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a Cardiorespiratory Unit, Great Ormond Street Hospital for Children, Great Ormond St, London, WC1N 3JH United Kingdom
b Department of Pediatric Cardiology, and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität Müunchen, Lazarettstr. 36, D-80636 München, Germany
(Email: alessandro5574{at}iol.it; hager{at}dhm.mhn.de).
It was a pleasure to read the article by Shiraishi and colleagues [1] regarding the impact of age at Fontan completion on long-term aerobic exercise capacity. In the last 3 decades, a series of technical innovations and refinement of surgical techniques have been developed to reduce mortality and improve morbidity of Fontan patients. Despite these advancements, functional outcomes in Fontan patients remain far from what is desirable, especially when long-term aerobic exercise capacity is considered [2, 3]. Some of the limitations of Fontan circulation are inherent, whereas some of the others are deemed as a consequence of the surgical strategy, particularly the timing of ventricular unloading [4]. Shiraishi and colleagues [1] analyzed the effect of age at Fontan completion on aerobic exercise capacity in 68 patients with a dominant left ventricle who received a total cavopulmonary connection (TCPC) between 1990 and 2001. They reported that at follow-up, patients operated on before 3 years of age (age at TCPC, 1.4 ± 0.5 years) had a better peak oxygen uptake (61.3 ± 11.5% of predicted value) than those who had surgery beyond 3 years of age (age at TCPC, 5.8 ± 3.4 years; peak oxygen uptake, 51.9 ± 9.1%; p = 0.0001). The authors concluded that early Fontan surgery was associated with improved long-term aerobic exercise capacity.
We agree that early Fontan surgery might be beneficial. However, this conclusion can not be drawn from the data presented by Shiraishi and colleagues [1]. Indeed, in Fontan patients, exercise capacity does not remain stable during follow-up, but seems to decline much quicker than in matched healthy peers. In particular, Fontan patients with an underlying dominant left ventricle show an average decrease in peak oxygen uptake of approximately –1.7 ± 2.0% for each year of follow-up [2]. Because exercise capacity in Fontan patients is so age-dependent, failure to report the age at testing in the two groups makes it difficult to interpret the data presented. For example, Shiraishi and colleagues [1] reported that the average difference in age at TCPC between the two groups was 4.4 years. If we assume a similar 4.4 years difference in age at exercise test between the two groups, then we would expect a 7.5% difference in peak oxygen uptake (–1.7% x 4.4 years) simply as a result of one group being older than the other one. Therefore, the authors should be cautious in drawing their conclusions because most of the 9.4% difference in exercise capacity observed by them might simply be related to age difference between the two groups.
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This article has been cited by other articles:
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  C. Pace Napoleone, A. Giardini, and G. Gargiulo Reply to d'Udekem et al. Eur J Cardiothorac Surg, January 1, 2011; 39(1): 144 - 145. [Full Text] [PDF]
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