Pediatric Cardiology

, Volume 40, Issue 1, pp 71–78 | Cite as

Determinants of Exercise Performance in Children and Adolescents with Repaired Tetralogy of Fallot Using Stress Echocardiography

  • Shivani M. BhattEmail author
  • Okan U. Elci
  • Yan Wang
  • Elizabeth Goldmuntz
  • Michael McBride
  • Stephen Paridon
  • Laura Mercer-Rosa
Original Article


Exercise performance is variable and often impaired in patients with repaired tetralogy of Fallot (rTOF). We sought to identify factors associated with exercise performance by comparing high to low performers on cardiopulmonary exercise testing (CPET) in patients with rTOF. We conducted a cross-sectional study of subjects presenting for CPET who underwent echocardiograms at rest and peak exercise. Patients with pacemakers and arrhythmias were excluded. Right ventricular (RV) global longitudinal strain was used as a measure of systolic function. Pulmonary insufficiency (PI) was assessed with the diastolic systolic ratio and the diastolic systolic time-velocity integral ratio by Doppler interrogation of the pulmonary artery. CPET measures included percent-predicted maximum \({{\text{V}}_{{{\text{O}}_2}}}\)\(\left( {{\text{\% m}}{{\text{V}}_{{{\text{O}}_2}}}} \right)\), percent-predicted maximum work and oxygen pulse. High versus low performers were identified as those achieving \({\text{\% m}}{{\text{V}}_{{{\text{O}}_2}}}\) of at least 80% or falling below, respectively. Differences in echocardiographic parameters from rest to peak exercise were examined using mixed-effects regression models. Compared to the low performers (n = 17), high performers (n = 12) were younger (12.8 ± 3.3 years vs. 18.3 ± 4.8 years), had normal chronotropic response (peak heart rate > 185 bpm) with greater heart rate reserve and superior physical working capacity. High performers also had a greater reduction in PI at peak exercise, despite greater PI severity at rest. Oxygen pulse was comparable between groups. For both groups, there was no association of PI severity and RV systolic function at rest with exercise parameters. There was no group difference in the magnitude of change in RV strain and diastolic parameters from rest to peak exercise. Chronotropic response to exercise appears to be an important parameter with which to assess exercise performance in rTOF. Chronotropic health should be taken into consideration in this population, particularly given that RV function and PI severity at rest were not associated with exercise performance.


Congenital heart disease Tetralogy of Fallot Stress echocardiography Cardiopulmonary exercise testing 



Repaired tetralogy of Fallot


Cardiopulmonary exercise test


Pulmonary insufficiency


Right ventricular global longitudinal strain


Diastolic systolic time velocity integral



This study was supported by CHOP Cardiac Center Grant (Mercer-Rosa, Bhatt), Matthew’s Hearts of Hope Grant (Bhatt), NIH K01HL125521 (Mercer-Rosa), NIH 5T32HL007915 (Bhatt) and NIH F32HL139042 (Bhatt).

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research Involving Human Participants and/or Animals

All procedures performed in studies involving human participants were in accordance with the Ethical Standards of the Institutional and/or National Research Committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.Division of CardiologyChildren’s Hospital of PhiladelphiaPhiladelphiaUSA

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