Cardiovascular response to exercise training in the systemic right ventricle of adults with transposition of the great arteries

Abstract

Key Pointsr Patients with transposition of the great arteries (TGA) and systemic right ventricles have premature congestive heart failure; there is also a growing concern that athletes who perform extraordinary endurance exercise may injure the right ventricle.r Therefore we felt it essential to determine whether exercise training might injure a systemic right ventricle which is loaded with every heartbeat.r Previous studies have shown that short term exercise training is feasible in TGA patients, but its effect on ventricular function is unclear.r We demonstrate that systemic right ventricular function is preserved (and may be improved) in TGA patients with exercise training programmes that are typical of recreational and sports participation, with no evidence of injury on biomarker assessment.r Stroke volume reserve during exercise correlates with exercise training response in our TGA patients, identifying this as a marker of a systemic right ventricle (SRV) that may most tolerate (and possibly even be improved by) exercise training.Abstract We aimed to assess the haemodynamic effects of exercise training in transposition of the great arteries (TGA) patients with systemic right ventricles (SRVs). TGA patients have limited exercise tolerance and early mortality due to systemic (right) ventricular failure. Whether exercise training enhances or injures the SRV is unclear. Fourteen asymptomatic patients (34 ± 10 years) with TGA and SRV were enrolled in a 12 week exercise training programme (moderate and high-intensity workouts). Controls were matched on age, gender, BMI and physical activity. Exercise testing pre-and post-training included: (a) submaximal and peak; (b) prolonged (60 min) submaximal endurance and (c) high-intensity intervals. Oxygen uptake (V O 2 ; Douglas bag technique), cardiac output (Q c , foreign-gas rebreathing), ventricular function (echocardiography and cardiac MRI) and serum biomarkers were assessed. TGA patients had lower peakV O 2 ,Q c , and stroke volume (SV), a bluntedQ c /V O 2 slope, and diminished SV response to exercise (SV increase from rest: TGA = 15.2%, controls = 68.9%, P < 0.001) compared with controls. After training, TGA patients increased peakV O 2 by 6 ± 8.5%, similar to controls (interaction P = 0.24). The magnitude of SV reserve on initial testing correlated witḣ Q c training response (r = 0.58, P = 0.047), though overall, no change in peakQ c was observed. High-sensitivity troponin T (hs-TnT) and N-terminal prohormone of brain naturetic peptide (NT pro-BNP) were low and did not change with acute exercise or after training. Our data show that TGA patients with SRVs in this study safely participated in exercise training and improved peakV O 2 . Neither prolonged submaximal exercise, nor high-intensity intervals, nor short-term exercise training seem to injure the systemic right ventricle.

Transposition of exercise protocols: cardiovascular response to exercise in patients with transposition of the great arteries

“…The training programme assigned by Shafer et al . () and Winter et al . () required an intensity and duration that may be difficult to sustain long‐term.…”

“…Shafer et al . () examined the cardiovascular and metabolic responses to exercise training in the SRVs of patients with TGA in order to investigate exercise tolerance and its effect on the SRV. All subjects underwent exercise testing before and after 3 months of an intensive training programme, with a primary endpoint of change in oxygen consumption () as a surrogate marker for changes in exercise tolerance.…”

“…The results of Shafer et al . () reported a 0.5 MET increase in aerobic fitness, which would translate to an approximate 5% reduction in all‐cause mortality if the subjects were healthy. The direct effects of an increase in aerobic fitness in TGA patients are unknown without long‐term follow up; however, we expect an improvement similar to that observed in heart failure (HF).…”

“…In summary, Shafer et al . () have demonstrated that TGA patients with systemic right ventricles are able to tolerate moderate to high intensity exercise training programmes with no detectable injury; however, the small sample size may impact the studies external validity. This opens the door for further investigations into optimal exercise protocols, predictors of efficacy and prognostic changes after exercise.…”

Why right is never left: the systemic right ventricle in transposition of the great arteries

“…However, the work by Shafer et al . () in a recent issue of The Journal of Physiology exploring the impact of exercise on the systemic right ventricle (SRV) highlights that some results and novel methodology are more widely applicable.…”