Cardiovascular, Pulmonary and Skeletal Muscle Evaluation Postoperative in Fontan Patients: Effects of Exercise Training

NCT02283255 | Completed DMC

• 1 other identifier: CAAE 01998712.7.0000.0068
• Study Type: interventional
• Target: 60
• Locations: 1 country
• Sites: 1

Brief Summary

Introduction: The Fontan operation is the surgical treatment in most patients with either anatomic or functional single ventricles. In this operation, the subpulmonary ventricle is bypassed, connecting the systemic veins directly to the pulmonary arteries. The lack of a subpulmonary ventricle is associated with a nonpulsatile pulmonary flow and triggers a sequence of adaptive mechanisms along the life of these patients. The most frequent consequence of these adaptative mechanisms is the reduction in functional capacity, objectively measured by the decrease in peak oxygen consumption (VO2). So, cardiovascular and pulmonary functioning and skeletal muscle alterations can explain exercise intolerance in these patients. Objectives: 1. To compare the cardiovascular, pulmonary, and musculoskeletal system variables in clinically stable Fontan patients with Healthy subjects; 2. To correlate the variables of the cardiovascular, pulmonary, and skeletal muscle with the functional capacity in Fontan patients; 3. To identify predictors of low functional capacity in this population; 4. To evaluate four-month aerobic exercise and inspiratory muscle training on functional capacity, pulmonary function, and autonomic control in patients after Fontan operation and compare to the group with no exercise training. Methods: All subjects were submitted to cardiovascular, pulmonary, and skeletal muscle evaluation at baseline to perform a cross-sectional study comparing Fontan Patients (FP) with Healthy Controls (HC). In addition, the FP accepted to participate in the longitudinal clinical trial to evaluate exercise programs were randomized into three groups: Aerobic Exercise Training (AET), Inspiratory Muscle Training (IMT), and Non-exercise Training Group (NET, a control group). All patient groups (AET, IMT, NET) were reassessed after four months of training or under usual care. Expected Outcomes: This study expects to demonstrate that impaired pulmonary function, altered neurovascular control, and reduced skeletal muscle could be an additional potential mechanism for reducing functional capacity in clinically stable Fontan patients. And this impairment could be diminished by exercise training, enhancing physical capacity, and exercise tolerance.

Conditions

Congenital Heart Disease; Single Ventricle; Univentricular Heart

Keywords

Fontan; Exercise; Pulmonary Function; Aerobic Capacity; Skeletal Muscle; Neurovascular control; Functional capacity

Outcome Measures

Primary Outcomes (1)

• Improvement exercise tolerance and physical capacity

  Change in parameters by cardiopulmonary exercise test; increase in lung volumes and capacities; improvement by neurovascular control and skeletical muscle metabolism

  Baseline and 4 months

Other Outcomes (6)

• Improvement in the functional capacity post exercise training program

  baseline and 4 months

• Improvement in pulmonary function post physical exercise program

  baseline and 4 months

• Change in autonomic function post exercise training program

  baseline and 4 months

Study Arms (3)

Aerobic Exercise Training Group

ACTIVE COMPARATOR

Aerobic Training: Aerobic training and muscle strength exercise for upper and lower limbs, 3 times a week for 4 months.

Other: Aerobic Exercise Training

Inspiratory Muscle Training Group

ACTIVE COMPARATOR

Respiratory Training: muscle training using POWERbreathe device, 7 times a week, 3 series of 30 repetitions per day, for 4 months.

Other: Inspiratory Muscle Training

No Exercise Trainint Group

ACTIVE COMPARATOR

No Physical Activity: Control group (usual care)

Other: No Exercise Training

Interventions

Aerobic Exercise Training OTHER

Supervised aerobic and light muscle resistance exercise training

Also known as: AET

Aerobic Exercise Training Group

Inspiratory Muscle Training OTHER

Inspiratory muscle training with POWERbreathe device

Also known as: IMT

Inspiratory Muscle Training Group

No Exercise Training OTHER

Usual care

Also known as: NET

No Exercise Trainint Group

Eligibility Criteria

• Age: 12 Years - 30 Years
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Child (0-17), Adult (18-64)

You may qualify if:

• Both gender, aged between 12 and 30 years
• Patients undergoing the Fontan operation with time postoperatively ≥5 years
• Clinically stable patients, no arrhythmia in the last electrocardiogram or clinical assessment
• Consent by the cardiologist
• Patients who voluntarily signed the consent form.

You may not qualify if:

• Patients with hypoplastic left heart syndrome
• Changes that reduce musculoskeletal walking skills
• Neurological sequelae, patients with associated genetic syndrome, disturbance cognitive or psychiatric
• Patients with a history of ventricular arrhythmias, cardio respiratory arrest, users of anti-arrhythmic drugs and / or underwent implantation of pacemaker
• Atrial arrhythmia requiring treatment in the last 6 months
• Patients with heart failure not controlled by medications and lung hypertension
• Patients with protein-losing enteropathy
• Severe hypoxemia (oxygen saturation \<80% at rest)
• Symptomatic patients with a diagnosis of diaphragmatic paresis or paralysis postoperative patients, with or without plication
• Patients with moderate to severe asthma
• Patients who live outside the area of Sao Paulo

Sponsors & Collaborators

• University of Sao Paulo: lead
• Fundação de Amparo à Pesquisa do Estado de São Paulo: collaborator

Study Sites (1)

InCor Heart Institute

São Paulo, 05403000, Brazil

Location

Related Publications (28)

• Ohuchi H, Ohashi H, Takasugi H, Yamada O, Yagihara T, Echigo S. Restrictive ventilatory impairment and arterial oxygenation characterize rest and exercise ventilation in patients after fontan operation. Pediatr Cardiol. 2004 Sep-Oct;25(5):513-21. doi: 10.1007/s00246-003-0652-7. Epub 2004 May 12.

  PMID: 15136907 BACKGROUND

• Brassard P, Poirier P, Martin J, Noel M, Nadreau E, Houde C, Cloutier A, Perron J, Jobin J. Impact of exercise training on muscle function and ergoreflex in Fontan patients: a pilot study. Int J Cardiol. 2006 Feb 8;107(1):85-94. doi: 10.1016/j.ijcard.2005.02.038. Epub 2005 Jul 19.

  PMID: 16046016 BACKGROUND

• Binotto MA, Maeda NY, Lopes AA. Altered endothelial function following the Fontan procedure. Cardiol Young. 2008 Feb;18(1):70-4. doi: 10.1017/S1047951107001680. Epub 2007 Dec 20.

  PMID: 18093358 BACKGROUND

• Steier J, Kaul S, Seymour J, Jolley C, Rafferty G, Man W, Luo YM, Roughton M, Polkey MI, Moxham J. The value of multiple tests of respiratory muscle strength. Thorax. 2007 Nov;62(11):975-80. doi: 10.1136/thx.2006.072884. Epub 2007 Jun 8.

  PMID: 17557772 BACKGROUND

• Anderson PA, Sleeper LA, Mahony L, Colan SD, Atz AM, Breitbart RE, Gersony WM, Gallagher D, Geva T, Margossian R, McCrindle BW, Paridon S, Schwartz M, Stylianou M, Williams RV, Clark BJ 3rd; Pediatric Heart Network Investigators. Contemporary outcomes after the Fontan procedure: a Pediatric Heart Network multicenter study. J Am Coll Cardiol. 2008 Jul 8;52(2):85-98. doi: 10.1016/j.jacc.2008.01.074.

  PMID: 18598886 BACKGROUND

• Trojnarska O, Gwizdala A, Katarzynski S, Katarzynska A, Szyszka A, Lanocha M, Grajek S, Kramer L. 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.

  PMID: 19387960 BACKGROUND

• d'Udekem Y, Cheung MM, Setyapranata S, Iyengar AJ, Kelly P, Buckland N, Grigg LE, Weintraub RG, Vance A, Brizard CP, Penny DJ. How good is a good Fontan? Quality of life and exercise capacity of Fontans without arrhythmias. Ann Thorac Surg. 2009 Dec;88(6):1961-9. doi: 10.1016/j.athoracsur.2009.07.079.

  PMID: 19932269 BACKGROUND

• Greutmann M, Le TL, Tobler D, Biaggi P, Oechslin EN, Silversides CK, Granton JT. Generalised muscle weakness in young adults with congenital heart disease. Heart. 2011 Jul;97(14):1164-8. doi: 10.1136/hrt.2010.213579. Epub 2011 Jan 21.

  PMID: 21258001 BACKGROUND

• Driscoll DJ, Durongpisitkul K. Exercise testing after the Fontan operation. Pediatr Cardiol. 1999 Jan-Feb;20(1):57-9; discussion 60. doi: 10.1007/s002469900397. No abstract available.

  PMID: 9861079 RESULT

• Neder JA, Andreoni S, Lerario MC, Nery LE. Reference values for lung function tests. II. Maximal respiratory pressures and voluntary ventilation. Braz J Med Biol Res. 1999 Jun;32(6):719-27. doi: 10.1590/s0100-879x1999000600007.

  PMID: 10412550 RESULT

• McCall R, Humphrey R. Exercise training in a young adult late after a fontan procedure to repair single ventricle physiology. J Cardiopulm Rehabil. 2001 Jul-Aug;21(4):227-30. doi: 10.1097/00008483-200107000-00007. No abstract available.

  PMID: 11508184 RESULT

• Minamisawa S, Nakazawa M, Momma K, Imai Y, Satomi G. Effect of aerobic training on exercise performance in patients after the Fontan operation. Am J Cardiol. 2001 Sep 15;88(6):695-8. doi: 10.1016/s0002-9149(01)01822-7. No abstract available.

  PMID: 11564403 RESULT

• Negrao CE, Rondon MU, Tinucci T, Alves MJ, Roveda F, Braga AM, Reis SF, Nastari L, Barretto AC, Krieger EM, Middlekauff HR. Abnormal neurovascular control during exercise is linked to heart failure severity. Am J Physiol Heart Circ Physiol. 2001 Mar;280(3):H1286-92. doi: 10.1152/ajpheart.2001.280.3.H1286.

  PMID: 11179075 RESULT

• American Thoracic Society/European Respiratory Society. ATS/ERS Statement on respiratory muscle testing. Am J Respir Crit Care Med. 2002 Aug 15;166(4):518-624. doi: 10.1164/rccm.166.4.518. No abstract available.

  PMID: 12186831 RESULT

• Larsson ES, Eriksson BO, Sixt R. Decreased lung function and exercise capacity in Fontan patients. A long-term follow-up. Scand Cardiovasc J. 2003;37(1):58-63. doi: 10.1080/14017430310007045.

  PMID: 12745804 RESULT

• Inai K, Saita Y, Takeda S, Nakazawa M, Kimura H. Skeletal muscle hemodynamics and endothelial function in patients after Fontan operation. Am J Cardiol. 2004 Mar 15;93(6):792-7. doi: 10.1016/j.amjcard.2003.11.062.

  PMID: 15019898 RESULT

• Rhodes J, Curran TJ, Camil L, Rabideau N, Fulton DR, Gauthier NS, Gauvreau K, Jenkins KJ. Impact of cardiac rehabilitation on the exercise function of children with serious congenital heart disease. Pediatrics. 2005 Dec;116(6):1339-45. doi: 10.1542/peds.2004-2697.

  PMID: 16322156 RESULT

• Opocher F, Varnier M, Sanders SP, Tosoni A, Zaccaria M, Stellin G, Milanesi O. Effects of aerobic exercise training in children after the Fontan operation. Am J Cardiol. 2005 Jan 1;95(1):150-2. doi: 10.1016/j.amjcard.2004.08.085.

  PMID: 15619417 RESULT

• Inai K, Nakanishi T, Nakazawa M. Clinical correlation and prognostic predictive value of neurohumoral factors in patients late after the Fontan operation. Am Heart J. 2005 Sep;150(3):588-94. doi: 10.1016/j.ahj.2004.10.030.

  PMID: 16169346 RESULT

• Moalla W, Maingourd Y, Gauthier R, Cahalin LP, Tabka Z, Ahmaidi S. Effect of exercise training on respiratory muscle oxygenation in children with congenital heart disease. Eur J Cardiovasc Prev Rehabil. 2006 Aug;13(4):604-11. doi: 10.1097/01.hjr.0000201515.59085.69.

  PMID: 16874152 RESULT

• Takken T, Hulzebos HJ, Blank AC, Tacken MH, Helders PJ, Strengers JL. Exercise prescription for patients with a Fontan circulation: current evidence and future directions. Neth Heart J. 2007;15(4):142-7. doi: 10.1007/BF03085970.

  PMID: 17612674 RESULT

• Pianosi PT, Johnson JN, Turchetta A, Johnson BD. Pulmonary function and ventilatory limitation to exercise in congenital heart disease. Congenit Heart Dis. 2009 Jan-Feb;4(1):2-11. doi: 10.1111/j.1747-0803.2008.00244.x.

  PMID: 19207396 RESULT

• Goldstein BH, Golbus JR, Sandelin AM, Warnke N, Gooding L, King KK, Donohue JE, Gurney JG, Goldberg CS, Rocchini AP, Charpie JR. Usefulness of peripheral vascular function to predict functional health status in patients with Fontan circulation. Am J Cardiol. 2011 Aug 1;108(3):428-34. doi: 10.1016/j.amjcard.2011.03.064. Epub 2011 May 19.

  PMID: 21600541 RESULT

• Lambert E, d'Udekem Y, Cheung M, Sari CI, Inman J, Ahimastos A, Eikelis N, Pathak A, King I, Grigg L, Schlaich M, Lambert G. Sympathetic and vascular dysfunction in adult patients with Fontan circulation. Int J Cardiol. 2013 Aug 20;167(4):1333-8. doi: 10.1016/j.ijcard.2012.04.015. Epub 2012 Apr 21.

  PMID: 22525342 RESULT

• Turquetto ALR, Caneo LF, Agostinho DR, Oliveira PA, Lopes MICS, Trevizan PF, Fernandes FLA, Binotto MA, Liberato G, Tavares GMP, Neirotti RA, Jatene MB. Impaired Pulmonary Function is an Additional Potential Mechanism for the Reduction of Functional Capacity in Clinically Stable Fontan Patients. Pediatr Cardiol. 2017 Jun;38(5):981-990. doi: 10.1007/s00246-017-1606-9. Epub 2017 May 12.

  PMID: 28500413 RESULT

• Turquetto ALR, Dos Santos MR, Sayegh ALC, de Souza FR, Agostinho DR, de Oliveira PA, Dos Santos YA, Liberato G, Binotto MA, Otaduy MCG, Negrao CE, Caneo LF, Jatene FB, Jatene MB. Blunted peripheral blood supply and underdeveloped skeletal muscle in Fontan patients: The impact on functional capacity. Int J Cardiol. 2018 Nov 15;271:54-59. doi: 10.1016/j.ijcard.2018.05.096. Epub 2018 May 25.

  PMID: 29861103 RESULT

• Turquetto ALR, Dos Santos MR, Agostinho DR, Sayegh ALC, de Souza FR, Amato LP, Barnabe MSR, de Oliveira PA, Liberato G, Binotto MA, Negrao CE, Caneo LF, Trindade E, Jatene FB, Jatene MB. Aerobic exercise and inspiratory muscle training increase functional capacity in patients with univentricular physiology after Fontan operation: A randomized controlled trial. Int J Cardiol. 2021 May 1;330:50-58. doi: 10.1016/j.ijcard.2021.01.058. Epub 2021 Feb 9.

  PMID: 33571562 RESULT

• Williams CA, Wadey C, Pieles G, Stuart G, Taylor RS, Long L. Physical activity interventions for people with congenital heart disease. Cochrane Database Syst Rev. 2020 Oct 28;10(10):CD013400. doi: 10.1002/14651858.CD013400.pub2.

  PMID: 33112424 DERIVED

MeSH Terms

Conditions

Heart Defects, Congenital; Univentricular Heart; Motor Activity

Interventions

beta-Aminoethyl Isothiourea

Condition Hierarchy (Ancestors)

Cardiovascular Abnormalities; Cardiovascular Diseases; Heart Diseases; Congenital Abnormalities; Congenital, Hereditary, and Neonatal Diseases and Abnormalities; Behavior

Intervention Hierarchy (Ancestors)

Thiourea; Urea; Amides; Organic Chemicals; Sulfur Compounds

Study Officials

• Marcelo B Jatene, MD,PhD

  Heart Institute, University of Sao Paulo, Medical School

  STUDY CHAIR

• Aida LR Turquetto, PhD student

  Heart Institute, University of Sao Paulo, Medical School

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: PARTICIPANT
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: PhD

Study Record Dates

• First Submitted: September 3, 2014
• First Posted: November 5, 2014
• Study Start: January 31, 2013
• Primary Completion: January 30, 2016
• Study Completion: October 30, 2020
• Last Updated: December 7, 2022

Record last verified: 2022-12

Locations

BR (1)