ABSTRACT
OBJECTIVES: Novel protocols were used to focus on dynamic cardiorespiratory function during submaximal exercise and on the recovery from 1-min pulses of exercise in children who had undergone Fontan corrections for single-ventricle lesions. BACKGROUND: Particularly in children, maximal oxygen uptake (VO2max), which is commonly used to assess the functional capability of patients after the Fontan procedure, is highly effort dependent and not physiologic and leads to uncomfortable metabolic and cardiorespiratory stress. Alternative approaches include the measurement of dynamic responses during progressive exercise and recovery after short bursts of exercise. These strategies yield mechanistic insight into cardiorespiratory impairment and can be used to gauge limitations in daily life activity. METHODS: Sixteen patients (mean [+/-SD] age 12.2 +/- 2.4 years; 9 boys) and 10 age-matched control subjects (mean age 12.2 +/- 2.4 years; 6 boys) performed two separate cycle ergometer tests in which gas exchange was measured on a breath by breath basis: 1) Progressive exercise was used to determine the dynamic relation among VO2, carbon dioxide production (VCO2), ventilation (VE), heart rate (HR) and work rate (WR). 2) A 1-min constant WR test was used to determine the recovery time for gas exchange and HR. RESULTS: Peak VO2 and anaerobic threshold were reduced in patients who underwent the Fontan procedure compared with control subjects by 57% and 52%, respectively (p < 0.001). Dynamic relations during progressive exercise--deltaVO2/deltaHR and deltaVO2/deltaWR--were decreased (p < 0.001) and deltaVE/deltaVCO2 was increased (p < 0.005) in the Fontan group patients. Recovery times for HR and VO2 were prolonged in the Fontan group patients by 154% and 69%, respectively (p < 0.01). CONCLUSIONS: The results demonstrate that submaximal gas exchange responses to progressive exercise and recovery times after brief high intensity exercise are abnormal in patients after the Fontan procedure. These observations complement the findings of reduced VO2max observed here and by others. We speculate that the mechanisms for these responses are related to 1) a pervasive reduction in stroke volume for both low and high intensity exercise, 2) an abnormal linkage of ventilation to tissue carbon dioxide production, and 3) increased dependence on anaerobic metabolism in skeletal muscles. The prolonged recovery of HR and VO2 provides a possible mechanism for reduced physical activity.
Subject(s)
Exercise , Fontan Procedure , Heart/physiopathology , Lung/physiopathology , Adolescent , Carbon Dioxide/metabolism , Child , Exercise Test , Female , Heart Function Tests , Heart Rate , Humans , Male , Oxygen/blood , Respiration , Respiratory Function TestsABSTRACT
The bidirectional Glenn anastomosis (BGA) has long been used as a surgical intervention for patients with single ventricle physiology. Initially, this procedure was the final stage in palliation and was performed in older children. Eventually, as the Fontan procedure came to be used as a method to separate circulations, the Glenn procedure was performed as an intermediate step. Over time, the BGA was performed as an alternative for patients who were considered to be at high risk with the Fontan procedure. Between January 1, 1988, and January 1, 1994, 129 patients underwent BGA at the University of California-Los Angeles. These patients were reviewed retrospectively, including clinic visits, catheterization, and echocardiographic information. The overall survival rate was 87% (112 of 129 patients). The average length of follow-up was 27 months. This information was then analyzed by univariate and multivariate analysis. Several factors were related to failure in patients who underwent BGA including pulmonary artery pressure, systemic right ventricle, and presence of anomolous pulmonary venous drainage and heterotaxy syndrome.
Subject(s)
Heart Defects, Congenital/surgery , Pulmonary Artery/surgery , Vena Cava, Superior/surgery , Adolescent , Age Factors , Anastomosis, Surgical/methods , Anastomosis, Surgical/mortality , Cardiopulmonary Bypass , Child , Child, Preschool , Female , Follow-Up Studies , Heart Defects, Congenital/blood , Heart Defects, Congenital/physiopathology , Humans , Infant , Male , Mitral Valve Insufficiency/complications , Multivariate Analysis , Oxygen/blood , Pulmonary Veins/abnormalities , Pulmonary Wedge Pressure , Retrospective Studies , Risk Factors , Spleen/abnormalities , Survival Rate , Tricuspid Valve Insufficiency/complications , Ventricular Function, RightABSTRACT
Decline of sacred fir (Abies religiosa) trees in the high elevation forest park, Desierto de los Leones, located south of Mexico City, is described. Trees located in the windward zone (exposed to air masses from Mexico City) were the most severely affected, especially trees at the distal ends of ravines. Examination of tree growth rings indicated decreases in ring widths for the past 30 years. Polluted air from Mexico City may be an important causal factor in fir decline. Drought, due to excessive removal of soil water, insects, mites and pathogens, and poor forest management are possible contributing and interactive factors in fir decline.
