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

Thank you for your attention

Massimo Chessa

Thank you for your attention

Massimo Chessa

Targu Mures-Romania