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Congenital heart disease in adults: Assessmentof functional capacity using cardiopulmonary exercise testing
Cardiopatia congénita em adultos: avaliação da capacidade funcional por prova de esforço cardiorrespiratória
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Soares, Lídia Sousa, José Alberto Oliveira, Ana Abreu, Ana Sofia Silva, Sandra Alves, Helena Aidos, Fátima F. Pinto, Rui Cruz Ferreira" "autores" => array:11 [ 0 => array:4 [ "nombre" => "Sílvia" "apellidos" => "Aguiar Rosa" "email" => array:1 [ 0 => "silviaguiarosa@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ana" "apellidos" => "Agapito" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Rui M." "apellidos" => "Soares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Lídia" "apellidos" => "Sousa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "José Alberto" "apellidos" => "Oliveira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Ana" "apellidos" => "Abreu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Ana Sofia" "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Sandra" "apellidos" => "Alves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "Helena" "apellidos" => "Aidos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 9 => array:3 [ "nombre" => "Fátima F." "apellidos" => "Pinto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 10 => array:3 [ "nombre" => "Rui Cruz" "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Cardiology Department, Santa Marta Hospital, Lisbon, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Telecomunicações, Instituto Superior Técnico, Portugal Minalytics, Advanced Solutions for Data Mining and Analytics, Lisbon, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Paediatric Cardiology Department, Santa Marta Hospital, Lisbon, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Cardiopatia congénita em adultos: avaliação da capacidade funcional por prova de esforço cardiorrespiratória" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1063 "Ancho" => 2683 "Tamanyo" => 100504 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Transposition of the great arteries. (A) Negative linear Pearson correlation between time from Mustard or Senning surgery to CPET and peak oxygen consumption (VO<span class="elsevierStyleInf">2</span>) (r=-0.564); (B) positive linear Pearson correlation between time from Mustard or Senning surgery to CPET and VE/VCO<span class="elsevierStyleInf">2</span> slope (r=0.554).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0010" class="elsevierStylePara elsevierViewall">Nowadays most patients with congenital heart disease (CHD) are expected to reach adulthood. Because exercise intolerance has been documented at all ages of CHD, these patients need close follow-up and an objective assessment of functional capacity.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Due to long-term adaption, the majority of adult patients with CHD self-report their exercise capacity status as satisfactory, even in the presence of significantly depressed functional status. Cardiopulmonary exercise testing (CPET) is an accurate method for quantitative assessment of exercise capacity, including assessment of aerobic capacity, chronotropic response and arrhythmias.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,3–6</span></a> Quantifying exercise capacity by measuring parameters such as peak oxygen consumption (VO<span class="elsevierStyleInf">2</span>) is an established technique in the management of patients with chronic heart failure. However, in adult CHD patients its role has been much less studied, and interpretation of test results remains a challenge. Previous studies have demonstrated that CPET data have an important influence on the treatment approach in CHD, including indication for cardiac transplantation, and on prognosis.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">2,7,8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of the present study was twofold: to assess and compare functional capacity in different CHD groups, measured objectively by CPET, and to investigate a possible association between CPET parameters and outcome.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0025" class="elsevierStylePara elsevierViewall">A retrospective analysis was performed of consecutive adult patients with CHD who underwent CPET for assessment of functional capacity. The data were collected in a single tertiary center between March 2009 and June 2015.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study population was divided according to diagnosis or pathophysiological status: repaired tetralogy of Fallot, transposition of the great arteries (TGA) after Senning or Mustard procedures and congenitally corrected TGA (both with a right ventricle functioning as a systemic ventricle), complex heart defects (univentricular heart, Fontan surgery, truncus arteriosus), shunts (atrial, ventricular or arterial), left heart valve disease with stenosis or regurgitation (bicuspid aortic valve, subaortic stenosis), and right ventricular outflow tract obstruction (RVOTO).</p><p id="par0035" class="elsevierStylePara elsevierViewall">CPET was performed in patients with some degree of effort intolerance, complex defects or significant residual lesions.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The combined outcome of hospitalization for cardiac cause and all-cause mortality was analyzed.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Cardiopulmonary exercise testing</span><p id="par0045" class="elsevierStylePara elsevierViewall">Maximal symptom-limited treadmill CPET was performed using the modified Bruce protocol. CPET and the recovery period were monitored with continuous 12-lead electrocardiogram, blood pressure cuff, saturation probe and a face mask to measure respiratory gases. Blood pressure was measured at rest, at each stage, at peak exercise and at the first, third and sixth minute of the recovery phase. Respiratory gases were analyzed using an Innocor<span class="elsevierStyleSup">®</span> gas analyzer and VO<span class="elsevierStyleInf">2</span>, carbon dioxide production and ventilation were measured on a breath-by-breath basis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patients were encouraged to perform exercise until the carbon dioxide production/oxygen consumption ratio was 1.15 or higher.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Peak VO<span class="elsevierStyleInf">2</span> adjusted for body mass, or for fat-free mass in obese patients (body mass index >30<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>), was analyzed, as well as the percentage of predicted peak VO<span class="elsevierStyleInf">2</span> for age and gender according to the Wasserman/Hansen equation. The minute ventilation (VE)/carbon dioxide production (VCO<span class="elsevierStyleInf">2</span>) slope was calculated by automatic linear regression with values obtained during CPET. The ratio between VE/VCO<span class="elsevierStyleInf">2</span> slope and peak VO<span class="elsevierStyleInf">2</span> was also calculated. Peak circulatory power was determined by multiplying peak VO<span class="elsevierStyleInf">2</span> by peak systolic blood pressure. Both baseline and peak oxygen saturations were also collected.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The chronotropic index was calculated as (peak heart rate/resting heart rate)/(220-age/resting heart rate), and considered normal for values between 0.8 and 1.3.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using SPSS Statistics version 22 (IBM SPSS, Chicago, IL). Continuous variables were expressed as mean ± standard deviation. CPET parameters were compared between study groups using one-way analysis of variance between mean values or the non-parametric Kruskal-Wallis test, and multiple comparisons between the study groups were performed with an appropriate post-hoc test. Pearson's chi-square or Fisher's exact test was applied for categorical variables. The Student's t test or the Wilcoxon-Mann-Whitney test for continuous variables was used for gender comparisons. Pearson's correlation was used to estimate correlation between continuous variables. The association between variables and the combined outcome was assessed with univariate Cox proportional hazards analysis (forward stepwise).</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">CPET data were analyzed from 154 patients, mean age 34.8±8.8 years, 55.8% male. The most frequent diagnosis was corrected tetralogy of Fallot (36%), followed by complex defects (21%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">There were significant differences in CPET parameters between the study groups. As shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, the lowest values for peak VO<span class="elsevierStyleInf">2</span> were seen in patients with cardiac shunts, related to the fact that 39% of these patients had Eisenmenger syndrome (17.2±7.1<span class="elsevierStyleHsp" style=""></span>ml/kg/min, compared to 26.2±7.0<span class="elsevierStyleHsp" style=""></span>ml/kg/min in tetralogy of Fallot patients; p<0.001). Peak VO<span class="elsevierStyleInf">2</span> differed significantly between genders only in the complex heart defect group (males 23.3±6.1<span class="elsevierStyleHsp" style=""></span>ml/kg/min vs. females 16.9±4.6<span class="elsevierStyleHsp" style=""></span>ml/kg/min; p<0.001). Percentage of predicted peak VO<span class="elsevierStyleInf">2</span> adjusted for age and gender was lower in the complex heart defect group (50.1±13.0%) compared to the other groups.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients with cardiac shunts and congenitally corrected TGA had higher VE/VCO<span class="elsevierStyleInf">2</span> slope (38.4±13.4 and 38.2±13.2, respectively), for which the lowest value was in left heart valve disease. A significant difference between genders was observed only in the complex defects group (males 32.3±12.4 vs. females 41.3±8.3; p<0.012). The ratio between VE/VCO<span class="elsevierStyleInf">2</span> slope and peak VO<span class="elsevierStyleInf">2</span> was higher in complex defects. Peak circulatory power was lower in patients with shunts and complex defects.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Peak oxygen saturation below 90% was seen in patients with RVOTO, TGA and shunts, and it was particularly low in complex defects (83.0±8.9%).</p><p id="par0090" class="elsevierStylePara elsevierViewall">Chronotropism was impaired in patients with complex defects, among whom 71.9% presented chronotropic incompetence, demonstrated by a chronotropic index <0.8 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Analyzing the overall population, cyanotic patients (n=33) presented significantly lower peak VO<span class="elsevierStyleInf">2</span> and higher VE/VCO<span class="elsevierStyleInf">2</span> slope than non-cyanotic patients (17.8±5.4 vs. 24.3±7.9<span class="elsevierStyleHsp" style=""></span>ml/kg/min; p<0.001 and 40.6±13.0 vs. 30.3±8.0; p<0.001, respectively). Patients with pulmonary hypertension (n=23) also presented lower peak VO<span class="elsevierStyleInf">2</span> (17.2±5.9 vs. 23.8±7.8<span class="elsevierStyleHsp" style=""></span>ml/kg/min; p<0.001) and higher VE/VCO<span class="elsevierStyleInf">2</span> slope (41.9±14.9 vs. 31.1±8.5; p=0.009). Eisenmenger syndrome (n=17) was associated with even lower peak VO<span class="elsevierStyleInf">2</span> (16.9±4.8 vs. 23.6±7.8<span class="elsevierStyleHsp" style=""></span>ml/kg/min; p=0.001) and higher VE/VCO<span class="elsevierStyleInf">2</span> slope (44.8±14.7 vs. 31.0± 8.5; p=0.002) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">TGA patients (after Mustard or Senning surgery) presented a negative linear correlation between time from intervention to CPET and peak VO<span class="elsevierStyleInf">2</span> (r=-0.564; p=0.070) and peak circulatory power (r=-0.632; p=0.037), and a positive linear Pearson correlation between time from intervention to CPET and VE/VCO<span class="elsevierStyleInf">2</span> slope (r=0.554; p=0.122) (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">In the overall population, 18.2% of patients (n=28) reached a carbon dioxide production/oxygen consumption ratio of 1.15 or higher.</p><p id="par0110" class="elsevierStylePara elsevierViewall">During a mean follow-up of 31.9 months (minimum six months; maximum 79 months), the combined outcome of all-cause mortality and hospitalization for cardiac cause was documented in 34 patients. In univariate Cox regression, age, cyanosis, CPET duration, peak systolic blood pressure, time to anaerobic threshold and heart rate at anaerobic threshold were predictors of the combined outcome (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Peak VO<span class="elsevierStyleInf">2</span> was not a predictor of the combined outcome (hazard ratio 0.995; confidence interval 0.949-1.043; p=0.829).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Although an increasing number of CHD patients reach adulthood, their exercise capacity is often significantly impaired. CPET enables more detailed assessment of functional capacity by measuring respiratory gases. Peak VO<span class="elsevierStyleInf">2</span>, which reflects VO<span class="elsevierStyleInf">2</span> in tissues and depends on cardiac output, arterial oxygen and the oxygen extraction capacity of muscle tissue, is an accurate measure of exercise capacity.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In line with previous research,<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,10–13</span></a> our study showed markedly depressed functional capacity in CHD patients, as shown by the fact that all study groups presented peak VO<span class="elsevierStyleInf">2</span> values below 70% of those predicted. Regardless of the type of CHD, the peak VO<span class="elsevierStyleInf">2</span> values reached by the study population were substantially lower than those expected for healthy subjects of the same age and gender.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Another useful parameter is VE/VCO<span class="elsevierStyleInf">2</span> slope, which expresses ventilatory efficiency and has been shown to be an independent predictor of outcome.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> The ratio between VE/VCO<span class="elsevierStyleInf">2</span> slope and peak VO<span class="elsevierStyleInf">2</span> integrates these parameters and also has prognostic value.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> By integrating the hemodynamic values monitored in this test it is possible to compute peak circulatory power. All these parameters were consistently abnormal in all groups.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Across the CHD spectrum, patients with left heart valve disease and repaired tetralogy of Fallot presented better exercise capacity. On the other hand, TGA (after Mustard or Senning surgery, or congenitally corrected), complex heart defects and shunts were associated with more severely impaired functional capacity.</p><p id="par0135" class="elsevierStylePara elsevierViewall">It should also be noted that 39% of patients with shunts presented Eisenmenger physiology, which explains the severe impairment of exercise tolerance in this group.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Irrespective of the baseline defect, cyanosis and pulmonary hypertension were associated with poor exercise tolerance, particularly when the two were combined, which was associated with lower peak VO<span class="elsevierStyleInf">2</span> and higher VE/VCO<span class="elsevierStyleInf">2</span> slope. According to Diller et al.,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> patients with Eisenmenger physiology have the most severe impairment in exercise capacity, reflected in the lowest peak VO<span class="elsevierStyleInf">2</span> and the highest VE/VCO<span class="elsevierStyleInf">2</span> slope.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Our data demonstrated a negative correlation between time from Mustard or Senning surgery to CPET and peak VO<span class="elsevierStyleInf">2</span> and peak circulatory power, and a positive correlation between time from surgery to exercise testing and VE/VCO<span class="elsevierStyleInf">2</span> slope. This deleterious evolution and ongoing morbidity could be explained by progressive failure of a systemic right ventricle and also by chronotropic incompetence.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Furthermore, chronotropic response to exercise is an important determinant of functional capacity, and diminished heart rate during exercise may contribute to reductions in peak VO<span class="elsevierStyleInf">2</span>.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">12,17</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Exercise intolerance has been associated with increased risk of hospitalization and mortality.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">2,7,18,19</span></a> However, unlike in previous studies, we found no correlation between peak VO<span class="elsevierStyleInf">2</span> or VE/VCO<span class="elsevierStyleInf">2</span> slope and the combined outcome of hospitalization for cardiac cause and all-cause mortality. This could be due to the small sample size and the heterogeneity of the study population. Instead, our data showed lower values of CPET duration, peak systolic blood pressure, time to anaerobic threshold and heart rate at anaerobic threshold as benchmarks of lower functional capacity correlated with poor prognosis. Our results are in line with Diller et al.’s study of 321 Fontan patients, in whom chronotropic capacity was strongly related to survival, contrasting with a lack of association between peak VO<span class="elsevierStyleInf">2</span> or ratio between VE/VCO<span class="elsevierStyleInf">2</span> slope and survival or cardiac transplantation.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> The relation between chronotropic incompetence and all-cause mortality in CHD patients could be secondary to underlying autonomic dysfunction, neurohormonal activation and arrhythmias.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">4,7</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">We also established an association between cyanosis and poor outcome, with a 3.6-fold increase in mortality and hospitalization compared to non-cyanotic patients. Similar data were reported by Dimopoulos et al., who also interestingly demonstrated that in adult CHD the VE/VCO<span class="elsevierStyleInf">2</span> slope is a strong predictor of mortality only in patients without cyanosis, suggesting that cyanotic patients differ substantially in pathophysiological processes and in these patients the prognostic value of the VE/VCO<span class="elsevierStyleInf">2</span> slope is weaker.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Age was also related to worse prognosis in our study, reflecting progressive impairment in left and/or right ventricular function, increasing prevalence of pulmonary hypertension and occurrence of arrhythmias in older CHD patients.</p><p id="par0170" class="elsevierStylePara elsevierViewall">To the best of our knowledge, this is the first Portuguese publication on CPET in adult CHD patients. We consider that the report of our initial experience is of interest, highlighting the importance of CPET in this population.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Study limitations</span><p id="par0175" class="elsevierStylePara elsevierViewall">This was a retrospective study at a tertiary adult CHD center that reflects daily clinical practice. There was thus certainly a bias in patient selection, favoring more symptomatic patients and those in which it is important not to rely only on self-reported functional capacity. This could explain the severity seen in the shunt subgroup, in which there was a large proportion of Eisenmenger syndrome.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The study population size inevitably reflects the limitations of a single-center experience. Considering that CPET is extremely important in the assessment of CHD patients and should be performed routinely, in future we intend to study more patients, with different clinical situations.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Our sample of adult CHD patients who underwent CPET presented exercise intolerance, which differed significantly across the spectrum of CHD. These data illustrate the more severe impairment in functional capacity and attenuated chronotropic response to exercise in Eisenmenger syndrome and complex defects.</p><p id="par0190" class="elsevierStylePara elsevierViewall">In this study, age, cyanosis and worse functional capacity were, as expected, associated with the combined outcome of all-cause mortality and hospitalization for cardiac cause.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Increasing the number of patients and the variety of defects and performing serial assessments in each patient will enable us to obtain more robust results in the future.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1029730" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec987173" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1029729" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec987172" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Cardiopulmonary exercise testing" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Study limitations" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-18" "fechaAceptado" => "2017-09-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec987173" "palabras" => array:3 [ 0 => "Adult congenital heart disease" 1 => "Functional capacity" 2 => "Cardiopulmonary exercise testing" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec987172" "palabras" => array:3 [ 0 => "Cardiopatias congénitas do adulto" 1 => "Capacidade funcional" 2 => "Prova de esforço cardiorrespiratória" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of the study was to compare functional capacity in different types of congenital heart disease (CHD), as assessed by cardiopulmonary exercise testing (CPET).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective analysis was performed of adult patients with CHD who had undergone CPET in a single tertiary center. Diagnoses were divided into repaired tetralogy of Fallot, transposition of the great arteries (TGA) after Senning or Mustard procedures or congenitally corrected TGA, complex defects, shunts, left heart valve disease and right ventricular outflow tract obstruction.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We analyzed 154 CPET cases. There were significant differences between groups, with the lowest peak oxygen consumption (VO<span class="elsevierStyleInf">2</span>) values seen in patients with cardiac shunts (39% with Eisenmenger physiology) (17.2±7.1<span class="elsevierStyleHsp" style=""></span>ml/kg/min, compared to 26.2±7.0<span class="elsevierStyleHsp" style=""></span>ml/kg/min in tetralogy of Fallot patients; p<0.001), the lowest percentage of predicted peak VO<span class="elsevierStyleInf">2</span> in complex heart defects (50.1±13.0%) and the highest minute ventilation/carbon dioxide production slope in cardiac shunts (38.4±13.4). Chronotropism was impaired in patients with complex defects. Eisenmenger syndrome (n=17) was associated with the lowest peak VO<span class="elsevierStyleInf">2</span> (16.9±4.8 vs. 23.6±7.8<span class="elsevierStyleHsp" style=""></span>ml/kg/min; p=0.001) and the highest minute ventilation/carbon dioxide production slope (44.8±14.7 vs. 31.0± 8.5; p=0.002). Age, cyanosis, CPET duration, peak systolic blood pressure, time to anaerobic threshold and heart rate at anaerobic threshold were predictors of the combined outcome of all-cause mortality and hospitalization for cardiac cause.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Across the spectrum of CHD, cardiac shunts (particularly in those with Eisenmenger syndrome) and complex defects were associated with lower functional capacity and attenuated chronotropic response to exercise.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparar a capacidade funcional nas cardiopatias congénitas, avaliada por prova de esforço cardiorrespiratória.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Análise restrospetiva dos doentes adultos com cardiopatia congénita, submetidos a prova de esforço cardiorrespiratória. Os doentes foram divididos em tetralogia de Fallot operada, transposição de grandes artérias após cirurgia de Senning/Mustard, transposição de grandes artérias congenitamente corrigida, defeitos complexos, shunts, doença valvular esquerda e obstrução do trato de saída do ventrículo direito.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram avaliadas 154 provas cardiorrespiratórias. Os valores mais baixos de consumo de oxigénio no pico foram observados nos doentes com shunt cardíaco (39% apresentavam síndrome de Eisenmenger) (17,2 ± 7,1<span class="elsevierStyleHsp" style=""></span>ml/kg/min, em comparação com 26,2 ± 7,0<span class="elsevierStyleHsp" style=""></span>ml/kg/min na tetralogia de Fallot; p < 0,001); o valor mais baixo da percentagem de consumo de oxigénio no pico relativamente ao previsto foi observado nos defeitos complexos (50,1 ± 13,0%) e o maior valor de rampa ventilação minuto/produção de dióxido de carbono nos shunts cardíacos (38,4 ± 13,4). O cronotropismo foi menos eficaz nos doentes com defeitos complexos. A síndrome de Eisenmenger (n = 17) associou-se ao valor mais baixo de consumo de oxigénio no pico (16,9 ± 4,8 versus 23,6 ± 7,8<span class="elsevierStyleHsp" style=""></span>ml/kg/min; p = 0,001) e ao maior valor de rampa ventilação minuto/produção de dióxido de carbono (44,8 ± 14,7 versus 31,0 ± 8,5; p = 0,002). Idade, cianose, duração da prova, pressão arterial sistólica no pico, tempo para o limiar anaeróbio e frequência cardíaca no limiar anaeróbio foram preditores do outcome combinado com mortalidade de todas as causas e hospitalização de causa cardíaca.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusão</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os shunts cardíacos (particularmente com síndrome de Eisenmenger) e os defeitos complexos associaram-se a menor capacidade funcional e resposta cronotrópica atenuada ao exercício.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1344 "Ancho" => 2665 "Tamanyo" => 206938 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Peak oxygen consumption (VO<span class="elsevierStyleInf">2</span>) and minute ventilation/carbon dioxide production (VE/VCO<span class="elsevierStyleInf">2</span>) slope in cyanotic patients and in patients with pulmonary hypertension and Eisenmenger syndrome.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1063 "Ancho" => 2683 "Tamanyo" => 100504 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Transposition of the great arteries. (A) Negative linear Pearson correlation between time from Mustard or Senning surgery to CPET and peak oxygen consumption (VO<span class="elsevierStyleInf">2</span>) (r=-0.564); (B) positive linear Pearson correlation between time from Mustard or Senning surgery to CPET and VE/VCO<span class="elsevierStyleInf">2</span> slope (r=0.554).</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">d</span> 39% had Eisenmenger syndrome.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">% predicted peak VO<span class="elsevierStyleInf">2</span>: percentage of predicted peak oxygen consumption; ccTGA: congenitally corrected transposition of the great arteries; CPET: cardiopulmonary exercise testing; OS: oxygen saturation; PCP: peak circulatory power; RVOTO: right ventricular outflow tract obstruction; TGA: transposition of the great arteries after Senning or Mustard procedure; ToF: tetralogy of Fallot; VE/VCO<span class="elsevierStyleInf">2</span>: minute ventilation/carbon dioxide production; VO<span class="elsevierStyleInf">2</span>: oxygen consumption.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Peak VO<span class="elsevierStyleInf">2</span> (ml/kg/min) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% predicted peak VO<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VE/VCO<span class="elsevierStyleInf">2</span> slope \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VE/VCO<span class="elsevierStyleInf">2</span> slope/VO<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PCP (mmHg/ml/kg/min) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline OS (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Peak OS (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CPET duration (min) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ToF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35.0±8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.2±7.0<span class="elsevierStyleSup">a,b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68.9±15.3<span class="elsevierStyleSup">a,b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27.5±5.3<span class="elsevierStyleSup">a,b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.2±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4195.6±1484.7<span class="elsevierStyleSup">a,b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.2±3.4<span class="elsevierStyleSup">a</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91.1±4.5<span class="elsevierStyleSup">b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.0±3.3<span class="elsevierStyleSup">a</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TGA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30.1±4.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22.0±5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.2±11.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34.0±9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.7±1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3388.2±1023.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93.3±3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88.4±6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.3±1.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ccTGA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34.4±8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.3±3.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57.0±11.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38.2±13.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.6±0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3917.3±540.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93.5±7.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.8±1.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complex defects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.4±7.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.1±6.2<span class="elsevierStyleSup">b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.1±13.0<span class="elsevierStyleSup">b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36.6±11.4<span class="elsevierStyleSup">b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8±1.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2958.0±1029.7<span class="elsevierStyleSup">b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">89.5±4.4<span class="elsevierStyleSup">a,b,c</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83.0±8.9<span class="elsevierStyleSup">a,b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.1±3.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shunts<span class="elsevierStyleSup">d</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38.4±11.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.2±7.1<span class="elsevierStyleSup">a</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54.4±17.9<span class="elsevierStyleSup">a</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38.4±13.4<span class="elsevierStyleSup">a</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.6±1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2680.9±1259.9<span class="elsevierStyleSup">a</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.1±4.6<span class="elsevierStyleSup">b</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">89.8±11.0<span class="elsevierStyleSup">a</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.8±4.3<span class="elsevierStyleSup">a,b</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left heart valve disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31.5±8.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.1±13.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.8±12.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.7±4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.2±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4612.2±1910.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94.2±4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92.8±3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.1±3.1<span class="elsevierStyleSup">b</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RVOTO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39.7±7.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22.8±8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64.3±18.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33.3±8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.4±0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4181.5±1857.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96.0±2.6<span class="elsevierStyleSup">c</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">86.2±8.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.6±4.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSup">a</span> p<0.001<br><span class="elsevierStyleSup">b</span> p=0.004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSup">a</span> p=0.005<br><span class="elsevierStyleSup">b</span> p<0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSup">a</span> p<0.001<br><span class="elsevierStyleSup">b</span> p=0.004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSup">a</span> p=0.028<br><span class="elsevierStyleSup">b</span> p=0.006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSup">a</span> p<0.001<br><span class="elsevierStyleSup">b</span> p=0.001<br><span class="elsevierStyleSup">c</span> p=0.005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSup">a</span> p=0.020<br><span class="elsevierStyleSup">b</span> p=0.015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleSup">a</span> p=0.030<br><span class="elsevierStyleSup">b</span> p=0.046 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1752653.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cardiopulmonary exercise testing data.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">ccTGA: congenitally corrected transposition of the great arteries; HR: heart rate; RVOTO: right ventricular outflow tract obstruction; TGA: transposition of the great arteries after Senning or Mustard procedure; ToF: tetralogy of Fallot.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Peak heart rate (bpm) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Chronotropic index <0.8 (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients under<br>Beta-blockers (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ToF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">156.7 ± 23.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TGA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">151.5 ± 34.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ccTGA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">147.0 ± 17.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complex defects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">143.8 ± 29.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shunts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">138.7 ± 23.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left heart valve disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">168.5 ± 27.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RVOTO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">157.7 ± 23.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1752654.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">Assessment of chronostropism.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">CI: confidence interval; CPET: cardiopulmonary exercise testing; HR: hazard ratio.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Predictors \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.065 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.019-1.113 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cyanosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.584 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.094-11.737 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.035 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CPET duration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.907 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.826-0.995 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.040 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peak systolic blood pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.982 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.967-0.998 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.029 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to anaerobic threshold \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.819 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.717-0.935 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart rate at anaerobic threshold \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.973 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.955-0.993 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.007 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1752655.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Predictors of the combined outcome (hospitalization for cardiac cause and all-cause mortality) by univariate Cox regression.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aerobic capacity in adults with various congenital heart diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P.M. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 11 | 5 | 16 |
| 2024 Outubro | 40 | 26 | 66 |
| 2024 Setembro | 41 | 18 | 59 |
| 2024 Agosto | 50 | 27 | 77 |
| 2024 Julho | 43 | 44 | 87 |
| 2024 Junho | 50 | 29 | 79 |
| 2024 Maio | 35 | 21 | 56 |
| 2024 Abril | 46 | 26 | 72 |
| 2024 Maro | 46 | 24 | 70 |
| 2024 Fevereiro | 40 | 22 | 62 |
| 2024 Janeiro | 29 | 19 | 48 |
| 2023 Dezembro | 27 | 21 | 48 |
| 2023 Novembro | 38 | 28 | 66 |
| 2023 Outubro | 18 | 13 | 31 |
| 2023 Setembro | 16 | 17 | 33 |
| 2023 Agosto | 27 | 28 | 55 |
| 2023 Julho | 21 | 21 | 42 |
| 2023 Junho | 22 | 13 | 35 |
| 2023 Maio | 38 | 31 | 69 |
| 2023 Abril | 30 | 10 | 40 |
| 2023 Maro | 39 | 28 | 67 |
| 2023 Fevereiro | 34 | 25 | 59 |
| 2023 Janeiro | 17 | 15 | 32 |
| 2022 Dezembro | 49 | 33 | 82 |
| 2022 Novembro | 47 | 34 | 81 |
| 2022 Outubro | 49 | 35 | 84 |
| 2022 Setembro | 30 | 41 | 71 |
| 2022 Agosto | 30 | 39 | 69 |
| 2022 Julho | 55 | 49 | 104 |
| 2022 Junho | 23 | 32 | 55 |
| 2022 Maio | 27 | 37 | 64 |
| 2022 Abril | 38 | 39 | 77 |
| 2022 Maro | 39 | 46 | 85 |
| 2022 Fevereiro | 27 | 59 | 86 |
| 2022 Janeiro | 27 | 25 | 52 |
| 2021 Dezembro | 23 | 32 | 55 |
| 2021 Novembro | 50 | 38 | 88 |
| 2021 Outubro | 78 | 40 | 118 |
| 2021 Setembro | 35 | 33 | 68 |
| 2021 Agosto | 46 | 43 | 89 |
| 2021 Julho | 15 | 20 | 35 |
| 2021 Junho | 25 | 31 | 56 |
| 2021 Maio | 21 | 42 | 63 |
| 2021 Abril | 44 | 36 | 80 |
| 2021 Maro | 69 | 20 | 89 |
| 2021 Fevereiro | 58 | 22 | 80 |
| 2021 Janeiro | 22 | 13 | 35 |
| 2020 Dezembro | 30 | 11 | 41 |
| 2020 Novembro | 42 | 20 | 62 |
| 2020 Outubro | 19 | 14 | 33 |
| 2020 Setembro | 42 | 10 | 52 |
| 2020 Agosto | 25 | 18 | 43 |
| 2020 Julho | 57 | 16 | 73 |
| 2020 Junho | 27 | 16 | 43 |
| 2020 Maio | 31 | 4 | 35 |
| 2020 Abril | 41 | 12 | 53 |
| 2020 Maro | 32 | 7 | 39 |
| 2020 Fevereiro | 72 | 25 | 97 |
| 2020 Janeiro | 17 | 9 | 26 |
| 2019 Dezembro | 36 | 7 | 43 |
| 2019 Novembro | 29 | 12 | 41 |
| 2019 Outubro | 19 | 15 | 34 |
| 2019 Setembro | 23 | 11 | 34 |
| 2019 Agosto | 34 | 18 | 52 |
| 2019 Julho | 41 | 13 | 54 |
| 2019 Junho | 46 | 21 | 67 |
| 2019 Maio | 39 | 19 | 58 |
| 2019 Abril | 21 | 18 | 39 |
| 2019 Maro | 35 | 14 | 49 |
| 2019 Fevereiro | 44 | 16 | 60 |
| 2019 Janeiro | 39 | 11 | 50 |
| 2018 Dezembro | 34 | 17 | 51 |
| 2018 Novembro | 98 | 13 | 111 |
| 2018 Outubro | 178 | 20 | 198 |
| 2018 Setembro | 46 | 12 | 58 |
| 2018 Agosto | 53 | 12 | 65 |
| 2018 Julho | 55 | 7 | 62 |
| 2018 Junho | 80 | 42 | 122 |
| 2018 Maio | 20 | 44 | 64 |
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