Oxygen uptake efficiency slope: a reliable surrogate parameter for exercise capacity in healthy and cardiac children?

OBJECTIVES: Cardiopulmonary exercise test (CPET) provides accurate evaluation of physical capacity and disease severity in children with congenital heart disease (CHD). However, full participation to obtain optimal measure of VO2max may be difficult. As an alternative, the oxygen uptake efficiency slope (OUES) is a reproducible and reliable parameter measured during CPET, which does not require a maximal exercise to be interpretable. This study aimed to evaluate the OUES of a large cohort of children with CHD, in comparison with healthy controls. We also intended to identify, in this specific population, the clinical and CPET variables associated with the OUES. METHODS: This cross-sectional study was carried out between November 2010 and September 2015 in two tertiary care paediatric and congenital cardiology centres. RESULTS: 709 children were included (407 CHD and 302 healthy controls). The association of clinical characteristics with weight-normalised OUES (OUESkg) was studied using a multivariable analysis. The mean OUESkg was significantly lower in CHD than in healthy controls (38.6±8.5 and 43.9±8.5; p<0.001, respectively), especially in the most severe CHD. The OUESkg correlated with VO2max (r=0.85, p<0.001), with cut-off values for normal exercise capacity of 38.4 in boys and 31.0 in girls. The decrease of OUESkg was associated with increased age, increased Body Mass Index, number of cardiac catheter or surgical procedures, female gender and decreased forced vital capacity (Z-score). CONCLUSION: The OUES is significantly impaired in children with CHD and strongly correlates with VO2max. The OUES has the same clinical determinants as VO2max and therefore may be of interest in submaximal exercise. TRIAL REGISTRATION NUMBER: NCT01202916.

Impact of a centre and home-based cardiac rehabilitation program on the quality of life of teenagers and young adults with congenital heart disease: The QUALI-REHAB study rationale, design and methods.

BACKGROUND: Advances in congenital heart disease (CHD) have transferred the mortality from childhood to adulthood. Exercise capacity in young patients with CHD remains lower than in the general population, resulting in deconditioning and impaired quality of life. Evidence based-medicine in cardiac rehabilitation in this age group with CHD remains limited. We present the QUALI-REHAB study rationale, design and methods. METHODS: The QUALI-REHAB trial is a nationwide, multicentre, randomised, controlled study, aiming to assess the impact of a combined centre and home-based cardiac rehabilitation program on the quality of life of adolescents and young adults (13 to 25 years old) with CHD. Patients with a maximum oxygen uptake (VO2max) < 80% and/or a ventilatory anaerobic threshold (VAT) < 55% of predicted VO2max, will be eligible. Patients will be randomised into 2 groups (12-week cardiac rehabilitation program vs. controls). The primary outcome is the change in the PedsQL quality of life score between baseline and 12-month follow-up. A total of 130 patients are required to observe a significant increase of 7 ±â€¯13.5 points in the PedsQL, with a power of 80% and an alpha risk of 5%. The secondary outcomes are: VO2max, VAT, stroke volume, clinical outcomes, physical and psychological status, safety and acceptability. CONCLUSION: After focusing on the survival in CHD, current research is opening on secondary prevention and patient-related outcomes. The QUALI-REHAB trial intends to assess if a combined centre and home-based rehabilitation program, could improve the quality of life and the exercise capacity in youth with CHD. TRIAL REGISTRATION: Clinicaltrials.gov (NCT03690518).

Feasibility of clinical hypnosis for transesophageal echocardiography in children and adolescents.

BACKGROUND: The use of hypnosis in children has been described more than two centuries ago, with a more recent research and clinical application. There is currently a good level of evidence for the efficacy of clinical hypnosis in children for minor surgery, medical procedures or pain management. The use of clinical hypnosis, in paediatric cardiology, for invasive procedures such as transesophageal echocardiography, has not been reported. AIMS: This study evaluated the feasibility of clinical hypnosis in children undergoing transesophageal echocardiography. METHOD: This prospective, non-randomised, cross-sectional study was carried out over 24 months in a paediatric cardiology referral centre. All children aged 10-18 years requiring a transesophageal echocardiography examination, outside the operating room and the catheterisation laboratory, were eligible for the study. Children and families could choose between transesophageal echocardiography under clinical hypnosis or under general anaesthesia (<15 years) or sedation (⩾15 years). RESULTS: We included 16 children aged 11-18 years (seven girls, mean age 14.1±2.5 years). The hypnotic state was achieved for 15 out of the 16 participating children (94%). The transesophageal echocardiography examination could be completely achieved with a full diagnosis for 15 out of 16 children (94%). In all cases, a transesophageal echocardiography examination under clinical hypnosis provided a complete diagnosis. CONCLUSION: This study demonstrated that hypnosis was feasible and effective for transesophageal echocardiography in adolescents and might be a good alternative to general anaesthesia. Further study with larger numbers of subjects and more diverse congenital cardiac conditions are needed to confirm the results in a more diverse sample.

Area at risk can be assessed by iodine-123-meta-iodobenzylguanidine single-photon emission computed tomography after myocardial infarction: a prospective study.

BACKGROUND: Myocardial salvage is an important surrogate endpoint to estimate the impact of treatments in patients with ST-segment elevation myocardial infarction (STEMI). AIM: The aim of this study was to evaluate the correlation between cardiac sympathetic denervation area assessed by single-photon emission computed tomography (SPECT) using iodine-123-meta-iodobenzylguanidine (I-MIBG) and myocardial area at risk (AAR) assessed by cardiac magnetic resonance (CMR) (gold standard). PATIENTS AND METHODS: A total of 35 postprimary reperfusion STEMI patients were enrolled prospectively to undergo SPECT using I-MIBG (evaluates cardiac sympathetic denervation) and thallium-201 (evaluates myocardial necrosis), and to undergo CMR imaging using T2-weighted spin-echo turbo inversion recovery for AAR and postgadolinium T1-weighted phase sensitive inversion recovery for scar assessment. RESULTS: I-MIBG imaging showed a wider denervated area (51.1±16.0% of left ventricular area) in comparison with the necrosis area on thallium-201 imaging (16.1±14.4% of left ventricular area, P<0.0001). CMR and SPECT provided similar evaluation of the transmural necrosis (P=0.10) with a good correlation (R=0.86, P<0.0001). AAR on CMR was not different compared with the denervated area (P=0.23) and was adequately correlated (R=0.56, P=0.0002). Myocardial salvage evaluated by SPECT imaging (mismatch denervated but viable myocardium) was significantly higher than by CMR (P=0.02). CONCLUSION: In patients with STEMI, I-MIBG SPECT, assessing cardiac sympathetic denervation may precisely evaluate the AAR, providing an alternative to CMR for AAR assessment.