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Exercise: Friend or Foe in Adult Congenital Heart Disease?

  • Congenital Heart Disease (J Deanfield, Section Editor)
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Abstract

Exercise training is beneficial in healthy adults as well as patients with acquired cardiovascular disease such as coronary artery disease and heart failure. While a reduced exercise capacity is common in adults with congenital heart disease, it is not clear if these patients stand to benefit from exercise training or if it could be potentially detrimental. International recommendations encourage regular exercise in these patients but the evidence base is limited. Data from cardiopulmonary exercise testing suggest a relatively low risk of adverse events during exercise in adults with congenital heart disease. This is also supported by studies investigating the mode of death in this patient group, reporting that only a minority of patients die during exercise. Regarding the benefits of exercise training in adults with congenital heart disease only a few studies with relatively small sample sizes are available pointing to beneficial effects in selected patients. Encouragingly, in none of these short-term studies were detrimental effects observed. Therefore, adult congenital heart disease patients should not be categorically discouraged from physical activity or from participating in non-competitive sports. However, individual exercise prescriptions should be based on a comprehensive assessment of the underlying cardiac condition, possible sequelae, cardiac function, arrhythmias, pulmonary hypertension, and aortic dimensions. Furthermore, the intensity of exercise should be adapted to individual exercise capacity.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. • Wen CP, Wai JP, Tsai MK, Yang YC, Cheng TY, Lee MC, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet. 2011;378(9798):1244–53. A large study showing the benefit of exercise training in the general population..

    Article  PubMed  Google Scholar 

  2. •• Kempny A, Dimopoulos K, Uebing A, Moceri P, Swan L, Gatzoulis MA, et al. Reference values for exercise limitations among adults with congenital heart disease. Relation to activities of daily life–single centre experience and review of published data. Eur Heart J. 2012;33(11):1386–96. A comprehensive review of CPET studies in more than 4400 ACHD patients..

    Article  PubMed  Google Scholar 

  3. Diller GP, Dimopoulos K, Okonko D, Li W, Babu-Narayan SV, Broberg CS, et al. Exercise intolerance in adult congenital heart disease: comparative severity, correlates, and prognostic implication. Circulation. 2005;112(6):828–35.

    Article  PubMed  Google Scholar 

  4. Hirth A, Reybrouck T, Bjarnason-Wehrens B, Lawrenz W, Hoffmann A. Recommendations for participation in competitive and leisure sports in patients with congenital heart disease: a consensus document. Eur J Cardiovasc Prev Rehabil. 2006;13(3):293–9.

    Article  PubMed  Google Scholar 

  5. Diller GP, Dimopoulos K, Okonko D, Uebing A, Broberg CS, Babu-Narayan S, et al. Heart rate response during exercise predicts survival in adults with congenital heart disease. J Am Coll Cardiol. 2006;48(6):1250–6.

    Article  PubMed  Google Scholar 

  6. Dimopoulos K, Okonko DO, Diller GP, Broberg CS, Salukhe TV, Babu-Narayan SV, et al. Abnormal ventilatory response to exercise in adults with congenital heart disease relates to cyanosis and predicts survival. Circulation. 2006;113(24):2796–802.

    Article  PubMed  Google Scholar 

  7. Inuzuka R, Diller GP, Borgia F, Benson L, Tay EL, Alonso-Gonzalez R, et al. Comprehensive use of cardiopulmonary exercise testing identifies adults with congenital heart disease at increased mortality risk in the medium term. Circulation. 2012;125(2):250–9.

    Article  PubMed  Google Scholar 

  8. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116(10):682–92.

    Article  PubMed  Google Scholar 

  9. O’Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301(14):1439–50.

    Article  PubMed  Google Scholar 

  10. McKelvie RS. Exercise training in patients with heart failure: clinical outcomes, safety, and indications. Heart Fail Rev. 2008;13(1):3–11.

    Article  PubMed  Google Scholar 

  11. McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012;33(14):1787–847.

    Article  PubMed  Google Scholar 

  12. Therrien J, Fredriksen P, Walker M, Granton J, Reid GJ, Webb G. A pilot study of exercise training in adult patients with repaired tetralogy of Fallot. Can J Cardiol. 2003;19(6):685–9.

    PubMed  Google Scholar 

  13. Dua JS, Cooper AR, Fox KR, Graham SA. Exercise training in adults with congenital heart disease: feasibility and benefits. Int J Cardiol. 2010;138(2):196–205.

    Article  PubMed  Google Scholar 

  14. •• Winter MM, van der Bom T, de Vries LC, Balducci A, Bouma BJ, Pieper PG, et al. Exercise training improves exercise capacity in adult patients with a systemic right ventricle: a randomized clinical trial. Eur Heart J. 2012;33(11):1378–85. The first randomized controlled clinical trial of exercise training in ACHD..

    Article  PubMed  CAS  Google Scholar 

  15. Martinez-Quintana E, Miranda-Calderin G, Ugarte-Lopetegui A, Rodriguez-Gonzalez F. Rehabilitation program in adult congenital heart disease patients with pulmonary hypertension. Congenit Heart Dis. 2010;5(1):44–50.

    Article  PubMed  Google Scholar 

  16. Becker-Grunig T, Klose H, Ehlken N, Lichtblau M, Nagel C, Fischer C, et al. Efficacy of exercise training in pulmonary arterial hypertension associated with congenital heart disease. Int J Cardiol. 2012. doi:10.1016/j.ijcard.2012.09.036.

    PubMed  Google Scholar 

  17. Beckerman J, Wu T, Jones S, Froelicher VF. Exercise test-induced arrhythmias. Prog Cardiovasc Dis. 2005;47(4):285–305.

    Article  PubMed  Google Scholar 

  18. Stuart Jr RJ, Ellestad MH. National survey of exercise stress testing facilities. Chest. 1980;77(1):94–7.

    Article  PubMed  Google Scholar 

  19. Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106(14):1883–92.

    Article  PubMed  Google Scholar 

  20. Koyak Z, Harris L, de Groot JR, Silversides CK, Oechslin EN, Bouma BJ, et al. Sudden cardiac death in adult congenital heart disease. Circulation. 2012;126(16):1944–54.

    Article  PubMed  Google Scholar 

  21. Zomer AC, Vaartjes I, Uiterwaal CS, van der Velde ET, van den Merkhof LF, Baur LH, et al. Circumstances of death in adult congenital heart disease. Int J Cardiol. 2012;154(2):168–72.

    Article  PubMed  Google Scholar 

  22. Takken T, Giardini A, Reybrouck T, Gewillig M, Hovels-Gurich HH, Longmuir PE, et al. Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology. Eur J Prev Cardiol. 2012;19(5):1034–65.

    Article  PubMed  CAS  Google Scholar 

  23. Valsangiacomo Buechel ER, Mertens LL. Imaging the right heart: the use of integrated multimodality imaging. Eur Heart J. 2012;33(8):949–60.

    Article  PubMed  Google Scholar 

  24. Driscoll DJ, Danielson GK, Puga FJ, Schaff HV, Heise CT, Staats BA. Exercise tolerance and cardiorespiratory response to exercise after the Fontan operation for tricuspid atresia or functional single ventricle. J Am Coll Cardiol. 1986;7(5):1087–94.

    Article  PubMed  CAS  Google Scholar 

  25. Driscoll DJ, Mottram CD, Danielson GK. Spectrum of exercise intolerance in 45 patients with Ebstein’s anomaly and observations on exercise tolerance in 11 patients after surgical repair. J Am Coll Cardiol. 1988;11(4):831–6.

    Article  PubMed  CAS  Google Scholar 

  26. Paridon SM, Sullivan NM, Schneider J, Pinsky WW. Cardiopulmonary performance at rest and exercise after repair of total anomalous pulmonary venous connection. Am J Cardiol. 1993;72(18):1444–7.

    Article  PubMed  CAS  Google Scholar 

  27. Nir A, Driscoll DJ, Mottram CD, Offord KP, Puga FJ, Schaff HV, et al. Cardiorespiratory response to exercise after the Fontan operation: a serial study. J Am Coll Cardiol. 1993;22(1):216–20.

    Article  PubMed  CAS  Google Scholar 

  28. Fritsch J, Winter UJ, Kaemmerer H, Hilger HH. Cardiopulmonary capacity of patients with congenital heart defects in childhood, adolescence and adulthood. Z Kardiol. 1994;83 Suppl 3:131–9.

    PubMed  Google Scholar 

  29. Harrison DA, Liu P, Walters JE, Goodman JM, Siu SC, Webb GD, et al. Cardiopulmonary function in adult patients late after Fontan repair. J Am Coll Cardiol. 1995;26(4):1016–21.

    Article  PubMed  CAS  Google Scholar 

  30. Weipert J, Koch W, Haehnel JC, Meisner H. Exercise capacity and mid-term survival in patients with tricuspid atresia and complex congenital cardiac malformations after modified Fontan-operation. Eur J Cardiothorac Surg. 1997;12(4):574–80.

    Article  PubMed  CAS  Google Scholar 

  31. Helber U, Baumann R, Seboldt H, Reinhard U, Hoffmeister HM. Atrial septal defect in adults: cardiopulmonary exercise capacity before and 4 months and 10 years after defect closure. J Am Coll Cardiol. 1997;29(6):1345–50.

    Article  PubMed  CAS  Google Scholar 

  32. MacLellan-Tobert SG, Driscoll DJ, Mottram CD, Mahoney DW, Wollan PC, Danielson GK. Exercise tolerance in patients with Ebstein’s anomaly. J Am Coll Cardiol. 1997;29(7):1615–22.

    Article  PubMed  CAS  Google Scholar 

  33. Durongpisitkul K, Driscoll DJ, Mahoney DW, Wollan PC, Mottram CD, Puga FJ, et al. Cardiorespiratory response to exercise after modified Fontan operation: determinants of performance. J Am Coll Cardiol. 1997;29(4):785–90.

    Article  PubMed  CAS  Google Scholar 

  34. Hechter SJ, Webb G, Fredriksen PM, Benson L, Merchant N, Freeman M, et al. Cardiopulmonary exercise performance in adult survivors of the Mustard procedure. Cardiol Young. 2001;11(4):407–14.

    Article  PubMed  CAS  Google Scholar 

  35. Fredriksen PM, Veldtman G, Hechter S, Therrien J, Chen A, Warsi MA, et al. Aerobic capacity in adults with various congenital heart diseases. Am J Cardiol. 2001;87(3):310–4.

    Article  PubMed  CAS  Google Scholar 

  36. Fredriksen PM, Therrien J, Veldtman G, Warsi MA, Liu P, Siu S, et al. Lung function and aerobic capacity in adult patients following modified Fontan procedure. Heart. 2001;85(3):295–9.

    Article  PubMed  CAS  Google Scholar 

  37. Fredriksen PM, Chen A, Veldtman G, Hechter S, Therrien J, Webb G. Exercise capacity in adult patients with congenitally corrected transposition of the great arteries. Heart. 2001;85(2):191–5.

    Article  PubMed  CAS  Google Scholar 

  38. Fredriksen PM, Therrien J, Veldtman G, Ali Warsi M, Liu P, Thaulow E, et al. Aerobic capacity in adults with tetralogy of Fallot. Cardiol Young. 2002;12(6):554–9.

    Article  PubMed  Google Scholar 

  39. Giardini A, Donti A, Formigari R, Specchia S, Prandstraller D, Bronzetti G, et al. Determinants of cardiopulmonary functional improvement after transcatheter atrial septal defect closure in asymptomatic adults. J Am Coll Cardiol. 2004;43(10):1886–91.

    Article  PubMed  Google Scholar 

  40. Giardini A, Hager A, Pace Napoleone C, Picchio FM. Natural history of exercise capacity after the Fontan operation: a longitudinal study. Ann Thorac Surg. 2008;85(3):818–21.

    Article  PubMed  Google Scholar 

  41. Hager A, Kanz S, Kaemmerer H, Hess J. Exercise capacity and exercise hypertension after surgical repair of isolated aortic coarctation. Am J Cardiol. 2008;101(12):1777–80.

    Article  PubMed  Google Scholar 

  42. Trojnarska O, Gwizdala A, Katarzynski S, Katarzynska A, Szyszka A, Lanocha M, et al. Evaluation of exercise capacity with cardiopulmonary exercise test and B-type natriuretic peptide in adults with congenital heart disease. Cardiol J. 2009;16(2):133–41.

    PubMed  Google Scholar 

  43. Giardini A, Khambadkone S, Taylor A, Derrick G. Effect of abnormal pulmonary flow distribution on ventilatory efficiency and exercise capacity after arterial switch operation for transposition of great arteries. Am J Cardiol. 2010;106(7):1023–8.

    Article  PubMed  Google Scholar 

  44. Diller GP, Giardini A, Dimopoulos K, Gargiulo G, Muller J, Derrick G, et al. Predictors of morbidity and mortality in contemporary Fontan patients: results from a multicenter study including cardiopulmonary exercise testing in 321 patients. Eur Heart J. 2010;31(24):3073–83.

    Article  PubMed  Google Scholar 

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Oktay Tutarel declares that he has no conflict of interest.

Harald Gabriel declares that he has no conflict of interest.

Gerhard-Paul Diller declares that he has no conflict of interest.

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Correspondence to Oktay Tutarel.

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This article is part of the Topical Collection on Congenital Heart Disease

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Tutarel, O., Gabriel, H. & Diller, GP. Exercise: Friend or Foe in Adult Congenital Heart Disease?. Curr Cardiol Rep 15, 416 (2013). https://doi.org/10.1007/s11886-013-0416-9

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