Effect of exercise on ACHD

1. SEMINAR
Effects of exercise training, with or without supplemental
oxygen, in adults with complex congenital heart disease

2. About
Name : Meshal Ejaz
Roll No: 17161560-016
Represented to: Mam Zunaira
Department: Biochemistry

3. Abstract:
The number of adults with complex congenital heart disease (ACHD) is
increasing and patients are living longer with the condition; therefore, there is
a need to investigate lifestyle factors and assess the physical fitness of these
patients and to prescribe exercise. We aimed to evaluate the effects of
exercise, with or without supplemental oxygen, in patients with complex
ACHD

4. Introduction:
Patients with ACHD have diminished physical fitness (peak oxygen consumption,
VO2max) and lower muscle function . Low VO2max predicts the frequency and
duration of hospitalization and the prognosis , and may be the result of the CHD
itself, the lack of exercise, and/or sufficient long-term physical activity (PA) levels.
Low PA is a concern because it is a risk factor for lifestyle-related diseases, such
as cardiovascular disease.Exercise is a simple and inexpensive method of
improving physical fitness in patients with ACHD . However, few studies have
examined exercise, and especially of its effects on muscle function, in patients
with complex ACHD. The effects of exercise with supplemental oxygen in patients
with ACHD has not been studied previously. One study showed greater systemic
arterial oxygen saturation when oxygen supplementation is provided, probably as
a result of pulmonary arterial vasodilation .

5. Intro..
We hypothesized that exercise training, with or without supplemental oxygen,
would be safe and feasible, and that supplemental oxygen would help patients
tolerate exercise of a higher intensity. Therefore, in the present study, we aimed to
evaluate the effects of exercise training on muscle function in patients with
complex ACHD, and secondarily, to determine the effects of supplemental oxygen
during exercise, especially according to the role of the etiology of the cyanosis.

6. Methods
Between August 2018 and December 2019, 35 patients were assessed and eight
were included in the study. A randomized crossover design was used, and
participants were randomized to start exercising with supplemental oxygen
(OxyStart) or without (OxyEnd). Muscle function, maximal oxygen uptake
(VO2peak), walking distance, physical activity level, patient-reported outcome
measures, and blood parameters were assessed.

8. Method
Thirty-five patients were assessed for potential inclusion in the study. Three were
excluded (8.6%) because they fulfilled on of the exclusion criteria: pregnancy (n ¼
0), pre-surgery phase, infection or unstable cardiorespiratory function (n ¼ 2),
cognitive impairment (difficulty completing questionnaires, participating in tests,
or exercising) (n ¼ 0), or other (n ¼ 1). Furthermore, 24 patients (68.6%) did not
wish to participate, principally because of work or study commitments. Therefore,
eight patients were included .

9. Measurements
Cardiopulmonary exercise test
Muscle function ( isoinertial shoulder flexion, heel-lift, isometric shoulder abduction, and handgrip
strength. )
Physical activity
Patient-reported outcome measures
Blood parameters (high-density lipoprotein (HDL)-cholesterol, high-sensitivity troponin T (hsTnT),
low-density lipoprotein (LDL)- cholesterol, and N-terminal prohormone brain natriuretic peptide
(NTproBNP))
Intervention and supplemental oxygen
Statistical methods

10. Results
Recruitment and demographics Four participants were randomized to the OxyStart
group and four to the OxyEnd group, and their characteristics are presented in
Table 1. Two participants in the OxyStart group had Eisenmenger syndrome and
two had single ventricles, and all the participants in the OxyEnd group had single
ventricles. No-one dropped out of the OxyStart group, but two participants in the
OxyEnd group dropped out: one before crossover because of a lack of time; and
one after crossover, because of a psychiatric illness . The primary aim of the study
was to assess the effects of exercise training, and because the number of
participants was low, they were assessed as a single group

11. Exercise training, with or without supplemental oxygen
The CPET and muscle function outcomes in the OxyStart and OxyEnd groups are
displayed in Fig. 2, and the PROM and PA data are displayed in Supplementary
Figures 1 and 2 (n ¼ 8). The patients’ experience of exercise with supplemental
oxygen was rated using the VAS, and a median value of 65 [7, 67] was recorded,
compared with a median value of 10 [5, 67] for exercise training without
supplemental oxygen. The oxygen flow rated used was approximately 10 L/min
for all the participant

13. Discussion
Exercise for adults with complex CHD has been controversial, especially for those
with Eisenmenger syndrome, and therefore the safety aspects of exercise were
closely monitored in the present study. We found that exercise training improved
VO2peak, muscle function and walking distance in participants who completed
the study (n ¼ 6). Furthermore, the participants tolerated high-intensity exercise
training, and no safety concerns or adverse events were identified during exercise.
However, patient recruitment proved to be difficult, and therefore the number of
participants was low. Thus, the results should be interpreted in this light. The
small sample was also significantly affected by drop-outs. Therefore, the primary
aim, to determine the effects of exercise training, was addressed using data from
all the patients who completed the entire study (n ¼ 6).

14. Exercise training
Impaired physical fitness is common in patients with complex ACHD and may be
caused by many factors, including decreased muscle function . A systematic review
of patients with Fontan circulation showed an increase of 6.3% in their VO2peak after
exercise training , which is relatively small, but may have a large impact on the
patient's life because such patients have severely diminished exercise capacity and
their activities of daily living are limited. In the present study we have shown an
improvement in VO2peak of 12.2% for the participants who completed the study (n ¼
6), which is comparable to the results of previous studies. Muscle function improved,
according to the results of three out of the four tests performed, and improvements
were seen in both isoinertial and isometric tests . This improvement in muscle
function is consistent with that demonstrated in a previous study, which showed
improvements in calf muscle function and an increase in muscle mass in patients
with complex ACHD

15. Conclusion
Patients with complex ACHD, who generally have a very low level of
physical fitness, pose a particular challenge in the prescription of an
individualized exercise program. We have shown that patients with
complex ACHD benefit from peripheral muscle function exercises.
Furthermore, exercise with supplemental oxygen for patients with
complex ACHD appeared to be safe. However, it may not affect patients
with different ACHD etiologies uniformly; therefore, further studies are
required to investigate this.