Analysis of exercise capacity, quality of life and leisure sports in patients with a Fontan circulation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Despite the improvement in survival, patients with a Fontan circulation are exposed to numerous complications as well as a reduced exercise capacity and quality of life. 

Purpose

To assess the influence of the type of single ventricle (right vs. left) and the amount of sporting activity on exercise capacity and health related quality of life (HRQol) in a large group of Fontan patients.

Methods

Retrospective analysis of standardised cardiopulmonary exercise tests (CPET) performed on a treadmill between 2014 and 2019. Questionnaires to measure HRQol and sporting activity were sent to study participants.

Results

79 patients were enrolled in this study (female, n = 31). 56 of them had a systemic right ventricle (SRV), 20 had a systemic left ventricle (SLV) and 3 had diverse anatomies. Median age at CPET was 12.2 years (range 6.2-34.4 years). The results for important exercise parameters were as follows: peak oxygen uptake (VO2max) 30.7 ± 6.2 ml/kg/min, oxygen uptake at anaerobic threshold (VO2-VAT) 24.7 ± 5.8 ml/kg/min, peak oxygen pulse 8.2 ± 3.4 mlO2/beat and VE/VCO2 slope 39.8 ± 9.1. There was no significant difference in VO2max, VO2-VAT, peak oxygen pulse and VE/CO2 slope between SRV and SLV patients: VO2max 30.2 ± 5.6 vs. 32.8 ± 7.5 ml/kg/min, p = 0.14; VO2-AT 24.4 ± 5.3 vs.25.7 ± 7.3 ml/kg/min, p = 0.53; peak oxygen pulse 7.8 ± 3.2 vs. 9.5 ± 3.9 mlO2/beat, p = 0.06; VE/CO2 slope 41.1 ± 9.6 vs. 36.9 ± 6.8, p = 0.10. Analyses of the questionnaires revealed that most of the patients do leisure sports (n = 60, 76%) with nearly half of them more than two hours per week (n = 26, 33%).

In a subgroup analysis of patients under 18 years (n = 51, 65%) we found that nearly all of them participate in school sports (n = 50) and have a good subjective healthiness (n = 47). VO2-VAT and VO2max correlated positively with subjective healthiness (VO2-VAT r = 0.32, p < 0.05; VO2max r = 0.35, p < 0.05) as well as with the amount of leisure sports activity (hours/week) (VO2-VAT r = 0.37, p < 0.01; VO2max r = 0.50, p < 0.01).

Conclusions

By analysing a large group of patients in Fontan circulation we could demonstrate that there is no difference in exercise capacity between SRV and SLV patients. Furthermore, most of the patients participate in leisure sports and have a good subjective healthiness. In a subgroup of paediatric patients, we were able to show that a better exercise capacity is associated with increased leisure sports activity and a better subjective healthiness.

A unique case of ventricular isomerism?

Isomerism of the atria has often been described with various complex cardiac malformations. As far as is known, a case of 'ventricular isomerism' has never been recorded. Described is a specimen where, on the basis of morphological criterions, there are two right ventricles.

A unique case of ventricular isomerism?

Isomerism of the atriums has often been described with various complex cardiac malformations. As far as is known, a case of 'ventricular isomerism' has never been recorded. Described is a specimen where, on the basis of morphological criterions, there are two right ventricles.

Elevated maternal urine level of beta-core fragment of human chorionic gonadotropin versus serum triple test in the second-trimester detection of down syndrome

OBJECTIVE

This study was undertaken to compare the Down syndrome screening efficiency of elevated maternal urine level of the beta-core fragment of human chorionic gonadotropin with that of the traditional serum triple test.

STUDY DESIGN

Urinary beta-core fragment and serum analyte levels were measured prospectively in women with singleton pregnancies who were undergoing second-trimester genetic amniocentesis. Urinary analyte levels were measured within a week of specimen collection. In some cases only alpha-fetoprotein was measured initially and human chorionic gonadotropin and unconjugated estriol levels were subsequently determined from the stored serum specimens. The Down syndrome screening efficiency of urinary concentration of beta-core fragment plus maternal age was compared with that of the traditional triple test. Receiver operating characteristic curves were generated for each algorithm and the areas under the curves were compared to determine which algorithm was superior.

RESULTS

There were a total of 926 study patients, of whom 21 (2.3%) carried fetuses with Down syndrome. The mean (+/-SD) gestations at amniocentesis were 16.6 +/- 1.5 weeks for the fetuses without Down syndrome and 17.7 +/- 2.3 for the fetuses with Down syndrome. A total of 539 women (4 of whom carried fetuses with Down syndrome) had serum alpha-fetoprotein alone measured initially. Urinary concentration of beta-core fragment had a 61.9% detection rate with a 4.9% false-positive rate for Down syndrome, whereas the values for the triple screen were 57. 1% and 11.2%, respectively. The areas under the receiver-operating characteristic curves were 0.8744 for elevated urinary beta-core fragment level and 0.7504 for the triple screen (P =.1116). When the false-positive rate was fixed at an ideal threshold value (</=5%) the urine test was superior (area under the curve, 0.0212 vs 0.0133, P <.05). Similarly, when we considered only cases in which the complete triple screen was performed prospectively (17 fetuses with Down syndrome and 431 fetuses without Down syndrome), the urine test was significantly better (area under the curve, 0.873 vs 0.624, P =.012).

CONCLUSION

In this first reported direct comparison we consistently observed higher sensitivity values for screening with urinary levels of beta-core fragment than for serum triple screen, suggesting an equivalent or superior Down syndrome screening performance for the urinary analyte. It is important that freezing and prolonged urine storage before testing be avoided. The reduced cost (single- versus triple-analyte testing) and excellent screening performance support large-scale testing and evaluation of maternal urinary beta-core fragment measurement as an alternative to the traditional serum triple test.

Following metastatic placental site trophoblastic tumor with urine beta-core fragment

OBJECTIVE

We document a case with metastatic placental site trophoblastic tumor in a 47-year-old postmenopausal women.

METHODS

beta-core fragment was measured in urine using the Triton UGP kit. hCG was also measured using the Bayer Immuno-1hCG assay (at Memorial Sloan-Kettering Cancer Center).

RESULTS

Over 2 years the patient underwent two courses of chemotherapy and two debulking operations. During this time, hCG levels decreased from 227 to 4.1 mIU/ml. hCG levels were close to the limit of detection (<3 mIU/ml), indicating complete or near-complete regression of disease. At this point urine beta-core fragment levels were determined. High levels were detected 7.9 fmol/ml, consistent with the continued existence of tumor (>1.9 fmol/ml). High-dose chemotherapy (CEM) was started with stem cell harvesting. In the following weeks hCG levels failed to identify the tumor (4.1 to <3 mIU/ml). In the first week (during therapy) beta-core fragment levels increased (12 fmol/ml), and in the following weeks (after therapy) levels regressed to 1.2 fmol/ml.

CONCLUSION

Urine beta-core fragment may be a useful tumor maker when serum hCG levels are near to or below the limit of detection.