title: Cardiovascular responses to treadmill and cycle ergometer exercise in children and adults. Severely Impaired Cardiac Autonomic Nervous Activity After the Fontan Operation Results of exercise testing at a mean age of 10 years after neonatal arterial switch operation Exercise capacity after complete repair of tetralogy of Fallot: deleterious effects of residual pulmonary regurgitation. Measurement and validity of the ventilatory threshold in patients with congenital heart disease Cardiopulmonary exercise parameters in children with atrial septal defect and increased pulmonary blood flow: short‐term effects of defect closure Six-minute walking test to assess exercise tolerance and cardiorespiratory responses during training program in children with congenital heart disease.
abstract: This study was conducted to determine whether submaximal cardiovascular responses at a given rate of work are different in children and adults , and , if different , what mechanisms are involved and whether the differences are exercise-modality dependent . A total of 24 children , 7 to 9 yr old , and 24 adults , 18 to 26 yr old ( 12 males and 12 females in each group ) , participated in both submaximal and maximal exercise tests on both the treadmill and cycle ergometer . With the use of regression analysis , it was determined that cardiac output ( Q ) was significantly lower ( P < /= 0.05 ) at a given O2 consumption level ( VO2 , l/min ) in boys vs. men and in girls vs. women on both the treadmill and cycle ergometer . The lower Q in the children was compensated for by a significantly higher ( P < /= 0.05 ) arterial-mixed venous O2 difference to achieve the same or similar VO2 . Furthermore , heart rate and total peripheral resistance were higher and stroke volume was lower in the children vs. in the adult groups on both exercise modalities . Stroke volume at a given rate of work was closely related to left ventricular mass , with correlation coefficients ranging from r = 0.89 - 0.92 and r = 0.88 - 0.93 in the males and females , respectively . It was concluded that submaximal cardiovascular responses are different in children and adults and that these differences are related to smaller hearts and a smaller absolute amount of muscle doing a given rate of work in the children . The differences were not exercise-modality dependent Background —Elevated neurohumoral activity and an abnormal cardiopulmonary response to exercise are well-established characteristics in patients after the Fontan operation .  However , there have been few studies addressing cardiac autonomic nervous activity ( CANA ) in these patients . Methods and Results —We evaluated CANA in 63 post-Fontan patients and 44 controls . Cardiac parasympathetic nervous activity ( PSNA ) was estimated by heart rate ( HR ) changes after cholinergic blockade , HR variability , and arterial baroreflex sensitivity . Cardiac sympathetic nervous activity was estimated by the heart to mediastinum [123I]metaiodobenzylguanidine activity ratio ( H/M ) and the HR increase ( & Dgr;HR ) after isoproterenol infusion ( & bgr ; ) . & Dgr;HR and peak oxygen uptake ( & OV0312;o2 ) were measured by exercise test . There was no difference in & bgr ; between the Fontan group and controls . PSNA and H/M were markedly lower than in controls ( P < 0.001 ) . PSNA and & bgr ; were related to & Dgr;HR ( P < 0.05 ) ; however , peak & OV0312;o2 was not correlated with & Dgr;HR . Neither PSNA nor H/M was associated with clinical features , including hemodynamics , type of repair , number of surgical procedures , age at Fontan operation , or follow-up period , and administration of an angiotensin-converting enzyme inhibitor did not improve the impaired CANA in these patients . Conclusions —After the Fontan procedure , postsynaptic & bgr;-sensitivity is maintained and is important in & Dgr;HR during exercise as is PSNA , although & Dgr;HR does not determine exercise capacity . The lack of a relationship between CANA and clinical features implies that , in addition to surgical damage , the Fontan circulation per se may impair CANA . Angiotensin-converting enzyme inhibitor administration does not change this abnormality Aim : This prospect i ve follow‐up study investigated long‐term exercise capacity at a mean age of 10 y after neonatal arterial switch operation for transposition of the great arteries in a large group of homogeneous unselected children . Methods : 56 asymptomatic children , aged 7.9–14.3 y ( 10.5 ± 1.6 , mean ± SD ) , were examined with respect to exercise tolerance , electrocardiographic ( ECG ) response and activity of biochemical markers for myocardial injury . The protocol included st and ard electrocardiography , M‐mode and two‐dimensional echocardiography at rest , a Bruce walking treadmill test to voluntary exhaustion , and determination of cardiac troponin I and T , creatine kinase and myoglobin from venous blood sample s at rest and 4 h after exercise . Heart rate , blood‐pressure response to exercise stress and endurance time were compared with published results of age‐matched normal children . Results : 54 patients ( 96.4 % ) had normal exercise capacity ; a reduction in 2 patients was not due to cardiac disease . Heart rate and systolic blood pressure rose significantly between rest and peak exercise and did not differ from normal controls , whereas diastolic blood pressure was lower . ECG remained normal at rest and on exercise in 54 children ( 96.4 % ) . Serum values of cardiac troponin I and T , creatine kinase and myoglobin were normal at rest and after exercise in all patients OBJECTIVE --To determine the effects of residual pulmonary regurgitation on exercise tolerance after complete repair of tetralogy of Fallot . DESIGN -- Prospect i ve study of symptom free patients more than five years after complete repair .  Grade d exercise performance was measured with st and ard Bruce protocol .  Maximal oxygen uptake and ventilatory anaerobic threshold were measured by respiratory mass spectrometry . Measurement of pulmonary regurgitant fraction was from pressure-volume loops constructed from measurements of right ventricular volume obtained from biplane angiograms and simultaneous pressures measured with a micromanometer . SETTING --Tertiary referral centre . PATIENTS --16 patients were studied . Two patients had been excluded because of residual cardiac lesions or inadequate data from cardiac catheterisation . Four were later excluded because they failed to reach a respiratory quotient of greater than 1.0 during grade d exercise . RESULTS --There was a significant negative correlation between the degree of residual regurgitation and both total duration of exercise and maximal heart rate achieved . Maximal heart rate and total duration of exercise were significantly lower in the patients than in normal controls . Patients with an abnormal maximal oxygen uptake ( less than 85 % of the predicted normal value ) had significantly greater residual pulmonary regurgitation than those in whom oxygen uptake was normal . CONCLUSIONS --Impaired exercise capacity after complete repair of tetralogy of Fallot is directly related to the degree of residual pulmonary regurgitation . These data should be taken into account when deciding the optimal timing and nature of corrective surgery Abstract The purpose of the present study was to measure oxygen uptake $ $ ( \dot VO_2 ) $ $ at the ventilatory threshold ( VT ) in patients with congenital heart disease using a progressive exercise protocol on a treadmill and to evaluate the validity and feasibility of this procedure . Eight control subjects and seventeen patients performed a maximal exercise test with breath-by-breath measurement of ventilation and gas exchange variables . VT(VE ) was determined by the change in the ventilatory equivalent for $ $ \dot VO_2 $ $ and carbon dioxide output , VT(V-sl ) by the V-slope method , and the lactate threshold ( LT ) by the change in blood lactate concentration ; these parameters were determined in 100 % , 88 % , and 96 % of subjects , respectively . The interobserver error among three evaluators was not significant , and LT was correlated with each VT ( r=0.97 , 0.92;p=0.0001 ) and with peak $ $ \dot VO_2 $ $ ( r=0.91;p=0.0001 ) . The VTs were correlated with each other when expressed as milliliter per minute and milliliters per kilogram per minute . It was concluded that a progressive exercise protocol on a treadmill was a feasible procedure for determining the VTs in most individuals and that VTs were valid , useful parameters for evaluating submaximal exercise tolerance in patients with congenital heart disease Markedly increased pulmonary blood flow because of a relevant atrial septal defect ( ASD ) leads to impaired cardiopulmonary function during maximum exercise in adults . No comparative preoperative and postoperative data are available on the short‐term effects of shunt closure on cardiorespiratory function at peak exercise in children .  Pulmonary function testing at rest and cardiopulmonary exercise testing together with haemodynamic assessment was done prospect ively in children with an ASD preoperatively and again after full recovery at 3–4 mo postoperatively and compared with a matched normal population . Sixteen children , aged 6.8–16.1 y , with a defect of 8–23 mm ( median 15 mm ) and a pulmonary/systemic flow ratio of 1.5–3.5 ( median 2.2 ) were tested and compared with 15 healthy children . Preoperatively , baseline pulmonary function parameters and exercise capacity were no different from normals . At peak exercise , patients with a shunt had increased pulmonary resistance , especially of the distal airways ( p= 0.04 ) , with a significantly larger proportion of children having a paradoxical increase in total airway resistance during exercise ( p < 0.05 ) . Maximum serum lactate at peak exercise was elevated ( p < 0.05 ) in patients . In patients , maximum oxygen uptake was impaired ( p= 0.03 ) and remained so at repeat evaluation postoperatively . The same observation was made for chronotropic response to exercise 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 Bl and -Altman plots . Cardiac subjects were r and omly 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
target: Children and adolescents with CHD have lower VO2max and HR compared to controls
background: BACKGROUND Children and adolescents with congenital heart disease often have alterations in their exercise capacity that can be evaluated by various functional testing .
  OBJECTIVE To evaluate the functional capacity of children and adolescents with congenital heart disease ( CHD ) with systematic review and meta-analyses .