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Cardiopulmonary exercise test in adults with prior Fontan operation: The prognostic value of serial testing
Alexander C Egbe1, David J Driscoll2, Arooj R Khan1
1Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
Insights
Serial cardiopulmonary exercise testing (CPET) can predict cardiovascular adverse events (CAEs) in adults with Fontan palliation. A decline in peak oxygen consumption (VO2) predicts CAE risk, aiding patient risk stratification.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Exercise Physiology
Background:
- Patients with Fontan palliation face long-term risks of cardiovascular adverse events (CAEs), including death or cardiac surgery.
- Identifying reliable predictors of CAEs is crucial for managing this complex congenital heart disease population.
- Cardiopulmonary exercise testing (CPET) assesses cardiovascular and respiratory function during exercise.
Purpose of the Study:
- To evaluate the prognostic value of cardiopulmonary exercise test (CPET) indices for predicting cardiovascular adverse events (CAEs) in adults with Fontan palliation.
- To determine if serial CPET measurements can identify patients at higher risk for adverse cardiovascular outcomes.
Main Methods:
- Retrospective review of adult Fontan patients who underwent treadmill CPET between 1994 and 2013.
- Inclusion criteria required maximal effort on serial CPETs with at least a 3-year interval and no intervening CAE.
- Analysis focused on changes in CPET indices, particularly peak oxygen consumption (VO2), and their association with CAE occurrence.
Main Results:
- A total of 145 adult Fontan patients met the study criteria.
- A decline in % predicted peak oxygen consumption (VO2) of ≥3 percentage points/year was the sole significant predictor of 5-year CAE risk (HR 1.86).
- CAEs (death or cardiac surgery) occurred in 37% of patients within 8 years of follow-up.
Conclusions:
- Serial cardiopulmonary exercise testing (CPET) provides prognostic information for cardiovascular adverse events (CAEs) in the adult Fontan population.
- CPET, specifically the rate of decline in peak VO2, can be utilized for risk stratification in these patients.
- This approach may aid in guiding clinical management and surveillance strategies for adults with Fontan palliation.
Background:
The purpose of the study was to determine the role of cardiopulmonary exercise test (CPET) indices in predicting cardiovascular adverse events (CAEs) in patients with Fontan palliation. CAE was defined as death or cardiac surgery.
Methods:
Retrospective review of adult Fontan patients who had treadmill CPET at Mayo Clinic, 1994-2013. Patients with loss of follow-up defined as ≥2years without clinical follow-up were excluded. The results of serial CPETs were reviewed, and patients with CPETs meeting the following criteria were selected for analysis: maximum effort on serial CPETs, minimum of 3-year interval between CPETs, and absence of CAE between CPETs.
Results:
A total of 145 patients met inclusion criteria for the study; age at baseline CPET was 24±3years; age at Fontan operation was 11±5years; and 91 (63%) were males. Baseline peak oxygen consumption (VO2) was 22.7±5.4ml/kg/min (63±11% predicted), peak heart rate was 135±31beats per minute, and oxygen saturation at peak exercise was 86±7%. Serial CPETs were performed in 71/145 patients (49%); mean duration between CPETs was 3.8±0.3years. The % predicted peak VO2 decreased by 1.7±0.9 percentage points/year. CAE (deaths n=22; cardiac surgery n=45) occurred in 54/145 patients (37%) within 8±3years. Decline in % predicted peak VO2≥3 percentage points/year was the only predictor of 5-year risk of CAE (HR 1.86, 95% CI 1.11-3.48, P=0.02).
Conclusions:
Serial CPET is prognostic of CAE in the adult Fontan population, and can be used to risk stratify these patients.
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Exercise stress testing, commonly known as a treadmill test, is a noninvasive procedure used to evaluate cardiovascular function and diagnose heart conditions.
Definition
An exercise stress test measures the heart's response to exertion using a treadmill or stationary bicycle. Chest electrodes record the heart's electrical activity through an ECG, and blood pressure is monitored regularly.
Purposes