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Ann Thorac Surg 2006;81:665-670
© 2006 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Physical Activity Patterns of Children After Neonatal Arterial Switch Operation

^a Division of Pediatric Cardiology, University of Liège, Belgium
^b Mathematical Institute, University of Liège, Belgium
^c Department of Pediatric Cardiology, Aachen University of Technology, Aachen, Germany

Accepted for publication July 13, 2005.

^_* Address correspondence to Dr Massin, Division of Pediatric Cardiology, CHR Citadelle (University of Liège), Boulevard du 12è de Ligne, 1, Liège B-4000, Belgium (Email: martial.massin{at}chrcitadelle.be).

Pediatric cardiac surgery: To participate in The Annals of Thoracic Surgery CME Program, please visit http://cme.ctsnetjournals.org.

 

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Southern Thoracic Surgical... Acknowledgments References

 
BACKGROUND: Physical inactivity is a major atherosclerosis risk factor. The exercise tolerance is usually excellent after neonatal arterial switch operation, but those patients in whom coronary anomalies remain the main late complication, risk developing atherosclerotic coronary disease owing to perceived physical activity restrictions.

METHODS: We investigated physical activity patterns of 52 unselected children 7 to 14 years after neonatal arterial switch operation for transposition of the great arteries by 24-hour continuous heart rate monitoring. The percentage of heart rate reserve was used to measure the amounts of activities. Comparisons were made with 35 children with repaired atrial or ventricular septal defect and with 127 age-matched healthy children.

RESULTS: Children after arterial switch operation accumulated 167.3 ± 70.6, 25.3 ± 12.9, and 15.7 ± 11.3 minutes a day (mean ± SD) of light, moderate, and vigorous physical activities, respectively. At the same activity levels, children with repaired septal defect accumulated 165.2 ± 82.2, 26.2 ± 11.7, and 16.2 ± 9.1 minutes a day, and their healthy peers 164.8 ± 74.5, 31.8 ± 13.9, and 21.9 ± 11.3 minutes a day. Both cardiac groups were significantly less active than the control group when considering moderate (p = 0.026) and vigorous activities (p = 0.006). Only 19% and 27% of the children after arterial switch operation engaged, respectively, in more than 30 minutes a day of moderate activity and 20 minutes a day of vigorous activity.

CONCLUSIONS: Children after arterial switch operation, just like other cardiac children, do not meet the guidelines for physical activity. We should encourage regular physical activity to offset adult sedentary behavior and to prevent atherosclerotic cardiovascular disease in those patients whose long-term function of the coronary arteries remains a matter of concern.

Health benefits of a physically active lifestyle are well documented in nondiseased populations [1]; and physical inactivity is a major risk factor for developing coronary heart disease, atherosclerosis, some cancers, and type 2 diabetes in adults [1]. Children with congenital heart disease have a risk of latent disease developing owing to real or perceived physical activity restrictions [2]. Exercise tolerance is usually normal after neonatal arterial switch operation (ASO) for transposition of the great arteries (TGA) [3–7], but those patients, in whom coronary anomalies remain the main late complication, risk the development of atherosclerotic coronary disease owing to perceived physical activity restrictions. In this study, the physical activity patterns of a large cohort of children and adolescents who had undergone a neonatal ASO for TGA were analyzed to study whether they differed from healthy subjects.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Southern Thoracic Surgical... Acknowledgments References

 
Patients
The study group (group A) consisted of 52 unselected children 7 to 14 years after neonatal ASO for TGA (38 male and 14 female). Sixty-four patients were initially included, but according to the aim of the study and to the limitations of the methods, 12 of them were excluded from analysis because of mental retardation (n = 3), ectopic rhythm on the resting electrocardiogram (n = 4), significant residual lesions (n = 2 with significant supravalvar pulmonary stenosis), or for technical reasons (n = 3). From the 52 study patients, 4 were annually followed up in the outpatient clinic in Liège and 9 in Aachen, two university hospitals approximately 35 miles apart; and the 39 other patients were referred from other German cardiac centers for a study performed by the Aachen team to assess cardiac and general health status 8 to 14 years after neonatal ASO for TGA [8]. The referred patients belonged to the cohort of 96 children who underwent a neonatal ASO in Aachen between 1986 and 1992. Participation was determined mainly by the distance of the family's residence from Aachen. Nonparticipating patients were similar to participants with respect to age, sex, cardiac health, endurance capacity, neurodevelopmental status, and socioeconomic background, as assessed by questionnaires completed by their treating pediatricians and pediatric cardiologists. Age at ASO ranged from 2 to 12 days.

Uniform surgery was performed under deep hypothermic circulatory arrest, as previously described [5]. Forty-one of the patients included in this study had a simple TGA, 8 had an unimportant ventricular septal defect that was not closed surgically and 1 had a ventricular septal defect that was closed through the right atrium during ASO. Two patients had a coarctation of the aorta corrected at a later date. Coronary artery status was usual in 43 of the studied patients, the circumflex coronary artery arose from the right coronary artery in 3 cases, the right coronary artery and the circumflex coronary artery were inverted in 3 cases, and a single ostium for the left and right coronary arteries was noted in 3 cases. A coronary artery angiography was selectively performed ± 1 year after surgery, for most of the patients as part of a study performed by the Aachen team to assess midterm results of ASO for TGA [9], and showed no lesion in any of the patients.

Their physical activity patterns were compared with those of 35 age-matched "cured" cardiac children (22 male and 13 female) who underwent an atrial (n = 16) or ventricular septal defect repair (n = 19) before the age of 3 years (group B). Those children were chosen because they can achieve levels of fitness equaling healthy people after surgery [10, 11]. Children with surgery performed later were not included because they usually show lower daily physical activity and cardiorespiratory capacity, mostly attributed to psychological restraints [11]. Children of this group were recruited from a cohort of children followed regularly because they were examined in the outpatient cardiac clinic at the time of the study.

The results were also compared with those of 127 age-matched healthy children (group C). The control subjects (65 male and 62 female) were recruited from a group of children referred to the outpatient clinic for assessment of a "new" functional heart murmur. All of them had a normal medical history and physical examination.

No subject was overweight or underweight, or had any known problem that might limit normal physical activity. None took medications. According to their cardiac health (normal heart size, no residual lesions, normal ventricular function, normal exercise study, and no arrhythmias or pacemaker in group A; no pulmonary hypertension, no arrhythmias, and no myocardial dysfunction in group B), the cardiac patients were allowed to participate in all competitive sports, and their pediatric cardiologists encouraged regular physical activity in a positive manner at clinic visits. Neither the cardiac patients nor the healthy subjects had received an educational program with promotion of physical activity. Parental informed consent and child assent were obtained. The study protocol was approved by the Human Ethical Committee of the Aachen University of Technology on May 8, 2000.

Methods
A general cardiac evaluation, including physical examination, standard electrocardiography, transthoracic echocardiography, and Bruce walking treadmill test to voluntary exhaustion, was performed in all subjects.

The volume of physical activity during normal weekdays was estimated from continuous heart rate monitoring. Physical activity is not directly measured in this way, but the relative stress placed upon the cardiopulmonary system by the activity is monitored. For ease of exposition, however, it will be assumed that volume of heart rate response is indicative of volume of physical activity.

Heart rate monitoring was recorded using an MR45 Oxford recorder type (Oxford Instruments, Largo, Florida). This equipment was easy to attach and gave freedom of movement. All tapes were analyzed with use of a Medilog Excel computer program (Oxford Instruments). Because it was determined that parents would not be likely to allow their children to be observed and monitored several days or all day on weekend days, all monitoring occurred Monday to Thursday over a 24-hour period. Parents were instructed to allow their child to engage in his normal daily activities, including sporting and other after-school activities.

Heart rate was averaged every minute. Resting heart rate was obtained from an electrocardiogram performed in the early morning, without prior exercise, at rest for 5 minutes. The percentage of heart rate reserve (%HRR) was used to measure the amounts of physical activity at different intensities [12, 13]. Resting heart rate was subtracted from maximal heart rate, recorded during maximal treadmill exercise, to calculate the heart rate reserve (HRR), and the percentage above resting heart rate was multiplied by HRR to estimate %HRR. To provide for the full range of activity definitions, we coded activity data between 20% and 100% of HRR. There is general agreement that children who meet the 20% to 40% HRR criteria are not engaged in sedentary behavior, that children who reach 40% HRR meet minimal guidelines for physical activity at intensities equivalent to at least 5 resting metabolic rates, and that the lower threshold for aerobic fitness effects is 50% of HRR [12]. As in previous papers [12, 13], we therefore considered the time spent in light activity, which corresponds to heart rate values between 20% and 40% of HRR, in moderate activity, which corresponds to values between 40% and 50% of HRR, and in vigorous activity, which corresponds to values above 50% of HRR.

We investigated the dependence of the results at each activity level on age, sex, and group by using the following method: all explanatory variables and their interactions were first introduced in an analysis of variance (ANOVA) model, and all the nonsignificant effects were then successively excluded to reach a final model in which all the remaining effects were significant at a p value less than 0.05. In addition, we separately investigated each group by the same method. Age, sex, and origin (Liège area, Aachen area, or other cardiac centers) and their interactions were the explanatory variables in group A; age, sex, and their interactions were the explanatory variables in groups B and C. To investigate the dependence of the proportion of subjects meeting the classical guidelines for physical activity on age, sex, and group, we used the same method as above, except that the ANOVA test was replaced by the logistic regression procedure.

	Results

Top Abstract Introduction Patients and Methods Results Comment Southern Thoracic Surgical... Acknowledgments References

 
The age at the time of the study averaged 9.8 ± 1.8 years in group A, 9.1 ± 2.0 years in group B, and 10.0 ± 2.3 years in group C. All the subjects were in stable sinus rhythm on the resting electrocardiogram. At echocardiographic examination, left ventricular function was homogeneous and normal (mean fraction shortening = 37.1% ± SD 4.9) in all patients of group A. Four of them had mild to moderate aortic regurgitation, 16 had mild or moderate supravalvar pulmonary stenosis. An echocardiogram was performed in all patients of group B, and none of them had residual lesions or ventricular dysfunction. It was also performed in all subjects of group C and confirmed that all murmurs were innocent. All the subjects had a normal exercise capacity when assessed by Bruce walking treadmill test to voluntary exhaustion. All of them were in sinus rhythm at rest and during exercise, and no ST-T changes or arrhythmias were observed on the electrocardiogram during exercise or during the recovery period.

The children of group A accumulated 167.3 ± 70.6, 25.3 ± 12.9, and 15.7 ± 11.3 minutes a day (mean ± SD) of light, moderate and vigorous physical activities, respectively. At the same activity levels, those of group B accumulated 165.2 ± 82.2, 26.2 ± 11.7, and 16.2 ± 9.1 minutes a day (mean ± SD), whereas their healthy peers accumulated 164.8 ± 74.5, 31.8 ± 13.9, and 21.9 ± 11.3 minutes a day (mean ± SD). Patients of group A and B were equally active but less active than healthy peers when considering moderate (p = 0.026) and vigorous activities (p = 0.0006; Table 1).

	Comment

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Understanding physical activity behavior requires a valid, reliable, and practical method of assessing activity levels that is appropriate for use in large groups [12–15]. The self-report of activity by children is difficult because they are less conscious of time than adults and tend to engage in physical activity that is chaotic, both in time and intensity. Classical pedometers are insensitive to nonlocomotor forms of movement and are unable to record the magnitude of the movement detected [12, 14, 15]. New accelerometers are more useful [16, 17], but very expensive and only reliable with cooperating subjects (children may mimic the movements detected by the sensors during periods of inactivity).

A classical alternative to accelerometers is to measure physical activity with heart rate, which is an indirect estimate of physical activity that makes assumption based on the linearity that exists through most of the heart rate–energy expenditure relationship. Heart rate monitoring can be implemented in large groups with multiple monitors; it has been the most popular objective measurement of physical activity in children [12, 13, 18, 20], and the technique has been validated in the general population (but not specifically in the cardiac population) against direct measures of energy expenditure, including oxygen consumption or doubly labelled water [12, 14, 21]. Moreover, we have a large experience with the method in healthy [13] and unhealthy [22] children and adolescents, and the method is especially of interest in patients in whom Holter recordings are regularly performed for clinical follow-up. For all those reasons, we decided to use continuous recording of heart rate throughout the day to evaluate the habitual physical activity of our patients.

Even if heart rate monitoring is a popular method, it has also limitations because it is an indirect estimate of physical activity. A slight chronotropic impairment is sometimes noted after intra-atrial surgery using a cardiopulmonary bypass procedure [23], including arterial switch operation [24], and it could be a source of underestimation of physical activity in groups A and B. However, in our ASO study population, heart rate rose regularly between rest and peak exercise and did not differ from normal controls [4]. Residual lesions may also alter heart rate adaptation to physical activity, and it could be a source of overestimation of physical activity in group A. Wearing a heart rate monitor may also influence the amount of physical activity, and children may not habituate as rapidly to wearing a recorder in comparison with less intrusive accelerometers. A last source of error is that our children were monitored during 24 hours on weekdays. Seven to 9 days of continuous monitoring would be necessary to produce more accurate estimates of daily activities and to account for differences in weekday and weekend activity [25]. Noncompliance of children and limited availability of expensive monitors make it not realizable when large cohorts of people are included, and many previous studies suffered from the same limitation [12, 13]. Moreover, the choice of prolonged recordings would certainly introduce a nonrepresentative selection of patients. For all these reasons, data must be carefully interpreted.

Regular physical activity is an essential component of a healthy lifestyle for all children and adolescents [26]. Early education and experience help to establish life-long physical activity habits. There is concern about the lack of physical activity in healthy people in industrialized countries. To encourage adoption of active lifestyles, different experts panels developed guidelines for the amount of physical activity required to produce health benefits. The Centers for Disease Control and Prevention and the American College of Sports Medicine recommend 30 minutes of daily moderate activity to be accumulated over short bouts [27], and the American Heart Association recommends that all children aged 5 and older also perform at least 20 minutes of vigorous activities at least 3 to 4 days each week to achieve and maintain a good level of cardiorespiratory fitness. In our healthy group, 57% of the children met the guidelines for the moderate activity and 47% for the vigorous activity. This finding suggests that our healthy children, just like other young Europeans and Americans [12, 13, 17–20], are not very active.

The exercise tolerance is usually excellent after anatomic repair of TGA. Previous studies assessed exercise performance by measurement of the maximal endurance time on a treadmill by Bruce protocol and showed that all patients were within normal limits [4, 5, 7]. The cardiorespiratory exercise function was also shown to be at the lower limit of normal [6] or normal [3]. However, as it was the case in previous studies among children with other congenital heart diseases [2], young patients after ASO are less active than their healthy peers and fail to reach the minimal level of activity recommended to obtain the additional benefits conferred by undertaking moderate and vigorous physical activity. As the reported low activity levels are not due to cardiovascular physiology and similar results are observed in children after septal defect repair, our data suggest that behavioral factors influence activity levels. Perceived restrictions, overprotection by parents, or altered self-perception of physical appearance due to surgical scars are factors that may explain the physical activity patterns of our cardiac children [28, 29].

This physical inactivity has serious implications for their current mental and physical health and may lead to an increased risk of developing atherosclerosis associated with sedentary lifestyles. This concern is very important for all cardiac children because some of them have residual lesions or ventricular dysfunction (eg, after Fallot repair), arterial hypertension and dysfunction of aorta (eg, after aortic coarctation repair), or dysfunction of coronary arteries (eg, after ASO or Ross operation). It is especially important in our study population because the function of the coronary arteries remains a matter of concern in patients after neonatal ASO for TGA. Late coronary mortality and myocardial infarction are rare after ASO [30], but the prevalence of late coronary lesions is high: in a recent study [30], the prevalence of coronary occlusion or significant stenosis was ± 7% whereas ± 4% of the other patients had minor lesions (minor stenosis, fistula, or hypoplasia). Many questions remain about long-term development of the coronary circulation of those patients, including the evolution of atherosclerosis and coronary flow reserve. Stress-induced perfusion defects and attenuated coronary flow reserve were also documented in children after ASO who had normal coronary artery angiography [3]. Although the cause of these myocardial perfusion abnormalities is not yet clarified, congenital and developmental anomalies of the coronary arteries, the insult from open-heart surgery, and coronary manipulation during the ASO are probably contributing factors [3]. Some of those abnormalities may also be accelerating factors for coronary atherosclerosis development. Finally, the addition of such abnormalities due to TGA and ASO with atherosclerotic disease due to unhealthy lifestyle could lead to numerous and very early cardiovascular events in that population.

Children who underwent ASO for TGA are seen infrequently by their pediatric cardiologist, and the most common mode of imparting advice about physical activity is verbal. Moreover, it has been shown that receiving advice from medical staff has little impact on these patients' subsequent physical activity behaviors [31]. That suggests that methods should be reviewed and new systems evaluated. Written instructions may be more effective. Regular follow-up contacts with parents and older children may provide opportunities for education, motivation, and guidance to choose appropriate activity options. Cardiac children who participate in special sports camps may also experience benefits in terms of subjective health status, with improved perception of physical functioning and self-esteem [32]. Concerning so many inactive children, the risk of decline into sedentary adulthood and associated latent lifestyle diseases is considerable in our young cardiac population. It is important, therefore, that promotion of increased physical activity in this group is implemented and evaluated, to improve their current health and reduce these risks.

In conclusion, most children after neonatal ASO for TGA do not meet the guidelines for physical activity and risk developing latent diseases because of perceived activity restrictions. We should encourage regular physical activity to offset adult sedentary behavior and to prevent atherosclerotic cardiovascular disease in patients whose long-term function of the coronary arteries remains a matter of concern.

	Southern Thoracic Surgical Association: Fifty-Third Annual Meeting

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The Fifty-Third Annual Meeting of the Southern Thoracic Surgical Association (STSA) will be held November 9–11, 2006, in Tucson, Arizona.

Members wishing to participate in the Scientific Program should submit an abstract by April 7, 2006, 12:00 Midnight, Central Daylight Time. Abstracts must be submitted electronically. Instructions for the abstract submission process can be found on the STSA Web site at www.stsa.org; on the CTSNet Web site at www.ctsnet.org; or in the back of the issue of The Annals of Thoracic Surgery.

Manuscripts accepted for the Resident Competition must be submitted to the STSA headquarters office no later than September 15, 2006. The Resident Award will be based on abstract, presentation, and manuscript.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Southern Thoracic Surgical... Acknowledgments References

 
We thank the Belgian National Foundation for Research on Pediatric Cardiology for financial support of the Division of Pediatric Cardiology of the University of Liège, Belgium.

	References

Top Abstract Introduction Patients and Methods Results Comment Southern Thoracic Surgical... Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Massin, M. M. Articles by Seghaye, M.-C. Search for Related Content PubMed PubMed Citation Articles by Massin, M. M. Articles by Seghaye, M.-C. Related Collections Congenital - cyanotic