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Pediatric Cardiology Department & Adult with Congenital Heart Disease
IRCCS Policlinico San Donato
Dr Massimo Chessa
CLINICAL CONSIDERATIONS
ADULT WITH CONGENITAL HEART DISEASE
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
CLINICAL CONSIDERATION
Exercise and Training
General health promotion and aerobic capacity improvements are the goal of exercise programs
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
There are two types of exercise:
• isotonic (also called dynamic):1. Volume overload
2. Oxygen consumption, HR, Stroke Volume, CO, SBP
• isometric (also called static):
1. Pressure overload (that can cause a sudden increase of BP)
2. Limited increase of oxygen consumption and CO
Exercise and Training
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Many pts with CHD have reduced aerobic capacity, due to both the heart disease and the low level of physical activity.
Exercise and Training
Even a modest increase in aerobic capacity may have a striking effect in those with congenital heart disease, and permit employment and improve social life.
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
•ECG
•Oxygen saturation
•BP
•Spirometry
•Maximal exercise test (if possible)
•Measurement of Oxygen uptake (cardiopulmonary exercise test)
Testing procedure
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
In pts repaired with a current mean pulmonary artery pressure of less than 25 mmHg and without arrhythmias, physical activity should not be limited
Limitation if PH or serious or uncontrolled Arrhythmias
Kaplan S. Philadelphia: WB Saunders; 1991:166-177
Some common lesions: II ASD
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
VSD repaired in early childhood with normal ventricular function, a mean pulmonary BP and trivial or no residual shunt
Some common lesions: VSD
Kaplan S. Philadelphia: WB Saunders; 1991:166-177
Small VSD no repaired
No restrictions
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Pts with significat residual shunt (Qp/Qs > 1.5) and mean pulmonary pressure > 25 mmHg
Some common lesions: VSD
Kaplan S. Philadelphia: WB Saunders; 1991:166-177
Isotonic exercise of mild intensity and limited duration; avoid isometric exercise
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
VSD and PH
Some common lesions: VSD
Kaplan S. Philadelphia: WB Saunders; 1991:166-177
No exercise because of risks of precipitating a
clinical event
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Risk of hypertension during exercise
Some common lesions: CoAo
Exercise testing if competitive sports are
being discussed
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Pts with a mean resting gradient lower than 20 mmHg
Some common lesions: AS
No restrictions
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Pts with a mean resting gradient of 20-40 mmHg
Some common lesions: AS
Should be advised to restrict themselves to low-intensity isotonic exercise
Graham TP jr. JACC 1994;24:867-73
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Pts with a mean resting gradient > 40 mmHg
Some common lesions: AS
Should be restricted from competitive and strenous
exercise!!
Risk of syncope and SDGraham TP jr. JACC 1994;24:867-73
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Exercise risks are related to:
1. RV pressure
2. Residual VSD
3. RV dilatation
Some common lesions: ToF
Fredriksen PM. Cardiol Young 2002;12:554-9
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Mean RVP < 25 mmHg
Mild PR
Trivial or no residual VSD
Normal RV dimension
Some common lesions: ToF
Fredriksen PM. Cardiol Young 2002;12:554-9
No restrictions
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Gradual widening of the QRS duration in the ECG and/or
Arrhythmias during exercise
Some common lesions: ToF
Restrictions
In pts with RVOT obstruction and
residual shunting
Isotonic exercise may induce hypoxemia by an increase in subpulmonary obstruction and reduction in SR, impairing pulmonary blood flow
Exercise test is mandatory in such pts
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Isometric exercise should likewise be avoided, because an abrupt increase in systolic blood pressure can direct blood
to the lungs and cause a significant reduction in systemic CO
Some common lesions: ToF
Fredriksen PM. Cardiol Young 2002;12:554-9
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
Generally, physical activity should be restricted to moderate intensity and duration in pts after Senning/Mustard.
Some common lesions: TGA
Hechter S. Am J Cardiol 2001;87:660-3
Exercise test is strongly recommended
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
There are not substantial data about pts who have that had a switch operation:
* be careful about AR
* be careful about coronary problems
Some common lesions: TGA
Exercise test is recommended
Pediatric Cardiology Department & Adult with Congenital Heart Disease
Dr Massimo Chessa
In Fontan pts moderate isotonic and isometric exercise is usually well tollerated.
Be careful if arrhythmias or depression of the ventricular function is present!
Some common lesions: Univentricular heart
Exercise test is strongly recommended