Quality of life of adult congenital heart disease patients: a systematic review of the literature

AIMS

This review explores the quality of life of adult congenital heart disease patients and the relationship between disease severity and quality of life.

METHODS

We searched seven electronic databases and the bibliography of articles. The 31 selected studies fulfilled the following criteria: adult population; quantitative; assessment of quality of life and/or impact of disease severity on quality of life using validated measures; English language. Data extraction forms were used to summarise the results.

RESULTS

There are evident methodological limitations within the reviewed studies such as heterogeneous populations, designs, and quality of life conceptualisations and measurements. Despite these problems, findings suggest that the quality of life of adult congenital heart disease patients is compromised in the physical domain compared with their healthy counterparts, whereas no differences were found in relation to the psychosocial and environmental/occupational domain. Some severity variables appear to be significant correlates of quality of life and could be considered in a future standardised classification of disease severity.

CONCLUSION

The methodological limitations of past research in relation to the definition and measurement of quality of life, the study designs, and disease severity classifications need to be addressed in future studies in order to provide robust evidence and valid conclusions in this area of study. This will enable the development of targeted interventions for the improvement of quality of life in the adult population of congenital heart disease patients.

Associations between exercise capacity, physical activity, and psychosocial functioning in children with congenital heart disease: a systematic review

BACKGROUND

Children and adolescents operated upon for congenital heart disease (ConHD) may show reduced exercise capacity and physical activity, possibly associated with lowered self-esteem and quality of life (QoL). The studies into associations between these parameters have not been reviewed before.

OBJECTIVE

Review of studies into associations between exercise capacity, physical activity, respectively exercise training, and psychosocial functioning of ConHD youngsters.

DATA SOURCES

PubMed, Embase and reference lists of related articles.

STUDY SELECTION

Articles published between January 2000 and December 2012 into exercise capacity and/or physical activity, and a measure of psychosocial functioning in children with ConHD.

DATA EXTRACTION

Two investigators independently reviewed the identified articles for eligibility, and one author extracted the data.

RESULTS

Although exercise capacity was strongly related to physical domains of parent-reported and self-reported QoL, it was almost never associated with psychosocial domains of QoL. Physical activity was rarely associated with physical or psychosocial domains of QoL. Remarkably, self-reported depressive symptoms were associated with both physical and psychosocial QoL. The few studies into exercise-training programmes showed promising results in QoL and emotional and behavioral problems, but they contained methodological flaws.

CONCLUSIONS

No clear relationships were found between exercise capacity, physical activity, and QoL in children and adolescents with ConHD. Therefore we recommend assessing QoL separately, preferably both self-reported and parent-reported. Since depressive symptoms were associated with reduced physical and psychosocial QoL, screening on these symptoms is also recommended.

Health-related quality of life compared with cardiopulmonary exercise testing at the midterm follow-up visit after tetralogy of Fallot repair: a study of the German competence network for congenital heart defects

This nationwide study aimed to evaluate health-related quality of life (QoL) experienced by children after tetralogy of Fallot repair and to compare self-reported physical ability with objective exercise performance. This prospective nonrandomized, government-funded multicenter study enrolled 168 patients (70 girls; ages 8-16 years) after tetralogy of Fallot repair at eight German heart centers. Health-related QoL was analyzed by the self-reported KINDL-R quality-of-life questionnaire. The patients' actual exercise capacity was evaluated by a cardiopulmonary exercise test. Health-related QoL and cardiopulmonary exercise capacity were compared with those of an age-matched German standard population. Correlation of health-related QoL with self-estimated physical rating and cardiopulmonary exercise capacity were analyzed. Health-related QoL in children and adolescents after tetralogy of Fallot repair is without limitation. Compared with the standard population, all the items evaluated by the KINDL-R questionnaire showed better or similar values, whereas objective exercise capacity compared with that of the standard population was impaired. Peak oxygen uptake correlated significantly with the physical well-being (p = 0.002) and the total score (p = 0.01) of the KINDL-R questionnaire. Health-related QoL experienced by children and adolescents after tetralogy of Fallot repair is comparable with that of the healthy standard population. However, closer inspection shows that self-estimated physical functioning is significantly overestimated compared with actual exercise capacity. Quality-of-life instruments and exercise tests, therefore, should be used in a complementary manner with children to avoid eventually fatal misinterpretation of patient-estimated physical ability.

Loss to specialist follow-up in congenital heart disease; out of sight, out of mind

OBJECTIVE

To evaluate the scale and clinical importance of loss to follow-up of past patients with serious congenital heart disease, using a common malformation as an example. To better understand the antecedents of loss to specialist follow-up and patients' attitudes to returning.

DESIGN

Cohort study using NHS number functionality. Content and thematic analysis of telephone interviews of subset contacted after loss to follow-up. PATIENTS, INTERVENTION AND SETTING: Longitudinal follow-up of complete consecutive list of all 1085 UK patients with repair of tetralogy of Fallot from single institution 1964-2009.

MAIN OUTCOME MEASURES

Survival, freedom from late pulmonary valve replacement, loss to specialist follow-up, shortfall in late surgical revisions related to loss to follow-up. Patients' narrative about loss to follow-up.

RESULTS

216 (24%) of patients known to be currently alive appear not to be registered with specialist clinics; some are seen in general cardiology clinics. Their median age is 32 years and median duration of loss to follow-up is 22 years; most had been lost before Adult Congenital services had been consolidated in their present form. 48% of the late deaths to date have occurred in patients not under specialist follow-up. None of those lost to specialist follow-up has had secondary pulmonary valve replacement while 188 patients under specialist care have. Patients lost to specialist follow-up who were contacted by telephone had no knowledge of its availability.

CONCLUSIONS

Loss to specialist follow-up, typically originating many years ago, impacts patient management.

Long-term outcome and quality of life after arterial switch operation: a prospective study with a historical comparison

AIM.: The study aims to describe the long-term cardiological and psychological results of our first surgical cohort of arterial switch operation (ASO) patients and compare the results with our earlier series of Mustard patients. METHODS.: Twenty-four survivors of ASO operated in our center (1985-1990) were evaluated by electrocardiography, echocardiography, magnetic resonance imaging, exercise testing, 24-hour Holter-monitoring, and health-related quality of life questionnaire. The results were compared with 58 adult Mustard patients who were evaluated in 2001 using the same study protocol. RESULTS.: Arterial switch operation was performed at a median age of 13 days and Mustard operation at 2 years. Median follow-up was 22 years (range 20-25) and 25 years (22-29), respectively. After ASO, survival was better (P =.04). The event-free survival after 22 years was 77% after ASO vs. 44% after Mustard (P =.03). Good systemic ventricular function was present in 93% after ASO vs. 6% after Mustard (P <.01). Exercise capacity in ASO was 85% of predicted, compared with 72% in Mustard patients (P =.01). Aortic regurgitation was found in 21% of ASO patients vs. 16% in Mustard patients. Arterial switch patients vs. Mustard patients reported significantly better quality of life and less somatic complaints. CONCLUSION.: The progression made in surgical treatment for transposition of the great arteries from Mustard to ASO has had a positive impact on survival, cardiac function, exercise capacity, and also self-reported quality of life and somatic complaints. Longer follow-up is warranted to monitor aortic regurgitation.

"It's no big deal": adolescents with congenital heart disease

Improved survival rates for congenital heart disease (CHD) have increasing numbers requiring lifelong specialized health care. In this interpretive description, interview data were analyzed to understand how adolescents with CHD describe everyday life and relate to questions about quality of life. Most viewed themselves as normal, their CHD something that they situated into the foreground or background of their lives as it suited their needs. They spoke of quality-of-life issues in a concrete manner focusing on physical activity limitations and their need to fit in. These findings can direct interventions for adolescents with CHD for transition to adulthood.

Heart failure associated with adult congenital heart disease

The population of adults with congenital heart disease (ACHD) now exceeds that of children with congenital heart disease. Within this relatively young population of adults in their third decade of life exist a population of patients with heart failure (HF) who, in functional status, closely resemble patients in their fifth and sixth decades of life with HF caused by coronary artery disease and myocardial ischemia. The ACHD patients currently at greatest risk for HF are those with single-ventricle physiology, those with a 2-ventricle circulation with the right ventricle as the systemic ventricle, and those with repaired tetralogy of Fallot and pulmonary valve insufficiency. This article will review the demographics, diagnosis, functional capacity, and treatment of HF in the ACHD population.

Tetralogy of Fallot in men: quality of life, family, education, and employment

INTRODUCTION

Little is known about the quality of life, health, family, education, and employment status among adult men with repaired tetralogy of Fallot.

MATERIAL AND METHODS

A total of 68 men who underwent repair of tetralogy of Fallot between 1971 and 1991 were studied. Fifty-three patients answered the SF-36 health survey and additional questions regarding offspring, education, and employment status. The men with repaired tetralogy of Fallot were compared with 32 healthy men and 40 women who also underwent repair of tetralogy of Fallot in the same period.

RESULTS

The patients scored lower than healthy men in the SF-36 categories physical functioning, general health, and physical component summary. There were no statistically significant differences in the scores from male and female patients except a lower score in bodily pain among women. Educational level for men operated for tetralogy of Fallot was similar to the general male population, whereas fewer were employed and more were retired, undergoing rehabilitation or receiving social benefits. The reproduction rate was lower compared with the general population (0.65 versus 1.02 children per man) but relatively higher than the rate among women with tetralogy of Fallot (0.88 versus 1.84 children per woman). The risk of having a child with congenital heart disease was 8.3%.

CONCLUSION

Men operated for tetralogy of Fallot have good quality of life and educational status. They start a family, although their reproduction rate is two-thirds that of the general population. The risk of having a child with congenital heart disease is higher compared with the background population. The overall quality of life is similar for men and women operated for tetralogy of Fallot.

Increase in N-terminus-pro-B-type natriuretic peptide during exercise of patients with univentricular heart after a total cavopulmonary connection

An increase in N-terminus pro-B-type natriuretic peptide (NT-proBNP) during exercise is related to myocardial ischemia, myocardial dysfunction, and inflammatory stress. Its value for patients with a univentricular heart after total cavopulmonary connection (TCPC) is unknown. For 66 patients with TCPC, a cardiopulmonary exercise test was performed. Venous NT-proBNP samples were drawn with the patient at rest and then 2-3 min after peak exercise. The median NT-proBNP during rest was 82 ng/l (range, 11-2,554 ng/l), with 22 patients above the upper reference limit. A higher NT-proBNP during rest was related to a worse peak oxygen uptake (peak [Formula: see text]), a higher ventilatory equivalent (VE/VCO(2) slope), and a need for diuretics administration. A small but significant increase in NT-proBNP during exercise at 6 ng/l (range, 0-314 ng/l) was related mainly to its resting value. The relative increase was solely related to a higher body mass and not to any of the investigated functional parameters. Usually, NT-proBNP during rest is not elevated in TCPC patients. If so, it is a valuable predictor of cardiac function. During exercise, only a minor increase in NT-proBNP occurs. Its extent is not related to any of the investigated functional parameters. Maybe the filling restriction from the lungs prevents atrial and ventricular overload as well as BNP secretion in TCPC patients.

Does pregnancy contribute to systemic right ventricular dysfunction in adults with an atrial switch operation?

BACKGROUND

To determine whether pregnancy might impact adversely on long-term outcomes in adults post an atrial switch repair on the background of data demonstrating an increased rate of heart failure and death in these adults with systemic right ventricles.

METHODS

We retrospectively analysed our adult population with an atrial switch repair for transposition of the great arteries to see whether any differences in outcomes (sudden cardiac death, heart failure admissions, use of heart failure medications) existed between women who had and women who had not undergone pregnancy. Controls from the remaining population (transposition of the great arteries and atrial switch operation women) were elected as long as their year of birth fell into the year of birth range seen in the patient group.

RESULTS

In women with transposition of the great arteries who have had an atrial switch repair, the long-term occurrence of sudden cardiac death and clinical heart failure (defined as a need for prescription of anti-failure medications or heart failure admissions) appears to be increased.

CONCLUSION

Pregnancy may have an adverse effect on long-term outcomes in women with systemic right ventricles.

Self-reported health status (EQ-5D) in adults with congenital heart disease

PURPOSE

Today, more patients with congenital heart disease (CHD) reach adulthood. There are conflicting findings concerning the relationship between quality of life (QoL) or health state for adults with CHD and the complexity of their CHD. The aim of the study was, firstly, to compare the reported health status and health perception of adult patients with CHD and, secondly, to investigate what variables influenced the patients' health status and health perception.

METHODS

Data from 1435 patients completing the EQ-5D questionnaire, which includes reported health status and health perception, were analyzed.

RESULTS

Valid EQ-5D data were reported by 1274 patients, showing overall results indicating a good health status. Problems were most frequently reported in the dimension "pain/discomfort" (31.9%) and "anxiety/depression" (29.8%). Higher occurrence of problems were reported by patients with complex disease i.e. single ventricle (p<0.001) and by female patients (p<0.0001). Symptomatic patients reported a lower health status (p<0.0001) and a lower perceived health on EQ-VAS (p<0.0001). Of the asymptomatic patients, 20.5% nevertheless reported problems in "pain/discomfort" and 22.2% in the "anxiety/depression" dimension.

CONCLUSION

The health status of adults with CHD is influenced by symptoms, NYHA-classification, age and gender. Adults with CHD report a lower occurrence of problems in comparison to previously published results from a general population, but the importance of actively asking about the patient's experience is demonstrated by the high degree of asymptomatic patients reporting problems on EQ-5D.

Quality of life of adolescents and young adults born at high risk

Research on quality of life (QoL) of adolescents and young adults born preterm and those with congenital heart disease (CHD) was systematically reviewed, and factors associated with QoL were identified. Forty-five studies met the inclusion criteria for review. Although the majority of studies found that self-reported QoL of adolescents and young adults born preterm did not differ from term controls, several studies reported lower QoL among individuals born preterm, especially those who had additional impairments. Most studies on adolescents and young adults with CHD reported lower QoL compared with healthy peers, which may be in part due to real or perceived physical activity limitations of individuals with CHD. Overall, parents reported that their adolescents born at high risk had a less favorable QoL compared with those who served as controls. Encouraging age-appropriate, safe, and enjoyable physical activity and avoiding unnecessary restrictions and overprotection are considerations for optimizing QoL.

Long-term myocardial scarring after operation for anomalous left coronary artery from the pulmonary artery

BACKGROUND

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a very rare disease. Accordingly, the incidence and distribution of myocardial scarring in long-term follow-up of patients after successful surgery of ALCAPA is unknown. Therefore, the aim of this study was to describe the distribution of left ventricular (LV) myocardial scarring by late gadolinium enhancement magnetic resonance in these patients.

METHODS

Fourteen consecutive patients over 12 years of age with ALCAPA without any further cardiac abnormalities, and after corrective surgery at our center, participated prospectively in this study. All patients underwent cardiac magnetic resonance including LV function analysis and late gadolinium enhancement magnetic resonance. Of these 14 patients, 12 patients also underwent cardiopulmonary exercise testing.

RESULTS

Four patients had no evidence of myocardial scarring. The median extent of the myocardial scar of all patients by late gadolinium enhancement magnetic resonance, expressed as a percentage of the total LV myocardial volume, was only 2% (range, 0% to 11%). Median LV ejection fraction was 0.55 (range, 0.31 to 0.73). Median LV end-diastolic volume indexed to body surface area was 84 mL/m(2) (39 to 120 mL/m(2)). Median peak oxygen uptake during cardiopulmonary exercise was 24 mL · kg(-1) · minute(-1) (range, 19 to 51 mL/kg/minute).

CONCLUSIONS

We conclude that despite often severely compromised LV function and evidence of scarring before corrective surgery of patients with ALCAPA, in long-term follow-up scar tissue is relatively scarce.

Daily physical activity in adults with congenital heart disease is positively correlated with exercise capacity but not with quality of life

OBJECTIVE

With the fear of heart failure and sudden death, many patients with congenital heart disease (CHD) traditionally were withheld from exercise activities. Much is reported on sedentary lifestyle with diminished exercise capacity in children with CHD which results in an increased cardiovascular risk. This study aimed to assess whether the sedentary lifestyle is also present in adulthood and whether this is associated with exercise capacity and quality of life (QoL) limitations.

PATIENTS AND METHODS

From October 2007 to January 2010 a total of 330 patients (149 female, 18-61 years) with various CHD completed the health-related QoL questionnaire SF-36 and performed a cardiopulmonary exercise test. Afterward a triaxial accelerometer was worn over the next consecutive 7 days to assess daily activity.

RESULTS

Patients achieved 59.2 ± 39.7 min of at least moderate activity per day and 76% of the investigated patients met the recommendations of daily activity. Exercise capacity was diminished in most of the patients with 25.6 ± 7.8 mL/min/kg (73.7 ± 19.5% of predicted). There was a moderate relationship between daily activity and exercise capacity (r = 0.437, p < 0.001). The correlation of daily activity to QoL was rather poor (r = 0.030 to r = 0.258).

CONCLUSIONS

Most adults with CHD are fairly active. Daily activity is positively correlated with exercise capacity. Therefore, promotion of an active lifestyle seems warranted after medical counseling.

Education and support needs of the older adult with congenital heart disease

AIM

  This article is a report of a study exploring health-related quality of life in adults with congenital heart disease and the extent to which it is associated with patients' illness beliefs and emotional health.

BACKGROUND

  A reduction in mortality in patients with congenital heart disease has led to an increasingly older population that faces new challenges. Studies in a younger adult population have reported inconsistent findings regarding health-related quality of life. Factors such as, the complexity of the congenital heart defect, have not been found to be associated with quality of life. The association between illness beliefs and health-related quality of life has not previously been reported.

METHOD

  A cross-sectional questionnaire study of adults with congenital heart disease attending an outpatient clinic in a specialist centre in the United Kingdom between October 2007 and May 2008.

RESULTS

  The mean age of the study population was 37·2 years. Participants reported poorer physical functioning, role functioning and general health than a general population. High levels of anxiety were reported in 38% and high levels of depression in 17%. In multivariate analysis, higher levels of anxiety and depression were associated with poorer mental functioning and higher levels of depression with poorer physical quality of life.

CONCLUSION

  We have reported that high levels of anxiety and depression in an older population of patients with congenital heart disease are associated with poorer quality of life. This highlights the need to routinely assess anxiety and depression in this patient group and to provide psychological support appropriately.

Indications for heart transplantation in congenital heart disease

In this review we have looked at indications for cardiac transplantation in congenital heart disease. An outline of the general principles of the use of transplant as a management strategy both as a first line treatment and following other surgical interventions is discussed. We explore the importance of the timing of patient referral and the evaluations undertaken, and how the results of these may vary between patients with congenital heart disease and patients with other causes of end-stage heart failure. The potential complications associated with patients with congenital heart disease need to be both anticipated and managed appropriately by an experienced team. Timing of transplantation in congenital heart disease is difficult to standardize as the group of patients is heterogeneous. We discuss the role and limitations of investigations such as BNP, 6 minute walk, metabolic exercise testing and self estimated physical functioning. We also discuss the suitability for listing. It is clear that congenital heart patients should not be considered to be at uniform high risk of death at transplant. Morbidity varies greatly in the congenital patient population with the failing Fontan circulation having a far higher risk than a failing Mustard circulation. However the underlying issue of imbalance between donor organ supply and demand needs to be addressed as transplant teams are finding themselves in the increasingly difficult situation of supporting growing numbers of patients with a diverse range of pathologies with declining numbers of donor organs.

Hypoxia in early life is associated with lasting changes in left ventricular structure and function at maturity in the rat

BACKGROUND

There is a growing population of adults with repaired cyanotic congenital heart disease. These patients have increased risk of impaired cardiac health and premature death. We hypothesized that hypoxia in early life before surgical intervention causes lasting changes in left ventricular structure and function with physiological implications in later life.

METHODS

Sprague-Dawley rats reared initially hypoxic conditions (FiO(2)=0.12) for days 1-10 of life were compared to rats reared only in ambient air. Cellular morphology and viability were compared among LV cardiomyocytes and histological analyses were performed on LV myocardium and arterioles. Intracellular calcium transients and cell shortening were measured in freshly-isolated cardiomyocytes, and mitochondrial hexokinase 2 (HK2) expression and activity were determined. Transthoracic echocardiography was used to assess LV function in anesthetized animals.

RESULTS

Cardiomyocytes from adult animals following hypoxia in early life had greater cellular volumes but significantly reduced viability. Echocardiographic analyses revealed LV hypertrophy and diastolic dysfunction, and alterations in cardiomyocyte calcium transients and cell shortening suggested impaired diastolic calcium reuptake. Histological analyses revealed significantly greater intima-media thickness and decreased lumen area in LV arterioles from hypoxic animals. Alterations in mitochondrial HK2 protein distribution and activity were also observed which may contribute to cardiomyocyte fragility.

CONCLUSIONS

Hypoxia in early life causes lasting changes in left ventricular structure and function that may negatively influence myocardial and vascular responses to physiological stress in later life. These data have implications for the growing population of adults with repaired or palliated cyanotic congenital heart disease.

Patient-reported outcomes in congenital cardiac disease: are they as good as you think they are?

Patient-reported outcomes are "any outcome based on data provided by patients or patient proxy as opposed to data provided from other sources". Examples of patient-reported outcomes are quality of life, well-being, functional status, symptoms, adherence to treatment, satisfaction with treatment, and utility or preference-based measures. The main question of this manuscript is whether patient-reported outcomes in patients with congenital cardiac disease are as good as we think they are. In general, we could say yes, because numerous studies show that patients with congenital cardiac disease have an excellent quality of life. By contrast, we could say no, because patients generally overestimate their functioning, and up to two out of three patients are not compliant with the prescribed therapy or recommendations for follow-up. However, most importantly, we have to say that we do not know whether the patient-reported outcomes are good, because research with patient-reported outcomes in congenital cardiac disease is limited. Hence, patient-reported outcomes should be a priority on the agenda for research in the domain of congenital cardiac disease.

The importance of socio-demographic factors for the quality of life of adults with congenital heart disease

PURPOSE

We conducted a study to measure the associations of socio-demographic factors with quality of life outcomes among adults with congenital heart disease (CHD).

METHODS

Results are drawn from a questionnaire-based survey in 676 adults with CHD and compared to age and sex-matched controls of a representative national survey. Subjective outcomes were measured as health-related quality of life (hrQoL), health and life satisfaction. The associations of the subjective well-being with the degree of severity of the underlying heart defect and socio-demographic factors such as educational and employment status were quantified in multiple linear regression models.

RESULTS

A significant correlation of the degree of severity of the heart defect was limited to the physical scale of the hrQoL, whereas for the mental scale of the hrQoL and the satisfaction scales, socio-demographic factors showed a stronger association. Furthermore, the associations of socio-demographic factors and subjective well-being were stronger in the patient group than in the control group.

CONCLUSIONS

Socio-demographic factors can be significantly associated with the subjective well-being of adults with CHD. In order to assist the surgical successes of the past decades, which have ensured the survival of most of these patients into adulthood, increased attention should be paid to these domains in the care of adults with CHD.

Noninvasive cardiac output determination for children by the inert gas-rebreathing method

Standard methods for determination of cardiac output (CO) are either invasive or technically demanding. Measurement of CO by the inert gas-rebreathing (IGR) method, applied successfully in adults, uses a low-concentration mixture of an inert and a blood-soluble gas, respectively. This study tested the feasibility of this method for determining CO during exercise for pediatric patients with complete congenital atrioventricular block (CCAVB) stimulated with a VVI pacemaker. In this study, 5 CCAVB patients (age 9.2-17.4 years) were compared with 10 healthy age-matched boys and girls. Testing was performed with the Innocor system. The patients were instructed to breathe the test gas from a closed system. Pulmonary blood flow was calculated according to the washout of the soluble gas component. During standardized treadmill testing, CO was determined at three defined levels. The CO measurements were successful for all the study participants. The patients reached a lower peak CO than the control subjects (5.9 l/min/m(2) vs 7.3 [boys] and 7.2 [girls]). The stroke volume increase under exercise also was reduced in the patients compared with the control subjects. The feasibility of the IGR method for exercise CO testing in children was documented. Application of the IGR method for children requires careful instruction of the patients and appears restricted to subjects older than 8 years. The method offers new insights into mechanisms of cardiovascular adaptation in children with congenital heart disease.

Minor symptoms of depression in patients with congenital heart disease have a larger impact on quality of life than limited exercise capacity

OBJECTIVE

In patients with congenital heart disease quality of life is only marginally associated with exercise capacity. The aim of this study was to determine the prevalence of depression and its impact on quality of life and exercise capacity.

PATIENTS AND METHODS

From November 2007 to October 2009 a total of 767 patients (352 female, 14-67 years) with various congenital heart diseases (37 palliated/native cyanotic, 57 Fontan, 74 Transposition of the Great Arteries (TGA) after atrial switch, 50 other TGA, 136 Fallot, 38 Ebstein, 47 Pulmonic stenosis/regurgitation, 68 aortic coarctation, 103 aortic stenosis, 90 isolated shunts, 67 other) completed the health-related quality of life questionnaire SF-36 and the German translation of the "Center for Epidemiologic Studies Depression Scale" (CES-D) to assess depressive symptoms. Afterwards a cardiopulmonary exercise test was performed.

RESULTS

Only 66 patients (8.6%) showed depressive symptoms fulfilling the CES-D definition for depression. The total prevalence of depression was lower than in the general population (Wilcoxon test, p<0.001) and did not differ substantially in between the diagnostic subgroups (Kruskal-Wallis test, p=0.195). CES-D score was correlated to all of the nine dimensions of quality of life (r=-0.170 to r=-0.740, p<0.001) and less pronounced to exercise capacity (r=-0.164, p<0.001). Correlation of peak oxygen uptake to quality of life was weaker than the CES-D scores in all subscales of life quality.

CONCLUSIONS

Patients with congenital heart disease are rarely depressive. However, even minor depressive symptoms have a stronger impact on quality of life than limited exercise capacity as seen in many patients.

Exercise testing and prescription in patients with congenital heart disease

The present paper provides a review of the literature regarding exercise testing, exercise capacity, and the role of exercise training in patients with congenital heart disease (CHD). Different measures of exercise capacity are discussed, including both simple and more advanced exercise parameters. Different groups of patients, including shunt lesions, pulmonary valvar stenosis, patients after completion of Fontan circulation, and patients with pulmonary arterial hypertension are discussed separately in more detail. It has been underscored that an active lifestyle, taking exercise limitations and potential risks of exercise into account is of utmost importance. Increased exercise capacity in these patients is furthermore correlated with an improvement of objective and subjective quality of life.