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/29/2020] [Indexed: 12/16/2022]
Abstract
Background Adults with a Fontan circulation tend to have myopenia and elevated adiposity when measured by dual energy x-ray absorptiometry. Bioelectrical impedance analysis is an alternative validated approach to assess body composition. We used bioelectrical impedance analysis to compare body composition between pediatric patients with a Fontan circulation and control individuals without heart disease. Methods and Results A retrospective chart review identified all patients aged <22 years with a Fontan circulation who presented for cardiopulmonary exercise testing and bioelectrical impedance analysis from April 2019 to January 2020. Data were compared with control subjects tested during the same period. We studied 47 patients with a Fontan circulation (53% boys; 15±3.1 years) and 165 controls (48% boys; 14.4±2.5 years). Fontan status was associated with shorter height, but similar age, sex, and overall body mass. Patients with Fontan had lower lean body mass (-12.0±22%, Z-score -0.5±1, P=0.005), skeletal muscle mass (-13.6±1.4%; Z-score, -0.5±1; P=0.004), skeletal muscle indexed to height (-10.3±13.3%; Z-score, -0.5±1; P=0.005), and higher percent body fat (+13.8±18.6%; Z-score, 0.4±1.2; P=0.03). Greater skeletal muscle mass was associated with higher peak oxygen consumption (r2=0.52, P<0.0001) and oxygen pulse (r2=0.68, P<0.0001). Patients who had suffered a late complication (ie, heart transplant referral or evidence of extracardiac organ dysfunction) of the Fontan operation (13 of 47, 27.7%) had lower skeletal muscle mass (P=0.048) and higher body fat percentage (P=0.003). Conclusions The Fontan circulation is associated with marked myopenia and increased adiposity. Higher muscle mass was associated with better exercise capacity. Fontan complications are associated with lower muscle mass and increased adiposity.
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Affiliation(s)
- Adam W. Powell
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Samuel G. Wittekind
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Tarek Alsaied
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Adam M. Lubert
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Clifford Chin
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | | | - Rachael Cordina
- Sydney Medical SchoolThe University of SydneyCamperdownNew South WalesAustralia
- Department of CardiologyRoyal Prince Alfred HospitalCamperdownNew South WalesAustralia
| | - David A. Katz
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Wayne A. Mays
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Sandra K. Knecht
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Alexander R. Opotowsky
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
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