Effects of aerobic exercise training in children after the Fontan operation

doi:10.1016/j.amjcard.2004.08.085

The American Journal of Cardiology

Volume 95, Issue 1, 1 January 2005, Pages 150-152

https://doi.org/10.1016/j.amjcard.2004.08.085 Get rights and content

It was demonstrated that patients who have undergone the Fontan operation can safely undertake exercise training and that this results in an improvement in aerobic capacity. These findings suggest that aerobic training could be useful in the long-term management of these patients to optimize their cardiovascular fitness for more active lives.

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Acknowledgment

We gratefully acknowledge Francesca Forner, Francesca Gasbarro, and Professor Giorgio Andreaggi for their excellent assistance during the exercise training session and Cecilia Giron, MD, for the statistical analysis.

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Cited by (66)

The impact of exercise and cardiac rehabilitation on the outcomes of children with repaired congenital heart disease: A scoping review
2024, Progress in Pediatric Cardiology
Over 90 % of children with congenital heart disease reach adulthood but remain at risk of significant morbidity and comparative early mortality when compared to the general population. These patients have lower exercise capacity, are often restricted by parents and medical practitioners, and are more likely to be obese. Cardiac rehabilitation aims to improve cardiovascular health and quality of life by utilizing exercise prescription, education, and nutritional and psychosocial assessment.
Previous meta-analyses have focused on the safety of exercise training and rehabilitation and shown there is insufficient evidence to ascertain the impact of exercise training in patients with CHD. This scoping review will instead aim to determine what impact exercise programs and cardiac rehabilitation can have on the outcomes of children with repaired CHD, identify and analyze gaps in this literature, look at specific subgroups of CHD patients, and make recommendations for future research.
There is a potential minimum effective cardiac rehabilitation duration of 12 weeks of twice-weekly exercise sessions, each of at least 20 min in duration. CPET can be used to define target HR and judge exercise effect, and utilizing this target HR with some form of patient monitoring can improve concordance.
In addition, Fontan patients may be better at submaximal exercise and may benefit the most from exercise rehabilitation with potential long term positive effects.
Quality of Life (QoL) scales have significant benefits and can be used as a tool for demonstrating clinical objective effects of exercise training, as well as to show families improvements in psychosocial metrics.
Finally, all studies that re-assessed children following completion of the rehab program showed sustained improvement in submaximal, maximal, and QoL metrics, giving reassurance that the rehabilitation effect is not temporary and effects on outcomes are likely to be long-lasting.
Becoming ‘Super Fontan’: Is slim and athletic the best prescription to improve prognosis in patients with Fontan circulation?
2023, International Journal of Cardiology
Barriers to completion of a novel pediatric cardiac rehabilitation program
2021, Progress in Pediatric Cardiology
Pediatric cardiac rehabilitation addresses physical and emotional challenges related to underlying heart disease. While the benefits of cardiac rehabilitation have largely been established, the challenges that patients and their families experience when participating in these programs have yet to be examined in detail. In this study, we evaluated the barriers that families face when asked to complete a structured cardiac rehabilitation program.
The objectives of this study were to measure the success of a novel pediatric cardiac rehabilitation program and to evaluate the barriers that families face when asked to complete a structured cardiac rehabilitation program.
Parents of patients referred for cardiac rehabilitation and who attended at least one session were recruited to participate in a phone survey regarding their experience using a published psychometric validation of the cardiac rehabilitation barriers scale.
9 families participated in the study. 67% of patients were male and 3 patients completed the program in its entirety. Challenges associated with time, travel, and insufficient insurance coverage, were the highest rated barriers to completion of the rehabilitation program. Families universally enjoyed the program. 5 of 9 felt that the biggest positive of the experience was gaining an understanding of what exercise is safe. 3 of 9 stated that cardiac rehabilitation should be a standard component of therapy for all pediatric cardiology patients.
Pediatric cardiac rehabilitation is effective and liked by families. The barriers to completing a structured in-person program are difficulty getting to appointments due to time and travel and level of insurance coverage for the program. As such, ensuring insurance coverage and perhaps virtual rehab programs would be beneficial.
Aerobic exercise and inspiratory muscle training increase functional capacity in patients with univentricular physiology after Fontan operation: A randomized controlled trial
2021, International Journal of Cardiology
The effect of exercise training and its mechanisms on the functional capacity improvement in Fontan patients (FP) are virtually unknown. This trial evaluated four-month aerobic exercise training and inspiratory muscle training on functional capacity, pulmonary function, and autonomic control in patients after Fontan operation.
A randomized controlled clinical trial with 42 FP aged 12 to 30 years and, at least, five years of Fontan completion. Twenty-seven were referred to a four-months supervised and personalized aerobic exercise training (AET) or an inspiratory muscle training (IMT). A group of non-exercise (NET) was used as control. The effects of the exercise training in peak VO₂; pulmonary volumes and capacities, maximal inspiratory pressure (MIP); muscle sympathetic nerve activity (MSNA); forearm blood flow (FBF); handgrip strength and cross-sectional area of the thigh were analyzed.
The AET decreased MSNA (p = 0.042), increased FBF (p = 0.012) and handgrip strength (p = 0.017). No significant changes in autonomic control were found in IMT and NET groups. Both AET and IMT increased peak VO2, but the increase was higher in the AET group compared to IMT (23% vs. 9%). No difference was found in the NET group. IMT group showed a 58% increase in MIP (p = 0.008) in forced vital capacity (p = 0.011) and forced expiratory volume in the first second (p = 0.011). No difference in pulmonary function was found in the AET group.
Both aerobic exercise and inspiratory muscle training improved functional capacity. The AET group developed autonomic control, and handgrip strength, and the IMT increased inspiratory muscle strength and spirometry.
Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02283255
The Fontan circulation: Is exercise training the solution?
2020, Progress in Pediatric Cardiology
The Fontan circulation lacks a subpulmonary ventricle and relies on non-cardiac forces for pulmonary blood flow to provide preload to the systemic ventricle, resulting in low cardiac output and systemic venous hypertension. Most people living with a Fontan circulation have reduced exercise capacity, which is predominantly related to inadequate preload-reserve.
In the absence of a subpulmonary ventricle, the contributions of the skeletal and thoracic muscle pumps to enhance venous return become vitally important. Concerningly, reduced skeletal muscle mass and higher rates of adiposity are found in those living with a Fontan and contribute to impaired muscle pump function and suboptimal outcomes. Although historically cautioned against moderate to vigorous physical activity, exercise training is safe and the most effective, non-invasive ‘therapy’ to improve exercise capacity in the Fontan population. Regular exercise is also a highly effective means to improve quality of life, mental health, and perceived health. Exercise training in the Fontan setting leads to improved skeletal muscle pump function and enhanced stroke volume and has consistently been shown to enhance peak oxygen consumption. Despite limited data, the thoracic muscle pump is also likely improved by exercise-mediated reductions in adiposity and improved respiratory muscle function. Whether advantageous cardiac and pulmonary vascular remodeling occurs related to increased flow and preload requires further investigation.
Encouraging an active and healthy lifestyle from a young age is essential in this unique population.
Physical Activity Promotion in Pediatric Congenital Heart Disease: Are We Running Late?
2020, Canadian Journal of Cardiology
Low levels of habitual physical activity in children and adolescents with congenital heart disease (CHD) leads to various negative health outcomes, yet review of the literature indicates that many physicians, caregivers, and patients restrict physical activity owing to safety concerns. There is no evidence supporting absolute restriction of physical activity in pediatric patients with CHD; in fact, physically active lifestyles are as important for pediatric patients living with CHD as for the general population. To encourage long-term maintenance of physically active lifestyles, physical activity counselling and exercise prescription should be started early in childhood and be a core component of every patient encounter. Physical activity counselling should include clear messaging from physicians about recommended physical activities—not just restrictions—and a personalised written exercise prescription for the patient and family. Regular follow-up is essential to ensure adherence to recommendations, monitor patient responses to the increased physical activity level, and long-term surveillance. This review discusses the importance of a physically active lifestyle in children and adolescents with and without surgically repaired CHD and hypertrophic cardiomyopathy, excluding those with electrical abnormalities and channelopathies. It outlines gaps in knowledge regarding best practices for physical activity promotion in these patient populations, and provides recommendations on how to include physical activity promotion and exercise prescription in clinical practice based on existing literature. An important role for clinicians is identified, because the type of messaging they provide regarding physical activity will have a major impact on patients’ and families’ decisions to adopt an active lifestyle.
Le manque d’activité physique régulière chez les enfants et les adolescents présentant une cardiopathie congénitale nuit de différentes manières à la santé et pourtant, une revue de la littérature révèle que beaucoup de médecins, d’aidants et de patients limitent l’activité physique pour des raisons de santé. Rien n’indique pourtant qu’il soit nécessaire d’interdire l’activité physique chez les enfants présentant une cardiopathie congénitale; au contraire, un mode de vie physiquement actif est aussi important pour ces patients que pour la population générale. Pour favoriser l’adoption à long terme d’un mode de vie actif, il convient de mettre en place un programme de counseling visant à encourager l’instauration d’un régime d’exercice physique tôt durant l’enfance; cette intervention devrait faire partie du traitement de tous les patients vus en consultation. Le counseling sur l’activité physique doit transmettre des messages clairs quant aux recommandations en matière d’activité physique – et non seulement quant aux restrictions; le médecin devrait remettre par écrit un plan d’activité physique personnalisé au patient et à sa famille. Un suivi régulier est essentiel pour assurer l’adhésion aux recommandations, surveiller les effets de l’augmentation de l’activité physique et exercer une surveillance à long terme. Nous discutons ici de l’importance d’un mode de vie physiquement actif pour les enfants et les adolescents atteints d’une cardiopathie congénitale ou d’une cardiomyopathie hypertrophique (ayant ou non fait l’objet d’une réparation par voie chirurgicale), exception faite de ceux qui présentent des anomalies électriques ou une canalopathie. Nous soulignons en outre le manque de connaissance des pratiques exemplaires en matière de promotion de l’activité physique auprès de ces populations de patients et, en nous fondant sur la littérature publiée, nous formulons des recommandations sur la façon d’inclure dans la pratique clinique la promotion de l’activité physique et la prescription d’un régime d’exercice physique. Les cliniciens ont un rôle important à jouer à cet égard, parce que la teneur des messages qu’ils transmettent au sujet de l’activité physique aura une grande incidence sur les décisions du patient et de sa famille quant à l’adoption d’un mode de vie actif.

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Brief reportsEffects of aerobic exercise training in children after the Fontan operation

Section snippets

Acknowledgment

J Am Coll Cardiol

J Am Coll Cardiol

Lancet

Cardiol Clin

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Effect of physical training on exercise performance of children following surgical repair of congenital heart disease

Pediatrics

Exercise response in patients with congenital heart disease after Fontan repair: patterns and determinants of performance

J Am Coll Cardiol

Brief reports
Effects of aerobic exercise training in children after the Fontan operation