Invited Commentary

Abstract

Giardini and colleagues [1Giardini A. Hager A. Napoleone C.P. Picchio F.M. Natural history of exercise capacity after the Fontan operation: a longitudinal study.Ann Thorac Surg. 2008; 85: 818-822Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar] assessed exercise capacity over time in patients who have undergone one of the variations of the Fontan procedure for single-ventricle physiology. The strength of this article is the length of follow-up of these patients, with an average of a 9-year interval between the first and last exercise tests. The results confirm the impression from previous cross-sectional studies that exercise performance is reduced after the Fontan operation and there is a progressive further decline in exercise capacity over time. This was more pronounced in those with morphologic single right ventricles compared with left ventricles and in those who underwent an atriopulmonary or atrioventricular connection compared with the total cavopulmonary connection.We are now in an era where excellent surgical survival has changed our patient demographics such that adults with congenital heart disease equal or outnumber children with these lesions. This means that longitudinal studies such as this one will be more and more possible. Although retrospective in design, the data are useful to guide our approach to monitoring these patients and helping with the difficult decisions about when to intervene with conversion to a total cavopulmonary connection or listing for cardiac transplantation. Future work could include evaluation of specific exercise indicators that might be useful to predict the need for surgery or listing for transplantation in the same way that low maximal oxygen consumption may lead to listing patients with dilated cardiomyopathy. Giardini and colleagues [1Giardini A. Hager A. Napoleone C.P. Picchio F.M. Natural history of exercise capacity after the Fontan operation: a longitudinal study.Ann Thorac Surg. 2008; 85: 818-822Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar] assessed exercise capacity over time in patients who have undergone one of the variations of the Fontan procedure for single-ventricle physiology. The strength of this article is the length of follow-up of these patients, with an average of a 9-year interval between the first and last exercise tests. The results confirm the impression from previous cross-sectional studies that exercise performance is reduced after the Fontan operation and there is a progressive further decline in exercise capacity over time. This was more pronounced in those with morphologic single right ventricles compared with left ventricles and in those who underwent an atriopulmonary or atrioventricular connection compared with the total cavopulmonary connection. We are now in an era where excellent surgical survival has changed our patient demographics such that adults with congenital heart disease equal or outnumber children with these lesions. This means that longitudinal studies such as this one will be more and more possible. Although retrospective in design, the data are useful to guide our approach to monitoring these patients and helping with the difficult decisions about when to intervene with conversion to a total cavopulmonary connection or listing for cardiac transplantation. Future work could include evaluation of specific exercise indicators that might be useful to predict the need for surgery or listing for transplantation in the same way that low maximal oxygen consumption may lead to listing patients with dilated cardiomyopathy. Natural History of Exercise Capacity After the Fontan Operation: A Longitudinal StudyThe Annals of Thoracic SurgeryVol. 85Issue 3PreviewPrevious studies have shown that older Fontan patients and those with an underlying morphologically right ventricle have lower exercise capacity. We sought to assess the natural history of exercise capacity after the Fontan operation in individual patients, and to identify the factors influencing the rate of decrease of exercise capacity over time. Full-Text PDF