Published Online
on June 12, 2006

A more recent version of this article appeared on June 20, 2006

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Submitted on October 12, 2005
Revised on April 9, 2006
Accepted on April 20, 2006

Abnormal Ventilatory Response to Exercise in Adults With Congenital Heart Disease Relates to Cyanosis and Predicts Survival

Konstantinos Dimopoulos MD, Darlington O. Okonko BSc, MRCP, Gerhard-Paul Diller MD, Craig S. Broberg MD, Tushar V. Salukhe MRCP, Sonya V. Babu-Narayan MRCP, Wei Li MD, PhD, Anselm Uebing MD, Stephanie Bayne BSc, Roland Wensel MD, PhD, Massimo F. Piepoli MD, PhD, Philip A. Poole-Wilson MD, FRCP, Darrel P. Francis MD, MRCP, and Michael A. Gatzoulis MD, PhD^*

From the Adult Congenital Heart Programme (K.D., G.-P.D., C.S.B., S.V.B.-N., W.L., A.U., S.B., M.A.G.), Department of Cardiology, Royal Brompton Hospital, London, United Kingdom; Department of Clinical Cardiology (K.D., D.O.O., G.-P.D., T.V.S., R.W., M.F.P., P.A.P.-W.), National Heart and Lung Institute, Imperial College School of Medicine, London, United Kingdom; and International Centre for Circulatory Health (T.V.S., D.P.F.), St. Mary’s Hospital & Imperial College, London, United Kingdom.

^* To whom correspondence should be addressed. E-mail: m.gatzoulis{at}rbh.nthames.nhs.uk.

Background--Limited data exist with which to stratify risk in adult congenital heart disease (ACHD). An increased ventilatory response to exercise, expressed as ventilation per unit of carbon dioxide production (VE/VCO₂ slope), is an established predictor of impaired survival in acquired heart disease. We sought to establish the distribution, relation to cyanosis, and prognostic value of the VE/VCO₂ slope across a wide spectrum of ACHD patients.

Methods and Results--Five hundred sixty ACHD patients of varying diagnoses and 50 healthy controls underwent cardiopulmonary exercise testing at a single laboratory between 2001 and 2004. Patient age was 33.2±12.9 years (mean±SD). Peak oxygen consumption was 23.5±9.0 mL · kg^-1 · min^-1. VE/VCO₂ slope for all patients was 36.3±15.3. The slope was raised in all ACHD groups compared with controls and was 73% higher in cyanotic patients. Cyanosis, with or without pulmonary arterial hypertension, was the strongest predictor of abnormal VE/VCO₂ slope. The VE/VCO₂ slope was the most powerful univariate predictor of mortality in the noncyanotic group and the only independent predictor of mortality among exercise parameters on multivariate analysis. In cyanotic patients, no parameter was predictive of death.

Conclusions--Ventilatory response to exercise is abnormal across the spectrum of ACHD. Cyanosis is a powerful stimulus for such exaggerated ventilatory patterns irrespective of the presence of pulmonary arterial hypertension. Increased VE/VCO₂ slope is the strongest exercise predictor of death in noncyanotic ACHD patients.

Key words: congenital heart defects • exercise test • ventilation • prognosis

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