Adults with Congenital Heart Disease Move Well but Lack Intensity: A Cross-Sectional Study Using Wrist-Worn Physical Activity Trackers.

OBJECTIVE: This study compared objectively measured and self-reported physical activity (PA) in adults with congenital heart disease (ACHD) to a healthy reference cohort (RC). PATIENTS AND METHODS: From May 2017 to August 2020, 211 ACHD (39.9 ± 9.7 years, 101 female) and 141 healthy adults (35.9 ± 14.7 years, 76 female) participated in a wearable-based and self-reported PA assessment. Moderate-to-vigorous PA (MVPA) and the step count were recorded with the Garmin vivofit® 3 device for 7 consecutive days. Additionally, subjects were asked to report the number of days they are active for ≥30 min throughout the week. RESULTS: Only 33 (17%) ACHD and 36 (26%) healthy controls (p = 0.030) accumulated the World Health Organization's (WHO) recommendation of 150 min MVPA per week. ACHD were less active per week (ACHD: 40.0 [0.0; 101.0] min. MVPA vs. RC: 75.0 [22.5; 152.5] min. MVPA, p = 0.002) and walked fewer daily steps (ACHD: 8,246 [6,505; 10,434] vs. RC: 9,413 [7,621; 11,654], p = 0.001) than healthy controls. Especially, patients with moderate (p = 0.030), complex (p < 0.001), or surgically corrected (p = 0.008) congenital heart disease accumulated significantly less MVPA than healthy peers throughout the week. A large majority of 72% of ACHD and 58% of the RC overestimated their weekly active days by more than one day. CONCLUSIONS: ACHD walked quite a few steps daily but lacked intensity. ACHD was less active than healthy controls and failed to reach international recommendations. They therefore need encouragement toward more intense movement to improve the exercise capacity and lower cardiovascular risk. Self-reported PA showed no agreement to the objectively measured PA.

Children with Congenital Heart Disease Are Active but Need to Keep Moving: A Cross-Sectional Study Using Wrist-Worn Physical Activity Trackers.

OBJECTIVE: To compare daily physical activity of children with congenital heart disease (CHD) with healthy peers measured using wearables bracelets in a large cohort. Additionally, subjectively estimated and objectively measured physical activity was compared. STUDY DESIGN: From September 2017 to May 2019, 162 children (11.8 ± 3.2 years; 60 girls) with various CHD participated in a self-estimated and wearable-based physical activity assessment. Step-count and moderate-to-vigorous physical activity were recorded with the Garmin vivofit jr. for 7 consecutive days and compared with a reference cohort (RC) of 96 healthy children (10.9 ± 3.8 years; 49 girls). RESULTS: Children with CHD were active and 123 (75.9%) achieved 60 minutes physical activity on a weekly average according to the World Health Organization criteria as 81 (84.3%) of the healthy peers did (P = .217). After correction for age, sex, and seasonal effects, only slightly lower step count (CHD: 10 206 ± 3178 steps vs RC: 11 142 ± 3136 steps; P = .040) but no lower moderate-to-vigorous physical activity (CHD: 80.5 ± 25.6 minutes/day vs RC: 81.5 ± 25.3 minutes/day; P = .767) occurred comparing CHD with RC. In children with CHD higher age (P = .004), overweight or obesity (P = .016), complex severity (P = .046), and total cavopulmonary connection (P = .027) were associated with not meeting World Health Organization criteria. Subjective estimation of daily moderate-to-vigorous physical activity was fairly correct in half of all children with CHD. CONCLUSIONS: Even though the majority is sufficiently active, physical activity needs to be promoted in overweight or obese patients, patients with complex CHD severity, and in particular in those with total cavopulmonary connection.

Motor Skills of Children and Adolescents With Obesity and Severe Obesity-A CIRCUIT Study.

Häcker, A-L, Bigras, J-L, Henderson, M, Barnett, TA, and Mathieu, M-E. Motor skills of children and adolescents with obesity and severe obesity-a CIRCUIT study. J Strength Cond Res 34(12): 3577-3586, 2020-During childhood, excessive weight is negatively associated with the development of motor skills, with overweight children or children with obesity having poorer motor skills compared with children with normal weight. The objectives of the current study are to identify the differences in motor skills between children and adolescents with obesity and severe obesity and the extent of this difference. To do so, we examined cross-sectionally 165 subjects. Physical fitness was analyzed in both subjects with obesity (>97th to 99.9th body mass index [BMI] percentile) and severe obesity (>99.9th BMI percentile) using 8 standardized tests: sit-and-reach, grip force, sit-ups, push-ups, balance, hand-eye coordination, standing long jump and 5-m shuttle run. Poorer performance were observed in subjects with severe obesity in sit-ups (children: 59%; 18.6 ± 17.0 vs. 29.5 ± 23.2 percentile value, p = 0.008), balance (adolescent: 59%; 12.1 ± 12.2 vs. 19.3 ± 13.9 seconds, p = 0.034), and in the 5-m shuttle run (children: 49%; 14.0 ± 13.9 vs. 20.8 ± 19.4 percentile value, p = 0.046; adolescents: 11%; 13.2 ± 2.2 vs. 11.8 ± 1.6 seconds, p = 0.008) compared with obese counterparts. In conclusion, although physical performance was found to be similar between the different obesity levels for most tests, youth with severe obesity demonstrated impairments ranging from 11 to 59% in specific tests.

High-sensitive troponin T and N-terminal pro-B-type natriuretic peptide independently predict survival and cardiac-related events in adults with congenital heart disease.

AIMS: High-sensitive troponin T (hs-TnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) are established prognostic biomarkers for cardiovascular (CV) morbidity and mortality and frequently used in symptomatic and/or hospitalized adults with congenital heart disease (ACHD). Their prognostic value in clinically stable ACHD has not yet been well established. This study investigates the predictive value of hs-TnT, NT-proBNP, and CRP for survival and CV events in stable ACHD. METHODS AND RESULTS: In this prospective cohort study, 495 outpatient ACHD (43.9 ± 10.0 years, 49.1% female) underwent venous blood sampling including hs-TnT, NT-proBNP, and CRP. Patients were followed up for survival status and the occurrence of CV events. Survival analyses were performed with Cox proportional hazards regression analysis and Kaplan-Meier curves. During a mean follow-up of 2.8 ± 1.0 years, 53 patients (10.7%) died or reached a cardiac-related endpoint including sustained ventricular tachycardia, hospitalization with cardiac decompensation, ablation, interventional catheterization, pacer implantation, or cardiac surgery. Multivariable Cox regression revealed hs-TnT (P = 0.005) and NT-proBNP (P = 0.018) as independent predictors of death or cardiac-related events in stable ACHD, whilst the prognostic value of CRP vanished after multivariable adjustment (P = 0.057). Receiver-operator characteristic curve analysis identified cut-off values for event-free survival of hs-TnT ≤9 ng/L and NT-proBNP ≤200 ng/L. Patients with both increased biomarkers had a 7.7-fold (confidence interval 3.57-16.40, P < 0.001) higher risk for death and cardiac-related events compared with patients without elevated blood values. CONCLUSION: Subclinical values of hs-TnT and NT-proBNP are a useful, simple, and independent prognostic tool for adverse cardiac events and survival in stable outpatient ACHD. REGISTRATION: German Clinical Trial Registry DRKS00015248.

Impaired grip strength in children with congenital heart disease.

OBJECTIVES: Grip strength is known to be reduced in adults with congenital heart disease (CHD). This study compared grip strength in paediatric patients with CHD with healthy controls and determined a possible association between grip strength and health-related physical fitness (HRPF). METHODS: Grip strength and HRPF were assessed in 569 children (12.4 years, 95% CI 12.16 to 12.72; 238 girls) with various CHD and compared with 2551 healthy controls (11.4 years, 95% CI 11.3 to 11.5; 1424 girls). Grip strength was determined as the maximum value of three repetitions with each hand. HRPF was tested by five motor tasks (FITNESSGRAM) and converted into an SD score (z-score). RESULTS: After adjusting for age, sex and weight, children with CHD showed significantly lower grip strength compared with healthy controls (CHD: 20.8 kg, 95% CI 20.4 to 21.2; controls: 24.5 kg, 95% CI 24.3 to 24.8). CHD subgroup analysis also revealed significantly lower grip strength than the controls, with the lowest values in patients with total cavopulmonary connection (19.1, 95% CI 18.0 to 20.2). Children with complex CHD showed the lowest values with 19.8 kg (95% CI 19.2 to 20.4), those with moderate 20.7 kg (95% CI 19.9 to 21.4) and those with simple 22.5 kg (95% CI 21.6 to 23.3), respectively. HRPF was also lower (z-score: -0.46, 95% CI -0.49 to -0.35) compared with healthy controls and poorly associated with grip strength (r=0.21). CONCLUSIONS: Grip strength is already reduced in children with CHD and poorly associated with HRPF. This suggests that grip strength and HRPF are different domains and have to be assessed separately.

Is Carotid Intima-Media Thickness Increased in Adults With Congenital Heart Disease?

Background Because of the increasing numbers of congenital patients surviving into adulthood, early diagnosis and prevention of acquired cardiovascular disease is reasonable. The aim of this study was to detect diagnostic subgroups of adults with congenital heart disease (ACHD) that have increased carotid intima-media thickness (cIMT), a subclinical marker of cardiovascular damage. Methods and Results This study enrolled 831 ACHD patients (392 women, aged 38.8±11.7 years) from May 2015 to February 2019 at their regular outpatient visit. Far wall cIMT was measured using a semiautomatic ultrasound system at 4 angles. Age, sex, height, weight, blood pressure, smoking status, and antihypertensive medication were registered and entered in a multiple linear regression model to compare diagnostic subgroups to 191 healthy controls (111 women, aged 36.7±13.5 years). There were no significant differences in cIMT of ACHD (0.538±0.086 mm) compared with healthy controls (0.541±0.083 mm; P=0.649) after adjusting for the aforementioned covariates. Only patients with coarctation of the aorta showed significantly higher cIMT values (0.592±0.075 mm; P<0.001) compared with healthy controls. In addition, ACHD patients who were men (P=0.032), older (P<0.001), and were prescribed antihypertensive medications (P=0.003) were all found to have thicker cIMT values. Conclusions Overall, we determined that within the ACHD cohort, only those patients with a history of coarctation have higher cIMT values. To better determine the mechanism of abnormal vasculature, further basic research is needed.

Functional outcomes in children with anatomically repaired transposition of the great arteries with regard to congenital ventricular septal defect and coronary pattern.

OBJECTIVE: Despite decreasing mortality, functional impairments in children with transposition of the great arteries (TGA) are still a concern. This study analyses health-related physical fitness (HRPF), arterial stiffness and health-related quality of life (HRQoL) in children with anatomically repaired TGA regarding congenital ventricular septal defect (VSD) and coronary patterns. PATIENTS AND METHODS: 68 children with anatomically repaired TGA with or without VSD (12.9±3.7 years, 19.1% female) were investigated between August 2014 and October 2017. HRPF was assessed by five tests of the FITNESSGRAM, arterial stiffness was measured by oscillometric measurement using Mobil-O-Graph and HRQoL was analysed with a self-report questionnaire (KINDL-R). All test results were compared with a healthy reference cohort (n=2116, 49.1% female) adjusted for sex and age. RESULTS: Children with anatomically repaired TGA had significantly worse HRPF (z-score: -0.58±0.81, p<0.001), increased pulse wave velocity (TGA: 4.9±0.3 m/s vs healthy: 4.8±0.3 m/s, p=0.028) and central systolic blood pressure (TGA: 105.9±5.8 mm Hg vs healthy: 103.3±5.7 mm Hg, p=0.001). No difference was found for HRQoL between the two groups (total HRQoL score: TGA: 76.5±10.2 vs healthy: 75.2±10.1, p=0.315). Neither the coronary pattern nor a congenital VSD resulted in significant differences in all functional outcomes. CONCLUSION: Children with anatomically repaired TGA exhibit impaired HRPF and increased arterial stiffness whereas their HRQoL is normal. The underlying coronary pattern seems to have no influence on the functional outcome, nor does an accompanied congenital VSD.

Metabolic syndrome in adults with congenital heart disease and increased intima-media thickness.

AIMS: Age-related cardiovascular diseases are a relevant risk in the aging population of adults with congenital heart diseases (ACHD). Risk factors such as the metabolic syndrome (MetS) impact the risk of increased carotid intima-media thickness (cIMT) and thereby long-term cardiovascular diseases. The aim of the study was to assess MetS in ACHD and outline a possible association to cIMT. METHODS AND RESULTS: In total, 512 ACHD (43.0 ± 9.6 years, 48.9% female) were screened for MetS by the standards of the International Diabetes Federation, and their cIMT by ultrasound from January 2017 to June 2019. MetS was prevalent in 72 (14.1%) of the ACHD population (34 female, 15.5%). Regarding severity class, patients with simple forms of CHD had a MetS prevalence of 11.8%, moderate 16.7%, and severe 13.8%. ACHD with MetS had significantly increased cIMT compared to ACHD without MetS (ACHD with MetS: 0.587 ± 0.079 mm, ACHD without MetS: 0.560 ± 0.087 mm, mean difference: 0.028 mm, P = .013). Such a difference in vascular structure corresponds to roughly five years of normal vascular aging of the vessels. CONCLUSION: ACHD with MetS have a thicker cIMT compared to ACHD without MetS. Screening for MetS and targeting risk factors in ACHD might help to prevent structural alterations of the vessels at an early stage.

Age-related cardiovascular risk in adult patients with congenital heart disease.

AIMS: Since the number of adults with congenital heart disease (ACHD) is increasing, age-related cardiovascular diseases become a relevant risk for ACHD. While previous studies investigated isolated risk factors only, this study examines the cardiovascular risk of ACHD based on the PROCAM scores. METHODS AND RESULTS: From January 2017 to April 2018, 551 ACHD aged 30 years or older (43.9 ±â€¯9.9 years, 48.3% female) were analyzed for their risk factors of major cardiovascular events within the next ten years using the PROCAM quick check and PROCAM health check. Compared to their individual reference, ACHD had a significantly lower absolute cardiovascular event risk in PROCAM quick check (ACHD: 2.5 ±â€¯4.9%, reference: 3.8 ±â€¯5.2%, p < .001) and PROCAM health check (ACHD: 1.8 ±â€¯3.5%, reference: 3.9 ±â€¯5.3%, p < .001). The relative risk of ACHD was 37% lower than in the general population calculated with the PROCAM quick test, and 57% lower with the PROCAM health check. Only 3.4% of the ACHD had a LDL cholesterol higher than 190 mg/dl, 8.3% had a HDL cholesterol lower than 40 mg/dl, and 26.0% had triglyceride higher than 150 mg/dl. Diabetes mellitus was prevalent in 4.0% of the ACHD and 10.9% were current smokers. CONCLUSION: According to the PROCAM risk score, ACHD have a lower 10-year risk for major cardiovascular events compared to a healthy reference population. Whether this lower rate of the established risk factors leads to a lower rate of acquired cardiovascular disease has to be clarified in this particular population.

Health-Related Physical Fitness and Quality of Life in Children and Adolescents With Isolated Left-to-Right Shunt.

Objective: Atrial (ASD) and ventricular septal defects (VSD) represent the most common congenital heart defects (CHD) and are considered simple and curable. This study investigates long-term functional outcomes in children with such defects. Patients and Methods : We examined 147 patients (74 girls, 12.1 ± 3.5 years) with isolated shunts (ASD: 54%, VSD: 46%) for their Health-Related Physical Fitness (HRPF) and Health-Related Quality of Life (HRQoL). Native condition was present in 58 patients, interventional closure of the defect was performed in 42 and surgical closure in 47. For comparison, a healthy control group (CG) of 1,724 children (48.9% girls, 12.8 ± 2.8 years) was recruited within two recent school projects. Results: After adjustment for age and sex, children with ASD and VSD presented lower HRPF (z-score healthy peers: 0.02 ± 0.73, ASD: -0.41 ± 0.73, p < 0.001; VSD: -0.61 ± 0.73, p < 0.001) then healthy peers. Transferred into percentiles, VSD were on the 26th and ASD on the 34th percentile of the healthy peers. HRQoL did not differ between peers and CHD with isolated shunts (healthy peers: 76.1 ± 9.7, ASD: 76.2 ± 9.9, p = 0.999; VSD: 78.7 ± 9.7, p = 0.316). Regarding the surgical history of the shunts (native, percutaneously treated, surgically treated), there were also no difference in-between these three states, nor differed HRPF and HRQoL in-between gender. Conclusions: Children with ASD or VSD have impaired HRPF but normal HRQoL. Early childhood sports promotion could be a good measure to counteract these restrictions in HRPF at an early stage.

Functional outcome in contemporary children and young adults with tetralogy of Fallot after repair.

OBJECTIVE: Functional outcome measures are of growing importance in the aftercare of patients with congenital heart disease. This study addresses the functional status with regard to exercise capacity, health-related physical fitness (HRPF) and arterial stiffness in a recent cohort of children, adolescents and young adults with tetralogy of Fallot (ToF) after repair. DESIGN: Single-centre, uncontrolled and prospective cohort study. SETTING: Outpatient department of the German Heart Centre Munich; July 2014-January 2018. PATIENTS: One hundred and six patients with ToF after repair (13.5±3.7 years, 40 females) were included. Data were compared with a recent cohort of healthy controls (HCs) (n=1700, 12.8±2.6 years, 833 females). MAIN OUTCOME MEASURES: Patients underwent a symptom-limited cardiopulmonary exercise test, performed an HRPF test (FitnessGram) and had an assessment of their arterial stiffness (Mobil-O-Graph). RESULTS: Compared with HC, patients with ToF showed lower predicted [Formula: see text]O2 peak (ToF: 80.4% ± 16.8% vs HC: 102.6% ± 18.1%, p<0.001), impaired ventilatory efficiency (ToF: 29.6 ± 3.6 vs HC: 27.4 ± 2.9, p<0.001), chronotropic incompetence (ToF: 167 ± 17 bpm vs HC: 190 ± 17 bpm, p<0.001) and reduced HRPF (ToF z-score: -0.65 ± 0.87 vs HC z-score: 0.03 ± 0.65, p<0.001). Surrogates of arterial stiffness, central and peripheral systolic blood pressure, did not differ between the two groups. CONCLUSIONS: Contemporary children, adolescents and young adults with ToF still have functional limitations. How impaired HRPF and limited exercise capacity interact and how they can be modified needs to be evaluated in further intervention studies.

Carotid Intima-Media Thickness in Children and Adolescents With Congenital Heart Disease.

BACKGROUND: With increased long-term survival, children with congenital heart disease (CHD) are at increased risk of early-onset adult cardiovascular disease. Carotid intima-media thickness (cIMT) is a surrogate marker of atherosclerosis. The aim of this present study was to detect high-risk diagnostic subgroups by measuring cIMT and determine its correlates in children with CHD and subgroups of CHD compared with healthy controls. METHODS: This cross-sectional study enrolled 385 patients (138 girls) aged 5 to 18 years (12.3 ± 3.3) who were recruited between May 2015 and June 2017. cIMT was measured using B-mode ultrasound. Height, weight, body mass index, age, mean arterial pressure, pulse-wave velocity, and central systolic blood pressure were assessed as possible risk factors. For subgroup analyses, the patients were divided according to the type of their heart defects. Furthermore, patient data were compared with 86 healthy controls (35 girls, 12.8 ± 2.5 years) measured in the same time frame with identical ultrasound protocol. RESULTS: Patients with CHD showed higher cIMT values (cIMT = 0.464 ± 0.039 mm) than healthy controls (cIMT = 0.449 ± 0.045 mm; P = 0.003), even after adjusting for sex, age, height, and weight differences. The highest cIMT values were found in children with coarctation of the aorta (cIMT = 0.486 ± 0.040 mm; P < 0.001) and transposition of the great arteries after arterial switch (cIMT 0.488 ± 0.041 mm; P < 0.001). No correlation was detected between cIMT and mean arterial pressure or pulse-wave velocity, but with central systolic blood pressure (P = 0.015; r = 0.150). CONCLUSIONS: Children with CHD have increased cIMT compared with healthy controls, particularly those with coarctation of aorta and transposition of the great arteries.

Increased arterial stiffness in children with congenital heart disease.

Objective Central systolic blood pressure (SBP) is a measure of arterial stiffness and strongly associated with atherosclerosis and end-organ damage. It is a stronger predictor of cardiovascular events and all-cause mortality than peripheral SBP. In particular, for children with congenital heart disease, a higher central SBP might impose a greater threat of cardiac damage. The aim of the study was to analyse and compare central SBP in children with congenital heart disease and in healthy counterparts. Patients and methods Central SBP was measured using an oscillometric method in 417 children (38.9% girls, 13.0 ± 3.2 years) with various congenital heart diseases between July 2014 and February 2017. The test results were compared with a recent healthy reference cohort of 1466 children (49.5% girls, 12.9 ± 2.5 years). Results After correction for several covariates in a general linear model, central SBP of children with congenital heart disease was significantly increased (congenital heart disease: 102.1 ± 10.2 vs. healthy reference cohort: 100.4 ± 8.6, p < .001). The analysis of congenital heart disease subgroups revealed higher central SBP in children with left heart obstructions (mean difference: 3.6 mmHg, p < .001), transpositions of the great arteries after arterial switch (mean difference: 2.2 mmHg, p = .017) and univentricular hearts after total cavopulmonary connection (mean difference: 2.1 mmHg, p = .015) compared with the reference. Conclusion Children with congenital heart disease have significantly higher central SBP compared with healthy peers, predisposing them to premature heart failure. Screening and long-term observations of central SBP in children with congenital heart disease seems warranted in order to evaluate the need for treatment.

Web-Based Motor Intervention to Increase Health-Related Physical Fitness in Children With Congenital Heart Disease: A Study Protocol.

Objective: Exercise interventions are underutilized in children with congenital heart disease (CHD) especially when the primary outcome is not peak oxygen uptake. Most of the studies are restricted to a low sample size and proximity of the patients to the study centers. Now eHealth approaches bear a promising but also challenging opportunity to transmit such intervention programs to participants, and check progress and compliance from remote. This study will aim to improve health-related physical fitness (HRPF) with a 24 weeks web-based exercise intervention. Methods and Design: The current study is planned as a randomized control trial (RCT) with a crossover design and the aim to improve functional outcome measures. It also estimates adherence and feasibility in patients with CHD in this web-based exercise/motor intervention over 24 weeks. Primary outcome will be the improvement of HRPF. Secondary outcomes are, functional and structural arterial stiffness measures and health-related quality of life. Thus, 70 children from 10 to 18 years with CHD of moderate and complex severity will be recruited and allocated randomly 1:1 in two study arms after baseline testing for their HRPF, arterial stiffness measures and health-related quality of life. For 24 weeks, participants in the intervention arm will receive three weekly exercise video clips of 20 min each. Every video clip comprises 20 child-oriented exercises which have to be executed for 30 s followed by a recovery period of 30 s. Each session will start with 3-4 warming-up exercises, followed by 10-12 strength and flexibility exercises, and ending with 3-4 min of cool down or stretching tasks. Continuous video clips will be streamed from a web-based e-Learning platform. The participant simply has to imitate the execution and follow some short advices. After each session, a brief online survey will be conducted to assess perceived exertion and feasibility. Discussion: The study will help to determine the efficacy and applicability of a web-based exercise intervention in children with CHD in regard to functional outcome measures. In addition, it will outline the effectiveness of remote monitoring, which provides a cost effective approach to reach patients with CHD that are low in prevalence and often do not live in close proximity to their tertiary center. Trial Registration: https://ClinicalTrials.gov Identifier: NCT03488797.

Physical Activity Programs with Post-Intervention Follow-Up in Children: A Comprehensive Review According to Categories of Intervention.

Only 9% of Canadian children meet the National Guidelines of 60 min of daily moderate-to-vigorous intensity physical activity. The aim of this review is to assess the mid- and long-term effectiveness of physical activity interventions and their impact on cardiovascular risk factors in children. We assessed the success of interventions within three different categories: those using a behavioural and social approach, an informational approach or an environmental approach. The average number of children included in these studies was 860 (range of 30-5106); the age range was from 2 to 18 years; and the mean intervention duration was 1607 min (range of 12-8160 min). The length of follow-up post-intervention averaged 13 months (ranging from 0.25 to 96 months). A positive impact on physical activity was found in 74% and on any measured outcomes in 90% of the studies reviewed. However, the benefits of physical activity interventions decreased with longer follow-up. Regardless of the approaches, physical activity interventions improved cardiovascular risk factors. However, the challenge of any program is to maintain beneficial effects once the intervention is completed. These findings will inform the development of future intervention programs in order to optimize sustained cardiovascular benefits.