Physical activity interventions for people with congenital heart disease

BACKGROUND

Congenital heart disease (ConHD) affects approximately 1% of all live births. People with ConHD are living longer due to improved medical intervention and are at risk of developing non-communicable diseases. Cardiorespiratory fitness (CRF) is reduced in people with ConHD, who deteriorate faster compared to healthy people. CRF is known to be prognostic of future mortality and morbidity: it is therefore important to assess the evidence base on physical activity interventions in this population to inform decision making.

OBJECTIVES

To assess the effectiveness and safety of all types of physical activity interventions versus standard care in individuals with congenital heart disease.

SEARCH METHODS

We undertook a systematic search on 23 September 2019 of the following databases: CENTRAL, MEDLINE, Embase, CINAHL, AMED, BIOSIS Citation Index, Web of Science Core Collection, LILACS and DARE. We also searched ClinicalTrials.gov and we reviewed the reference lists of relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCT) that compared any type of physical activity intervention against a 'no physical activity' (usual care) control. We included all individuals with a diagnosis of congenital heart disease, regardless of age or previous medical interventions.  DATA COLLECTION AND ANALYSIS: Two review authors (CAW and CW) independently screened all the identified references for inclusion. We retrieved and read all full papers; and we contacted study authors if we needed any further information. The same two independent reviewers who extracted the data then processed the included papers, assessed their risk of bias using RoB 2 and assessed the certainty of the evidence using the GRADE approach. The primary outcomes were: maximal cardiorespiratory fitness (CRF) assessed by peak oxygen consumption; health-related quality of life (HRQoL) determined by a validated questionnaire; and device-worn 'objective' measures of physical activity.

MAIN RESULTS

We included 15 RCTs with 924 participants in the review. The median intervention length/follow-up length was 12 weeks (12 to 26 interquartile range (IQR)). There were five RCTs of children and adolescents (n = 500) and 10 adult RCTs (n = 424). We identified three types of intervention: physical activity promotion; exercise training; and inspiratory muscle training. We assessed the risk of bias of results for CRF as either being of some concern (n = 12) or at a high risk of bias (n = 2), due to a failure to blind intervention staff. One study did not report this outcome. Using the GRADE method, we assessed the certainty of evidence as moderate to very low across measured outcomes. When we pooled all types of interventions (physical activity promotion, exercise training and inspiratory muscle training), compared to a 'no exercise' control CRF may slightly increase, with a mean difference (MD) of 1.89 mL/kg^-1/min^-1 (95% CI -0.22 to 3.99; n = 732; moderate-certainty evidence). The evidence is very uncertain about the effect of physical activity and exercise interventions on HRQoL. There was a standardised mean difference (SMD) of 0.76 (95% CI -0.13 to 1.65; n = 163; very low certainty evidence) in HRQoL. However, we could pool only three studies in a meta-analysis, due to different ways of reporting. Only one study out of eight showed a positive effect on HRQoL. There may be a small improvement in mean daily physical activity (PA) (SMD 0.38, 95% CI -0.15 to 0.92; n = 328; low-certainty evidence), which equates to approximately an additional 10 minutes of physical activity daily (95% CI -2.50 to 22.20). Physical activity and exercise interventions likely result in an increase in submaximal cardiorespiratory fitness (MD 2.05, 95% CI 0.05 to 4.05; n = 179; moderate-certainty evidence). Physical activity and exercise interventions likely increase muscular strength (MD 17.13, 95% CI 3.45 to 30.81; n = 18; moderate-certainty evidence). Eleven studies (n = 501) reported on the outcome of adverse events (73% of total studies). Of the 11 studies, six studies reported zero adverse events. Five studies reported a total of 11 adverse events; 36% of adverse events were cardiac related (n = 4); there were, however, no serious adverse events related to the interventions or reported fatalities (moderate-certainty evidence). No studies reported hospital admissions.

AUTHORS' CONCLUSIONS

This review summarises the latest evidence on CRF, HRQoL and PA. Although there were only small improvements in CRF and PA, and small to no improvements in HRQoL, there were no reported serious adverse events related to the interventions. Although these data are promising, there is currently insufficient evidence to definitively determine the impact of physical activity interventions in ConHD. Further high-quality randomised controlled trials are therefore needed, utilising a longer duration of follow-up.

Cardiopulmonary Rehabilitation Improves Respiratory Muscle Function and Functional Capacity in Children with Congenital Heart Disease. A Prospective Cohort Study

Critical surgical and medical advances have shifted the focus of congenital heart disease (CHD) patients from survival to achievement of a greater health-related quality of life (HRQoL). HRQoL is influenced, amongst other factors, by aerobic capacity and respiratory muscle strength, both of which are reduced in CHD patients. This study evaluates the influence of a cardiopulmonary rehabilitation program (CPRP) on respiratory muscle strength and functional capacity. Fifteen CHD patients, ages 12 to 16, with reduced aerobic capacity in cardiopulmonary exercise testing (CPET) were enrolled in a CPRP involving strength and aerobic training for three months. Measurements for comparison were obtained at the start, end, and six months after the CPRP. A significant improvement of inspiratory muscle strength was evidenced (maximum inspiratory pressure 21 cm H₂O, 23%, p < 0.01). The six-minute walking test showed a statistically and clinically significant rise in walked distance (48 m, p < 0.01) and a reduction in muscle fatigue (1.7 out of 10 points, p = 0.017). These results suggest CPRP could potentially improve respiratory muscle function and functional capacity, with lasting results, in children with congenital heart disease, but additional clinical trials must be conducted to confirm this finding.

[Cardiac rehabilitation in adults with congenital heart diseases]

The great advances in the medical and surgical management of congenital heart diseases have allowed many children to reach adulthood with often a good hemodynamic result. Nevertheless most of these adults have a limitation of their functional capacity. This limitation is more or less important, penalizes them in their daily life and alters their quality of life. The origin of this limitation is generally multifactorial. It is linked, of course, to the severity of the heart disease and the quality of the operative result. But there is very often a physical deconditioning. It can be secondary to the heart disease but is often secondary to a lack of physical activity. It is the parents, sometimes overprotective, but frequently the doctors who imposed, often wrongly, this restriction. It is essential to take this dimension into account in view of the important benefits expected for health and quality of life. Cardiac rehabilitation is a privileged tool for providing advice in a suitable environment. This requires close collaboration between cardiac rehabilitators and congenital cardiologists to offer appropriate care. We bring here some reflections and the basic elements to guide the re-training of these patients.

An Early Glenn Operation May be Associated with the Later Occurrence of Protein-Losing Enteropathy in Fontan Patients : Association of Early Glenn and Failing Fontan

Protein-losing enteropathy (PLE) and plastic bronchitis (PB) are major causes of long-term mortality after Fontan operation. The objective of this study was to determine early clinical risk factors before the onset of PLE and PB. In a cohort study, 106 Fontan patients between 2005 and 2013 were examined. A median of 5.3 (1.5-8.5) years later, follow-up questionnaires were used to group the patients in a PLE or PB group (n = 14) and a non-PLE/PB group (n = 92). Prevalence of PLE was 9.4% (n = 10) and of PB 3.8% (n = 4). At follow-up, five patients (4.7%) died of PLE or PB. Median age at death was 6.2 years (IQR 10.5, 95% CI 5.3-23.4). We observed no significant group differences in gender distribution (p = 0.73), ventricular morphology (p = 0.87), surgical technique (p = 0.64), conduit fenestration (p = 0.34), age at Fontan operation (p = 0.54), and need for diuretics (p = 0.56). Hypoplastic left heart syndrome was more frequent in the PLE/PB group 50 vs. 22.8% (p = 0.03) OR 3.4 (95% CI 1.1-10.8). The modified Glenn procedure was performed at a median age of 4 months (IQR 4.0) in the PLE/PB group versus 8 months (IQR 8.0) in the non-PLE/PB group (p = 0.01). The early Glenn procedure and hypoplastic left heart syndrome may be associated with the development of PLE and PB.

Evolution of weight and height of children with congenital heart disease undergoing surgical treatment

OBJECTIVE

To evaluate the height and weight development of children with congenital heart disease undergoing surgery with the goal of determining when they reach the threshold of normal development and whether there are differences between patients with developmental pattern below the level of normality preoperatively (z-score<-2 for the analyzed parameter) in comparison to the total group of cardiac patients.

METHODS

We prospectively followed up 27 children undergoing operation into five time periods: preoperatively and at four subsequent outpatient appointments: 1st month, 3rd month, 6th month and 12th month after hospital discharge. The anthropometric parameters used were median z-score (MZ), weight (WAZ), height (HAZ), subscapular skinfold (SSFAZ), upper arm circumference (UAC) and triceps skinfold (TSFAZ). The evolution assessment of the parameters was performed by analysis of variance and comparison with the general normal population from unpaired t test, both in the total group of cardiac patients, and in subgroups with preoperative parameters below the normal level (Zm<-2).

RESULTS

In the total group there was no significant evolution of MZ of all parameters. WAZ was statistically lower than the normal population until the 1st month of follow-up (P=0.028); HAZ only preoperatively (P=0.044), SSFAZ in the first month (P=0.015) and at 12th month (P=0.038), UAC and TSFAZ were always statistically equal to the general population. In patients whose development was below the level of normality, there were important variation of WAZ (P=0.002), HAZ (P=0.001) and UAC (P=0.031) after the operation, and the WAZ was lower than the normal population until the 3rd month (P=0.015); HAZ and UAC, until the first month (P=0.024 and P=0.039 respectively), SSFAZ, up to the 12th month (P=0.005), the TSFAZ only preoperatively (P=0.011).

CONCLUSION

The operation promoted the return to normalcy for those with heart disease in general within up to three months, but for the group of patients below normal developmental pattern of the return occurred within 12 months.

Physical activity recommendations for patients with electrophysiologic and structural congenital heart disease: a survey of Canadian health care providers

Determining safe levels of physical activity for children and adolescents with electrophysiologic and structural congenital heart disease is a challenging clinical problem. The body of evidence for making these recommendations is limited and likely based on expert opinion, medicolegal concerns, and perceived risks of sudden cardiac death (SCD) with activity. The Bethesda Conference has established consensus guidelines for determining the eligibility of athletes with cardiovascular abnormalities for competitive sports and their disqualification from them. However, literature on guidelines for noncompetitive physical activity is not available. A survey was designed to determine practice patterns for patients with electrophysiologic and structural congenital heart disease. Between July 2011 and December 2011, approximately 350 health care providers working with this group of patients were recruited by email or while attending professional meetings. The survey received 81 responses, primarily from pediatric cardiologists (70 %). The findings indicate that the majority of Canadian cardiac care providers surveyed are only partially implementing current recommendations. Areas of variance included physical activity recommendations for hypertrophic cardiomyopathy, long QT syndrome, catecholaminergic polymorphic ventricular tachycardia, and heart transplantation, among others. The development of comprehensive consensus guidelines for activity recommendations was supported by 96 % of the respondents. The heterogeneity of responses may be attributable to conflicting and poorly evidenced information in the literature, a lack of emphasis on recreational activity, an entrenched tendency toward bed rest in the cardiology community, and a lack of awareness by cardiac care providers regarding the actual risk associated with physical activity in electrophysiologic and structural congenital heart disease. A balanced discussion is required in considering both the significant benefit of physical activity in reducing cardiovascular risk factors and the small possibility of SCD in children and young adults with electrophysiologic and structural congenital heart disease.

[Cardiac rehabilitation in congenital heart disease]

Pediatric Cardiology is a medical subspecialty that emerged in a systematic manner during the beginning of the 20th century. Throughout time, with the use of several methods we have been able to establish a series of diagnosis, offer surgical treatments and currently we evaluate and analyze the results of such proceedings. In the cardiac rehabilitation programs, children and adolescents are taught to identify the safety limits of their hearts, being able to relate them to their daily effort activities, providing them with a better quality of life and where they learn to live with the limitations that their illness implies.

Physical activity, sports participation and aerobic fitness in children who have undergone surgery for congenital heart defects

AIM

To investigate physical activity, sports participation and aerobic fitness in children who have undergone surgery for congenital heart defects.

SUBJECTS AND METHODS

Children who had undergone surgery for congenital heart defects and healthy controls in the Gothenburg area were invited to participate in the study. All participants were aged 9-11 or 14-16 years. The activity monitor ActiReg was used to assess physical activity. Participants were interviewed about their participation in sports and performed a maximal exercise test on a bicycle with measured oxygen uptake.

RESULTS

A total of 32 and 25 patients, and 61 and 45 controls, in the two age-groups were included, respectively. The patients had a wide range of severity of congenital heart defects. The physical activity level was similar in the patients and the controls. The rate of sports participation was high for both patients and controls; 80-94% of all participants took part in sports at least once a week. The majority of the patients were considered to have at least a moderate level of aerobic fitness.

CONCLUSIONS

Although children who have undergone surgery for congenital heart defects have a similar level of physical activity compared with that of healthy children, some of them may require support to participate in exercise and vigorous physical activity.

Rehabilitation protocols in children with corrected congenital heart defects due to the presence of pulmonary complications

BACKGROUND

The Aim of our study was to present early rehabilitation protocols for children with and without pulmonary complications after the correction of congenital heart defects and to estimate the optimal time for the initiation of early rehabilitation in both groups of children.

METHODS

In our study, 176 children treated at the University Children's Hospital in Belgrade were evaluated during the period 2003-2007. All patients were children with the corrected congenital heart defects from birth to 12 months of life.

RESULTS

In the group of patients without pulmonary complications we administered 3.64 +/- 1.02 exercises and in the group with present pulmonary complications we implemented 2.71 +/- 0.79 exercises. The optimal time for the initiation of early rehabilitation is 1.54 +/- 1.37 days for the group of children that did not have pulmonary complications, but for the other group the period was longer: 2.27 +/- 1.68 days.

DISCUSSIONS

The optimal number of exercises in children younger than one year of life is from 2 to 4 and the early rehabilitation should start as soon as possible. A desirable time for beginning of such program is within 24 to 48 hours post surgery but it cannot be limited to this interval due to possible complications stating that every child should have an individual approach (Tab. 3, Ref. 14).

Cardiac rehabilitation improves heart rate recovery following peak exercise in children with repaired congenital heart disease

We assessed heart rate (HR) recovery following peak exercise before and after a 12-week cardiac rehabilitation program in 14 children, 12.1+/-1.8 years of age, with repaired complex congenital heart disease (CHD; 11 with Fontan surgery) and impaired exercise performance. Exercise testing using bicycle ergometry was performed at baseline, after completion of the rehab program and 1.0+/-0.2 years after the baseline test. These data were compared to HR recovery in 15 controls (age, 12.7+/-2.4 years) with CHD (13 with Fontan surgery) with two serial exercise tests at an interval of 1.1+/- 0.3 years. There was no change in peak HR between the two serial tests in either group. Peak VO2 improved in the rehab group (26.3+/-9.6 ml/kg/min at baseline vs 30.9+/-9.6 ml/kg/min after rehab, p=0.01) but remained unchanged in controls on serial testing. One-minute HR recovery (in beats per minute) improved significantly following completion of the rehab program (27+/-15 at baseline vs 40+/-23 after rehab, p=0.01). Partial improvement in 1-minute HR recovery in the rehab group persisted 1 year later (1-minute HR recovery, 35+/-19; p=0.1 compared to baseline). There was no change in 1-minute HR recovery over time in the control group (37+/-16 vs 40+/-13, p = not significant). In conclusion, HR recovery following peak exercise improves in children with CHD after participation in a cardiac rehab program.

Differing views on quality of life

Perspective on the paper by Knowles et al (see page 388 )

Quality of life and congenital heart defects: comparing parent and professional values

OBJECTIVE

To compare preferences obtained from health professionals with those from parents for the longer-term health outcomes of children with congenital heart defects.

SETTING

Cardiology conference; hospital.

PARTICIPANTS

109 paediatric cardiology professionals (72% female, median age 38 years) and 106 parents of children with congenital heart defects (82% female, median age 37 years).

INTERVENTIONS

Eight health state descriptions, for cardiac and neurological disability resulting from congenital heart defects, were developed and presented with a self-administered anonymous questionnaire. Respondents were asked to rank health state descriptions from best to worst, score each health state using a visual analog scale and mark death on this scale.

RESULTS

Health professionals and parents agreed in the order of ranking health states from best to worst. Both groups assigned the lowest scores to health states with severe neurological disability. Scores did not differ significantly by age, sex or whether the respondent was in the health professional or parent group. Of all respondents, 8% (17) scored at least one health state description worse than death.

CONCLUSIONS

Parents and health professionals place similar values on the quality of life outcomes of children with congenital heart defects. Both are more averse to health states describing worse neurological than cardiac disability. Improving our understanding of the relative importance of different outcomes to children and families is an important basis for sharing decisions about clinical care. The views of young people with congenital heart defects should be an important focus for future enquiry into health outcomes.

Determinants of neuropsychological and behavioural outcomes in early childhood survivors of congenital heart disease

AIMS

To evaluate the relative effect of cyanosis, surgical interventions and family processes on neuropsychological and behavioural outcomes in 4-year-old survivors of serious congenital heart disease (CHD).

METHODS

90 children with a range of cyanotic and acyanotic conditions, who underwent either corrective or palliative surgery, completed a neuropsychological and behavioural evaluation. Families of participants were also profiled by evaluation of maternal mental health, worry, social support, parenting style and family functioning.

RESULTS

Compromised neuropsychological outcomes were associated with a combination of cyanotic conditions and open-heart surgery, but this was not exacerbated by having a complex, palliative, status. Both cyanotic and acyanotic conditions were associated with specific sensorimotor delays, regardless of method of the correction. Only children with complex conditions and palliative interventions seemed at risk of poor behavioural outcomes; indeed, children with cyanosis with complete repair showed favourable behavioural outcomes compared with controls. Multivariate analyses highlighted the sometimes greater relevance of family processes (eg parenting style, maternal mental health and worry), rather than disease or surgical factors, in predicting especially behavioural outcomes.

CONCLUSIONS

The findings (1) suggest a more complex relationship between cyanosis, surgical methods of correction, neuropsychological and behavioural outcomes than previously charted, (2) highlight that family processes may be aetiologically more important than disease and surgical factors, and (3) indicate specific targets for secondary prevention programmes for this at-risk population.

Herzgruppen in Deutschland—Status quo und Perspektiven

Currently, more than 6,600 heart groups (AHGs) have been established in Germany, in which more than 110,000 patients are physically active. Following cardiac rehabilitation (CR) after an acute event, in the AHG patients aim to meet the set rehabilitation goals in groups of about 15-20 patients, instructed by a competent exercise therapist and attended by a physician. While physical activity has been the dominant aspect thus far, psychosocial and educative elements are now more strongly integrated to stabilize secondary prevention. According to the German rehabilitation law, the patient is legally entitled to participate in AHGs. The insurance companies pay 6.00 Euros for 90 therapeutic units at 60-90 min each. Thereafter, the patient should be encouraged to continue participation at his/her own cost. The opportunity to participate in AHG is not yet sufficiently responded to by the patients. According to different studies, only 13-40% of all patients attend an AHG after phase II CR. In future, special emphasis has to be placed on the recruitment of more patients into AHGs, especially those groups which are known to be underrepresented (e. g., women, old patients, patients with low socioeconomic status). Furthermore, AHGs have to be established for patients with special needs, e. g., heart failure patients or young grown-ups with congenital heart diseases. Until now, the efficiency of AHG participation has not been sufficiently investigated. In a case-control study analyzing the long-term results of AHG participation, an improvement in physical performance as well as a reduction of cardiovascular morbidity (54%) and medical costs (approximately 47%) were observed. In future, more high-class investigations on this field are needed.

Sustained effects of cardiac rehabilitation in children with serious congenital heart disease

OBJECTIVE

Past studies have documented the acute benefits of cardiac rehabilitation in children with congenital heart disease. It is not known whether these benefits persist.

PATIENTS AND METHODS

Fifteen patients, ages 8 to 17 years, with complex congenital heart disease, whose exercise function immediately after a 12-week cardiac rehabilitation program was superior to that present on a precardiac rehabilitation exercise test, were restudied 6.9 +/- 1.6 months after completion of the cardiac rehabilitation program (approximately 1 year after the precardiac rehabilitation study). Changes in exercise function relative to baseline, precardiac rehabilitation exercise tests were also compared with changes observed in a group of 18 control subjects, with similar diagnoses, who also had 2 exercise tests separated by a year but did not undergo cardiac rehabilitation.

RESULTS

The cardiac rehabilitation patients' exercise function did not change significantly over the 6.9-month period after the completion of the cardiac rehabilitation program; percentage of predicted peak oxygen consumption and peak work rate remained significantly superior to baseline, precardiac rehabilitation values. These changes were also associated with improvements in self-esteem, behavior, and emotional state. In contrast, among the control subjects, small, but statistically insignificant declines in peak oxygen consumption and peak work rate were observed on the final exercise test compared with values obtained at baseline, 1 year earlier. The improvements realized by the cardiac rehabilitation patients differed significantly from the concurrent changes observed among the control subjects and appeared to be a result of an increase in the oxygen pulse at peak exercise; significant changes in peak heart rate were not observed.

CONCLUSIONS

In patients with congenital heart disease, cardiac rehabilitation produces significant, sustained improvements in exercise function, behavior, self-esteem, and emotional state.

[Organization of care for adults with congenital heart disease]

The increasing number of adult patients with congenital heart disease and the better survival of patients with complex disease into adulthood, as a result of the success of pediatric cardiology and cardiac surgery over the last years, have increased the need for specific structures, the so-called grown-up congenital heart disease units, able to provide comprehensive care to these patients. Many of the adult patients with congenital heart disease will require, over time, further operations, urgent in-hospital admission for a wide range of complications such as arrhythmias, hemorrhage, heart failure and bacterial endocarditis. Furthermore, these patients may often experience despair due to their awareness of residual morbidities and the knowledge of possible early mortality, or limitations in their social lives and educational or occupational attainment. Provision of care for children with congenital heart disease is well established in most parts of the world. In contrast, clinical services for the adults with congenital heart disease are scarce. In this scenario, adult cardiologists are not always equipped to deal with the range ad complexity of grown-up patients with congenital heart disease, whereas pediatric cardiologists cannot be expected to manage the many acquired adult diseases in a pediatric medical environment.

Can a child who has been operated on for congenital heart disease participate in sport and in which kind of sport?

Exercise training and sports participation is an important part of the physical, psychological and metabolic growth of any child and adolescent, and this is also true for patients with congenital heart disease (CHD). As one can expect, exercise tolerance varies widely according to the CHD and to the treatment received, but the functional result achieved in the single patient is more important. Individual counselling is necessary and should be based on observations/results of thorough cardiovascular assessment. Exercise testing is the ideal tool to identify patients in whom exercise may induce arrhythmias or haemodynamic instability. In general, some degree of aerobic, isometric exercise training can be granted to most patients operated on for CHD. Serial evaluations may be required because of changing haemodynamic and functional status with time.

Cardiopulmonary Rehabilitation and Cancer Rehabilitation. 2. Pulmonary Rehabilitation Review

Pulmonary rehabilitation includes the rehabilitation of not only patients with respiratory failure in need of ventilatory support but also patients with primary pulmonary disease. New advances in medical management now offer treatment to patients with end-stage emphysema, pulmonary hypertension, and interstitial disease, and the principles of rehabilitation can add both function and quality to the lives of these patients. New surgical approaches and better transplantation outcomes that restore pulmonary function have also been introduced. Rehabilitation professionals need to be aware of these advances and be able to incorporate this knowledge into the practice of rehabilitation medicine.

OVERALL ARTICLE OBJECTIVES

(a) To identify major categories of pulmonary disease seen in pulmonary rehabilitation, (b) to know appropriate interventions and support for patients with respiratory failure, (c) to describe the new interventions available for end-stage lung disease, and (d) to describe the appropriate pulmonary rehabilitation for people with pulmonary disease.

Changes in perceived health of children with congenital heart disease after attending a special sports camp

Sports camps for children with cardiac anomalies have existed for many years. However, no formal evaluation of the benefits of attending such camps has been undertaken heretofore. We assessed potential changes in the self-perceived health of children with congenital heart disease who attended a special sports camp. Thirty-one children with cardiac anomalies attended a 3-day multisports camp. Sixteen children, all of whom were 10 years or older, literate, and Dutch- or French-speaking, completed the Child Health Questionnaire (CHQ-CF87) before and after attending the camp. The scores of the children were compared with those of healthy peers by calculating mean standardized differences. After attendance at the sports camp, the children achieved significant improvements in the self-perception of their physical functioning, role functioning due to emotional problems, role functioning due to behavioral problems, mental health, and general behavior. The children's self-esteem and general behavior after the camp were significantly better than that of their healthy counterparts. We conclude that children with congenital heart disease who participate in activities at special sports camps may reap benefits in terms of their subjective health status. Although further research is needed, we recommend the participation in sport activities by children with heart defects, and more specifically their participation in sports camps.

Impact of cardiac rehabilitation on the exercise function of children with serious congenital heart disease

OBJECTIVES

The exercise capacity of children with congenital heart disease (CHD) is often depressed. This depression is thought to be attributable to (1) residual hemodynamic defects and (2) deconditioning secondary to physical inactivity. We hypothesized that this latter component would be ameliorated by a formal cardiac rehabilitation program designed specifically for children. The objective of this study was to characterize the effect of a cardiac rehabilitation program on the exercise performance of children with CHD and to define the physiologic mechanisms that might account for any improvements that are observed.

METHODS

Nineteen patients with CHD who were referred for exercise testing and found to have a peak oxygen consumption (VO2) and/or peak work rate <80% of predicted were enrolled in the study. Sixteen patients (11 Fontan patients, 5 with other CHD) completed the program and had postrehabilitation exercise tests, results of which were compared with the prerehabilitation studies.

RESULTS

Improvements were found in 15 of 16 patients. Peak VO2 rose from 26.4 +/- 9.1 to 30.7 +/- 9.2 mL/kg per min; peak work rate from 93 +/- 32 to 106 +/- 34 W, and the ventilatory anaerobic threshold from 14.2 +/- 4.8 to 17.4 +/- 4.5 mL/kg per min. The peak heart rate and peak respiratory exchange ratio did not change, suggesting that the improvements were not attributable merely to an increased effort. In contrast, the peak oxygen pulse rose significantly, from 7.6 +/- 2.8 to 9.7 +/- 4.1 mL/beat, an improvement that can be attributed only to an increase in stroke volume and/or oxygen extraction at peak exercise. No patient experienced rehabilitation-related complications.

CONCLUSION

Cardiac rehabilitation can improve the exercise performance of children with CHD. This improvement is mediated by an increase in stroke volume and/or oxygen extraction during exercise. Routine use of formal cardiac rehabilitation may greatly reduce the morbidity of complex CHD.

Six-Minute Walking Test to Assess Exercise Tolerance and Cardiorespiratory Responses During Training Program in Children With Congenital Heart Disease

This study assessed the exercise tolerance and the cardiorespiratory responses to a training program by the six-minute walk test (6'WT) in children with congenital heart disease (CHD). Seventeen cardiac and 14 healthy children performed maximal cardiopulmonary exercise test (CPET) and 6'WT. Reliability of 6'WT was assessed in all subjects (test-retest) by Bland-Altman plots. Cardiac subjects were randomly divided in training (T-CHD) and control groups (C-CHD). T-CHD underwent an individualized training exercise at the ventilatory threshold (VT) intensity during 12 weeks. We found that the 6'WT is a reliable and reproducible test. CHD children walked a lower distance than healthy children before training (472.5 +/- 18.1 vs. 548.8 +/- 7.7 m, respectively, p < 0.001). Likewise, power output, oxygen uptake (V.O (2)), and heart rate (HR) at the maximum and the VT levels, were significantly lower in patients (p < 0.001). After training, a significant improvement of walking distance (WD) was shown in T-CHD (529.6 +/- 15.3 vs. 467.7 +/- 17.1 m, p < 0.001). The power output, VO2, HR, and V.E increased slightly (6 to 10 %, p > 0.05) at peak exercise and significantly at ventilatory threshold level (p < 0.05) in T-CHD. Significant relationships between WD and VO2max as well as VO2 at VT were founded (p < 0.05). We concluded that the 6'WT is a useful and reliable tool in the assessment and follow-up of functional capacity during rehabilitation program in children with CHD.

Is the severity of congenital heart disease associated with the quality of life and perceived health of adult patients?

OBJECTIVE

To explore whether the severity of congenital heart disease is associated with the quality of life and perceived health status of adult patients.

DESIGN

Descriptive, cross sectional study.

SETTING

Adult congenital heart disease programme in one tertiary care centre in Belgium.

PATIENTS

629 patients (378 men, 251 women) with a median age of 24 years.

MAIN OUTCOME MEASURES

Disease severity was operationalized in terms of initial diagnosis (classification of Task Force 1 of the 32nd Bethesda Conference), illness course (disease severity index), and current functional status (New York Heart Association (NYHA) class, ability index, congenital heart disease functional index, and left ventricular ejection fraction). Quality of life was measured by a linear analogue scale, the satisfaction with life scale, and the schedule for evaluation of individual quality of life. Perceived health status was also assessed with a linear analogue scale.

RESULTS

Scores derived from the disease severity classification systems were weakly negatively associated with quality of life and health status, ranging from -0.05 to -0.27. The NYHA functional class and ability index were consistently associated with quality of life and perceived health.

CONCLUSIONS

This study showed that the severity of congenital heart disease is marginally associated with patients' quality of life and perceived health. Functional status was more related to patients' assessment of their quality of life than was the initial diagnosis or illness course.

Comparison of health related quality of life with cardiopulmonary exercise testing in adolescents and adults with congenital heart disease

OBJECTIVES

To compare self reported quality of life with measured exercise capacity in patients with congenital heart disease.

DESIGN

Prospective cross sectional clinical study.

SETTING

Tertiary referral centre for congenital cardiology.

PATIENTS AND METHODS

149 patients (60 female, 14-60 years old) with various congenital heart defects completed a health related quality of life questionnaire (medical outcomes study 36 item short form). Then they performed a cardiopulmonary exercise test on a bicycle in a sitting position.

RESULTS

Peak oxygen uptake correlated significantly with the physical functioning (r = 0.521, p < 0.0005) and general health scales (r = 0.313, p < 0.0005) but not with role-physical, bodily pain, vitality, social functioning, role-emotional, mental health, and health transition scales. Closer examination of the data showed that despite an overall good correlation a substantial number of patients overestimated their physical capabilities.

CONCLUSIONS

Exercise tests and quality of life instruments should be used together to get an appropriate overview of the health status of patients with congenital heart disease.

Educational and behavioral issues in transitioning from pediatric cardiology to adult-centered health care

It is assumed that when they begin growing up, a child with congenital heart disease will take personal responsibility for his or her care. For this purpose, patients need sufficient knowledge on the heart defect, treatment,and measures to prevent complications. However, empirical studies indicated that the levels of knowledge and understanding of both parents and children with congenital heart disease are poor. Therefore, sound patient education is imperative, particularly when patients are transitioned from pediatric cardiology to adult congenital cardiology. In this respect, the focus of communication shifts from the parent to the young patient; moreover, education should be tailored according to the developmental level of the patient. Issues that should typically be covered by educational programs for adolescents with congenital heart disease are information on the heart defect, treatment, endocarditis, sexuality and reproduction, sports, employability and insurability, and cardiovascular risk factor. International guidelines indicate that advanced practice nurses are key in developing and implementing patient education programs during the transition from pediatric cardiology to adult-centered health care.

Adolescents in transition of adult care: why the concern?

This article has described issues associated with transition planning for youth with CHD. A number of approaches have been described to address the needs of this growing number of youth with CHD. Transition to adulthood has been and will continue to be a significant clinical concern as the adult survival rate increases. Health care professionals who are involved in transition planning will be focused on the health-related concerns of the transfer to an ACHD, insurability, and long-term CHD management, as well as issues related to employment, education, social relationships, and independent living. Successful transitioning is dependent on long-term planning,. youth-centered approaches, service coordination, and referral to adult agencies. As youth, families, adult survivors, and experts have discovered, long-term survival means more than the physical aspects of CHD.

Psychosocial issues affecting adults with congenital heart disease: one patient's perspective

This article addresses a number of psychosocial issues that advance practice nurses and other health care providers should be aware of when working with patients who have congenital heart disease. If not properly addressed, particularly during adolescence, these issues can have a strong impact on a person's medical care and over-all quality of life. This article includes information from medical literature, conversations with adult patients, and my own experiences as both a patient with congenital heart disease and as a clinical social worker.

Occupational performance challenges for children with congenital heart disease: a literature review

BACKGROUND

Paediatric specialists have advocated for exercise training programs for children with congenital heart disease without addressing other common deficits, such as behavioural and psychological problems. Despite evidence of the role of occupational therapy in rehabilitation for adults with cardiac disease, there has been little published about occupational therapy for children with congenital heart disease.

PURPOSE

This literature review on the outcomes of congenital heart disease, guided by the Canadian Model of Occupational Performance, highlights the comprehensive needs of these children.

RESULTS

The findings of the review are that congenital heart disease can have wide-ranging neurological and psychosocial implications. This suggests that occupational therapists should be concerned about limitations in the participation of these children in age-appropriate childhood occupations related to self-care, productivity or leisure.

PRACTICE IMPLICATIONS

As cardiac rehabilitation program planning becomes more commonplace for children, comprehensive programs that promote optimal occupational performance need to be developed, implemented and evaluated.

Life insurance and mortgage application in adults with congenital heart disease1

OBJECTIVE

To compare the outcome of life insurance and mortgage applications of adults with congenital heart disease (CHD) with controls and at different severities of CHD.

METHODS

Two hundred and ninety-nine adult CHD patients underwent a questionnaire-based interview by a trained nurse. They were asked to give an identical questionnaire to a friend to act as a control. One hundred and seventy-seven controls replied. CHD patients were classified into three categories based on severity. Comparisons were made between matched controls and between different severities of CHD.

RESULTS

Similar proportions of the CHD group (59%) had applied for life insurance as matched controls (56%). Compared to controls, significantly more of the adults with CHD who had applied for life insurance have been refused (34 vs 4%, P < 0.0001) or asked to pay extra (37 vs 6%, P = 0.0002). Mortgage application rate was also similar in both groups with more of the CHD patients refused than matched controls (20 vs 3%, P = 0.0004). These differences in both life insurance and mortgage remain significant when the cases and controls are matched by employment status and NYHA functional class. There was no significant difference in life insurance and mortgage application outcome between the groups of mild, significant and complex CHD.

CONCLUSIONS

Adults with CHD are significantly more likely to have difficulty obtaining life insurance or a mortgage than controls. Refusal rates appear to be independent of the severity of CHD. This suggests that the label of CHD may have a negative impact despite the lesion being minor and that the outcome of an individual application is difficult to predict based on the severity of the CHD. The increasing numbers of adults with CHD suggest that this problem is likely to increase and needs to be addressed as it can have a major impact on the patient's quality of life.

Length of stay after infant heart surgery is related to cognitive outcome at age 8 years

OBJECTIVE

To test the hypothesis that postoperative length of stay (LOS) after infant heart surgery might be an easily measured surrogate marker for various events that culminate in later adverse cognitive outcome.

METHODS

Among 160 eligible patients with D-transposition of the great arteries undergoing reparative surgery in infancy, 155 (97%) were reevaluated at age 8 years with IQ and achievement testing. We explored whether LOS quartiles were associated with these outcomes when adjusting for perioperative and sociodemographic variables.

RESULTS

Longer cardiac intensive care unit (CICU) LOS quartiles were associated at age 8 years with lower full-scale IQ (P=.02), lower verbal IQ (P=.02), and with tendencies toward lower performance IQ (P=.08) and math achievement (P=.08) in adjusted models. Compared with patients in the first quartile of CICU LOS, those in the fourth quartile had mean scores for full-scale IQ that were lower by 7.2 points (P=.01); verbal IQ, 7.3 points (P=.02); performance IQ, 5.8 points (P=.05); and math achievement, 6.0 points (P=.07). Analyses on hospital LOS quartile were similar.

CONCLUSIONS

Longer postoperative LOS is associated with worse later cognitive function, even when adjusted for perioperative events, perfusion times, and sociodemographic variables. Further research is necessary to determine the mechanisms underlying this relation.

Use of complementary and alternative medical therapies among children with special health care needs in southern Arizona

OBJECTIVE

The objective of this study was to assess the frequency and type of complementary and alternative medicine (CAM) therapies used by families of children with special health care needs in southern Arizona, as well as the correlates of their use.

METHODS

Families of 376 children who were receiving services in a regional facility that serves children with special health care needs and were residing in southern Arizona were surveyed regarding CAM use.

RESULTS

Sixty-four percent of these families reported using CAM for their child. The most common CAM therapies were spiritual healing/prayer/blessings. Of the conditions that were evaluated as correctable, the use rate was 24% as compared with a 76% use rate for children with a nonrepairable condition. Use of CAM for the child was strongly related to the use of CAM in the past by the family member who responded to the survey. The reasons that parents most frequently chose for using CAM were advice from a medical practitioner and advice from a family member.

CONCLUSIONS

Use of CAM for children with special health care needs is common. Its frequency and type are significantly associated with the child's condition and prognosis.

The views of parents concerning the planning of services for rehabilitation of families of children with congenital cardiac disease

BACKGROUND AND PURPOSE

Although much previous research has focused on the medical aspects of congenital cardiac disease, there is a growing body of research which suggests that families may need help and support with the wider issues associated with the medical condition. We have previously ascertained from young people with congenital cardiac disease their views on this subject. The purpose of this study was to obtain the views of their parents about the need for, and shape of, services for rehabilitation.

METHODS

This was a qualitative study using semi-structured interviews. We interviewed 17 parents in their own home. Interviews were tape-recorded and transcribed.

RESULTS

Parents would welcome more help and support from health professionals to enable them to manage more effectively the condition with their children. Particular areas of concern relate to the information they receive about the condition; communication between themselves and health professionals; establishing safe levels of activity; and managing the condition at school.

CONCLUSIONS

This is a small study of the experiences and views of parents, which provides some important information on ways in which health professionals could address the current lack of services for rehabilitation.

Quality of life experienced by adults with congenital heart disease

Adults with congenital heart disease (CHD) represent a growing population of patients. Medical and surgical advances have increased the number of CHD adult survivors, which may create quality-of-life (QOL) issues not previously considered. Quality-of-life issues pertinent to this patient population involve health and life insurance acquisition, birth control, genetic counseling, pregnancy concerns, employment, and independent living arrangements. The purpose of this study was to describe the QOL of adults with CHD. The study used a prospective cross-sectional case-control design to examine QOL using the Sickness Impact Profile (SIP). The study participants were a sample of 124 adults with CHD from an outpatient cardiology clinic in a metropolitan university-affiliated teaching hospital in the Northeast and 124 matched healthy control subjects. Between the participants and the matched control subjects, there was a significant difference in the total mean SIP score, the physical and psychosocial dimension scores, and all the category scores (P < 0.05). The areas of life the adults with CHD reported as lacking in quality involved the categories of work (SIP of 11.1, moderate disability) and sleep and rest (SIP of 9.03, mild disability). The results of this study indicate that the SIP can be used for quantitative and subjective QOL assessment of adults with CHD. It is suggested that cardiac advanced practice nurses use the results of this study to develop appropriate information, counseling, and anticipatory guidance for this patient population.

[Social problems and rehabilitation of operated or unoperated adults with congenital heart disease]

Advances in surgical management have enabled a large number of children with cardiac malformations, even very severe lesions, to reach adulthood. Besides the purely medical problems which may persist, difficulties in social and professional integration may alter their quality of life and raise doubts about the utility of treatment. It is necessary to assess the symptoms, the causes and therapeutic options available, as if this situation was a true illness. The quality and precocity of surgical techniques make the outcomes more optimistic in adulthood, but those patients now over 30 years of age have difficulties in founding a family and do not enjoy the same chances of training as the rest of the population, even though they may get more acceptable jobs than in previous years. To this end, legislative help may be useful in the most difficult cases.

Provision of services for rehabilitation of children and adolescents with congenital cardiac disease: a survey of centres for paediatric cardiology in the United Kingdom

A postal questionnaire survey of the 17 centres for paediatric cardiology in the UK investigated the attitudes of staff towards rehabilitation and the current level of provision. The majority of respondents (82%) believed they should provide rehabilitation for their patients, but only one centre had a programme for rehabilitation. Few respondents (18%) believed they were meeting the needs of their patients' for rehabilitation. Major barriers to providing rehabilitation were funding and the wide geographical catchment areas.

[Social concern and independence in adults with congenital heart disease]

OBJECTIVES

Recent advances in medical and surgical treatment have led to the survival of increasing numbers of adults with congenital heart disease (CHD). However, the social status of these patients remains unknown. This survey investigated the social prospects for adults with CHD, and the limiting factors for social independence.

METHODS

A written questionnaire on patient characteristics, education, employability, marital status and insurability was designed to define the characteristics of social independence in adults with CHD. Randomly selected adults with CHD were enrolled: 13 patients with cyanotic unrepaired CHD (4 males, 9 females, mean age: 29.8 +/- 10 years, range: 18-56 years) and 102 patients with other CHDs (48 males, 54 females, mean age: 29.5 +/- 10 years, range: 18-74 years).

RESULTS

University of California at Los Angeles functional class I-II was found in 94% of patients, medication in 46%, and hospitalization in 51%. Compared with the data from Japanese general population, study patients had a lower ratio of high school graduates (86% vs 94%), life insurability (51% vs 71%), marital status (31% vs 32%) and employability (82% vs 80%). Patients with unrepaired cyanotic CHD had significantly lower ratio than those with other CHDs (marital status 15%, p = 0.19; employability 40%, p = 0.0003; high school graduates 69%, p = 0.06; life insurability 18%, p = 0.02, respectively).

CONCLUSIONS

Factors affecting social independence in adults with CHD were severity of disease, continuing medication, lower level of education, lower self-esteem, and unknown natural history of CHD. To improve social independence in these patients, further development of medical and surgical therapy and more detailed knowledge of the patients, caretakers and society in this field are needed.

Exercise and sports participation after surgery for congenital heart disease: the European perspective

The success of surgery for congenital heart disease which has been performed since many years has created a population of patients who require careful follow-up in order to determine their clinical progress and to establish the type and intensity of physical activity which they can safely perform. The authors illustrate the opinion of the European Community regarding children, sport and organizational aspects and also problems concerning the management of pediatric cardiac patients in Europe and Italy. Cardiological and surgical aspects are considered together with the practice of physical activity, with emphasis upon the differences between the various countries. Particular attention is paid to the Italian legislation regarding the certification to participate in competitive or non-competitive sport in such a population of patients. Great importance is given to pediatric cardiac rehabilitation programs which aim at improving the aerobic fitness of patients operated upon for complex congenital heart disease and at illustrating their own cardiovascular limitations so that they can perform physical exercise with the utmost safety.

Holt-Oram syndrome. Three case reports and their physiotherapeutic, ergotherapeutic, and technical orthopedic treatment

The combination of organ and skeletal malformation as well as the fact that Holt-Oram syndrome appears in many forms with related functional disturbances and makes it mandatory that the therapy for these patients be determined on an individual basis. Supportive statomotoric therapy of young patients plays a particularly central role, as do development-synchronized treatment aids. Physiotherapy, ergotherapy, and technical orthopedic support oriented toward functionality are all part of the therapeutic concept.