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Disappearance of the shunt and lower cardiac index during exercise in small, unrepaired ventricular septal defects

Published online by Cambridge University Press:  25 March 2020

Marie Maagaard Open the ORCID record for Marie Maagaard [Opens in a new window] ,
Filip Eckerström ,
Johan Heiberg Open the ORCID record for Johan Heiberg [Opens in a new window] ,
Benjamin Asschenfeldt Open the ORCID record for Benjamin Asschenfeldt [Opens in a new window] ,
Steffen Ringgaard  and
Vibeke E. Hjortdal
Marie Maagaard*
Affiliation:
Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, DK-8200Aarhus N, Denmark Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, DK-8200Aarhus N, Denmark
Filip Eckerström
Affiliation:
Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, DK-8200Aarhus N, Denmark
Johan Heiberg
Affiliation:
Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, DK-8200Aarhus N, Denmark
Benjamin Asschenfeldt
Affiliation:
Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, DK-8200Aarhus N, Denmark Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, DK-8200Aarhus N, Denmark
Steffen Ringgaard
Affiliation:
The MR Research Centre, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, DK-8200Aarhus N, Denmark
Vibeke E. Hjortdal
Affiliation:
Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, DK-8200Aarhus N, Denmark
*
Author for correspondence: M. Maagaard, MD, PhD, Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Blv. 99, DK-8200Aarhus N, Denmark. Tel: +45 7845 3086; Fax: +45 7845 3079. E-mail: maagaard@clin.au.dk
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Abstract

Objectives:

Clinical studies have revealed decreased exercise capacity in adults with small, unrepaired ventricular septal defects. Increasing shunt ratio and growing incompetence of the aortic and pulmonary valve with retrograde flow during exercise have been proposed as reasons for the previously found reduced exercise parameters. With MRI, haemodynamic shunt properties were measured during exercise in ventricular septal defects.

Methods:

Patients with small, unrepaired ventricular septal defects and healthy peers were examined with MRI during exercise. Quantitative flow scans measured blood flow through ascending aorta and pulmonary artery. Scans were analysed post hoc where cardiac index, retrograde flows, and shunt ratio were determined.

Results:

In total, 32 patients (26 ± 6 years) and 28 controls (27 ± 5 years) were included. The shunt ratio was 1.2 ± 0.2 at rest and decreased to 1.0 ± 0.2 at peak exercise, p < 0.01. Aortic cardiac index was lower at peak exercise in patients (7.5 ± 2 L/minute/m2) compared with controls (9.0±2L l/minute/m2), p<0.01. Aortic and pulmonary retrograde flow was larger in patients during exercise, p < 0.01. Positive correlation was demonstrated between aortic cardiac index at peak exercise and previously established exercise capacity for all patients (r = 0.5, p < 0.01).

Conclusions:

Small, unrepaired ventricular septal defects revealed declining shunt ratio with increasing exercise and lower aortic cardiac index. Patients demonstrated larger retrograde flow both through the pulmonary artery and the aorta during exercise compared with controls. In conclusion, adults with unrepaired ventricular septal defects redistribute blood flow during exercise probably secondary to a more fixed pulmonary vascular resistance compared with age-matched peers.

Keywords

Ventricular septal defectsbicycle exercise testMRIadult congenital heart disease
Type
Original Article
Information
Cardiology in the Young , Volume 30 , Issue 4 , April 2020 , pp. 526 - 532
Copyright
© The Author(s), 2020. Published by Cambridge University Press

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References

Baumgartner, H, Bonhoeffer, P, De Groot, NM, et al.ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). Eur Heart J 2010; 31: 2915–2957.Google Scholar
Silversides, CK, Dore, A, Poirier, N, et al.Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: shunt lesions. Can J Cardiol. 2010; 26: e70–e79.10.1016/S0828-282X(10)70354-8CrossRefGoogle Scholar
Videbaek, J, Laursen, HB, Olsen, M, Hofsten, DE, Johnsen, SP.Long-term nationwide follow-up study of simple congenital heart disease diagnosed in otherwise healthy children. Circulation 2016; 133: 474–483.10.1161/CIRCULATIONAHA.115.017226CrossRefGoogle ScholarPubMed
Karonis, T, Scognamiglio, G, Babu-Narayan, SV, et al.Clinical course and potential complications of small ventricular septal defects in adulthood: late development of left ventricular dysfunction justifies lifelong care. Int J Cardiol 2016; 208: 102–106.10.1016/j.ijcard.2016.01.208CrossRefGoogle ScholarPubMed
Menting, ME, Cuypers, JA, Opic, P, et al.The unnatural history of the ventricular septal defect: outcome up to 40 years after surgical closure. J Am Coll Cardiol 2015; 65: 1941–1951.10.1016/j.jacc.2015.02.055CrossRefGoogle ScholarPubMed
Gabriels, C, Van De Bruaene, A, Helsen, F, et al.Recall of patients discharged from follow-up after repair of isolated congenital shunt lesions. Int J Cardiol 2016; 221: 314–320.10.1016/j.ijcard.2016.07.066CrossRefGoogle ScholarPubMed
Gabriels, C, De Backer, J, Pasquet, A, et al.Long-term outcome of patients with perimembranous ventricular septal defect: results from the Belgian registry on adult congenital heart disease. Cardiology 2016; 136: 147–155.10.1159/000448513CrossRefGoogle ScholarPubMed
Heiberg, J, Laustsen, S, Petersen, AK, Hjortdal, VE.Reduced long-term exercise capacity in young adults operated for ventricular septal defect. Cardiol Young 2015; 25: 281–287.10.1017/S1047951113002084CrossRefGoogle ScholarPubMed
Maagaard, M, Heiberg, J, Hjortdal, VE.Small, unrepaired ventricular septal defects reveal poor exercise capacity compared with healthy peers: a prospective, cohort study. Int J Cardiol 2017; 227: 631–634.10.1016/j.ijcard.2016.10.086CrossRefGoogle ScholarPubMed
Heiberg, J, Schmidt, MR, Redington, A, Hjortdal, VEDisrupted right ventricular force-frequency relationships in adults operated for ventricular septal defect as toddlers: abnormal peak force predicts peak oxygen uptake during exercise. Int J Cardiol 2014; 177: 918–924.10.1016/j.ijcard.2014.10.009CrossRefGoogle ScholarPubMed
Maagaard, M, Heiberg, J, Eckerstrom, F, et al.Biventricular morphology in adults born with a ventricular septal defect. Cardiol Young 2018 Dec; 28(12): 1379–1385.10.1017/S1047951118001361CrossRefGoogle ScholarPubMed
Rex, CE, Eckerstrom, F, Heiberg, J, et al. Surgical closure of a ventricular septal defect in early childhood leads to altered pulmonary function in adulthood: a long-term follow-up. Int J Cardiol 2019 Jan 1; 274: 100–105.10.1016/j.ijcard.2018.06.109CrossRefGoogle Scholar
Asschenfeldt, B, Heiberg, J, Ringgaard, S, Maagaard, M, Redington, A, Hjortdal, VE.Impaired cardiac output during exercise in adults operated for ventricular septal defect in childhood: a hitherto unrecognised pathophysiological response. Cardiol Young 2017 Oct; 27(8): 1591–1598.10.1017/S1047951117000877CrossRefGoogle ScholarPubMed
Stout, KK, Daniels, CJ, Aboulhosn, JA, et al.2018 AHA/ACC guideline for the management of adults with congenital heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation 2019; 139: e637–e97.Google Scholar
Maagaard, M, Heiberg, J, Asschenfeldt, B, Ringgaard, S, Hjortdal, VE.Does functional capacity depend on the size of the shunt? A prospective, cohort study of adults with small, unrepaired ventricular septal defects. Eur J Cardiothorac Surg 2017; 51: 722–727.10.1093/ejcts/ezw420CrossRefGoogle ScholarPubMed
Craig, CL, Marshall, AL, Sjostrom, M, et al.International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003; 35: 1381–1395.10.1249/01.MSS.0000078924.61453.FBCrossRefGoogle ScholarPubMed
Heiberg, J, Asschenfeldt, B, Maagaard, M, Ringgaard, SDynamic bicycle exercise to assess cardiac output at multiple exercise levels during magnetic resonance imaging. Clin Imaging 2017; 46: 102–107.10.1016/j.clinimag.2017.07.010CrossRefGoogle ScholarPubMed
Hjortdal, VE, Emmertsen, K, Stenbog, E, et al.Effects of exercise and respiration on blood flow in total cavopulmonary connection: a real-time magnetic resonance flow study. Circulation 2003; 108: 1227–1231.10.1161/01.CIR.0000087406.27922.6BCrossRefGoogle ScholarPubMed
Shrout, PE, Fleiss, JLIntraclass correlations: uses in assessing rater reliability. Psychol Bull 1979; 86: 420–428.10.1037/0033-2909.86.2.420CrossRefGoogle ScholarPubMed
Bendien, C, Bossina, KK, Buurma, AE, et al.Hemodynamic effects of dynamic exercise in children and adolescents with moderate-to-small ventricular septal defects. Circulation 1984; 70: 929–934.10.1161/01.CIR.70.6.929CrossRefGoogle ScholarPubMed
Otterstad, JE, Simonsen, S, Erikssen, JHemodynamic findings at rest and during mild supine exercise in adults with isolated, uncomplicated ventricular septal defects. Circulation 1985; 71: 650–662.10.1161/01.CIR.71.4.650CrossRefGoogle ScholarPubMed
Merkus, D, de Beer, VJ, Houweling, B, Duncker, DJControl of pulmonary vascular tone during exercise in health and pulmonary hypertension. Pharmacol Ther 2008; 119: 242–263.10.1016/j.pharmthera.2008.04.003CrossRefGoogle ScholarPubMed
Schindler, MB, Bohn, DJ, Bryan, AC, Cutz, E, Rabinovitch, MIncreased respiratory system resistance and bronchial smooth muscle hypertrophy in children with acute postoperative pulmonary hypertension. Am J Respir Crit Care Med 1995; 152: 1347–1352.10.1164/ajrccm.152.4.7551393CrossRefGoogle ScholarPubMed
Moller, T, Brun, H, Fredriksen, PM, et al.Right ventricular systolic pressure response during exercise in adolescents born with atrial or ventricular septal defect. Am J Cardiol 2010; 105: 1610–1616.10.1016/j.amjcard.2010.01.024CrossRefGoogle ScholarPubMed
Brun, H, Moller, T, Fredriksen, PM, Thaulow, E, Pripp, AH, Holmstrom, HMechanisms of exercise-induced pulmonary hypertension in patients with cardiac septal defects. Pediatr Cardiol 2012; 33: 782–790.10.1007/s00246-012-0216-9CrossRefGoogle ScholarPubMed
Neumayer, U, Stone, S, Somerville, JSmall ventricular septal defects in adults. Eur Heart J 1998; 19: 1573–1582.10.1053/euhj.1998.1083CrossRefGoogle ScholarPubMed
Otterstad, JE, Erikssen, J, Michelsen, S, Nitter-Hauge, SLong-term follow-up in isolated ventricular septal defect considered too small to warrant operation. J Intern Med. 1990; 228: 305–309.10.1111/j.1365-2796.1990.tb00237.xCrossRefGoogle ScholarPubMed