We are all aware that exercise is good for us and in the general population, exercise is recommended for everyone to help maintain a healthy weight, keep a normal blood pressure and maintain physical fitness. We have seen the strength of the cardiac rehabilitation service in the UK for patients following heart attacks and the effects that exercise has had on improving their quality of life and stamina.
Despite this we know that often teenagers and adults born with (congenital) heart disease are often less active than their peers and that this is despite the clear benefits of exercise for patients with congenital heart disease. There are lots of reasons why this can happen but we do know that often not enough advice or help is given from hospitals to patients on the benefits of exercise in grown up congenital heart (GUCH) patients.
In this short article, we will discuss one of the particular interests of the department in Bristol, exercise and sport for GUCH patients, and we will take a short look at a few of our current projects.
Increasing activity in teenagers with Congenital Heart Disease: Utilising social media
As mentioned earlier, teenagers with congenital heart problems are not getting as much exercise as some of their peers and trying to change this can be tricky as the teenage years for all are a busy time. One of the major changes we have all seen recently has been the explosion of social media into every walk of life including health and wellbeing and their widespread use by young people. Based on this, lead researcher, Dr Graham Stuart, is currently running a project using a commercially available accelerometer Nike fuelband™ to increase physical activity in young patients with congenital heart disease by incorporating the output measured by the device and uploading this to a Facebook™ site to encourage and motivate participants.
In this study, by taking the standard method of prescribing exercise and incorporating a self-motivational tool like the fuelband, which uses a kind of reward based game theory that has previously been used successfully in young people, we hope this will help support our young patients to become more active and feel better. The other novel aspect of this study compared to most previous work is to use Facebook and social media to encourage a sense of peer support that may support patients in a way that traditional doctor – patient interactions don’t and appeal to our younger patients.
How does the systemic right ventricle function during exercise?
In patients with transposition of the great arteries or ahypoplastic left ventricle (a rare congenital heart defect in which the left ventricle of the heart is severely underdeveloped), the right ventricle which normally functions to pump blood at low pressure has to take on the work of pumping blood round the body which is normally the function of the systemic left ventricle. There is evidence that exercising this systemic right ventricle does not cause any harm or damage, even at high intensity and can result in improved exercise capacity for those taking part in the programme. What is still an area of limited understanding is exactly how the right ventricle working harder than it is designed to, works during exercise.
Currently, the department has research fellows looking at the function of the right heart during exercise and advanced echocardiogram techniques so we can have a better understanding of this ventricle. In this study, we are fortunate to have help from the Manchester United youth team and elite university rowers to compare with our patients. This collaboration is ideal as we get to compare some of the fittest young people in the country to our patients and see differences in their cardiac performance.
While we know lots about the left ventricle during exercise and can thus help understand exercise recommendations, it is hoped that we can use information from this study to guide patients with a systemic ventricle to exercise more and better understand their response to exercise.
Patent foramen ovale and diving
Scuba diving is an extremely popular activity in the UK with the British Sub-Aqua Association having over 1000 clubs nationwide. Whilst a very safe activity, there is a small risk of decompression illness that can be very serious and this risk is increased in patients with a patent foramen ovale (PFO), a failure of the foramen ovale between the left and right atrium to close after birth, which can occur in the general population but is more common in those with some types of congenital heart disease.
One way to help these people return to diving if they have suffered a decompression illness episode is to close the PFO using a keyhole procedure. The lead for our program, Dr Mark Turner, has previously looked at the types of devices that can be used and their safety. The department has recently submitted research of the programmes safety and outcomes to the journal Diving and Hyperbaric Medicine. In addition the same journal has accepted an article on the medical assessment of congenital heart patients for fitness to scuba dive.
Closure of a simple congenital heart defect like a PFO has helped many people return to a job or sport they love and helped maintain a healthy physical lifestyle and is an important part of what our department is committed to.
MRI and exercise
Many patients with congenital heart disease have complex problems or repairs that may be difficult to assess using what has been the mainstay of imaging tests, the echocardiogram and have needed MRI scans to help their doctors treat and follow up them over the years.
What has always been difficult about MRI has been the long scan times, the need to stay very still and an inability to make measurements during exercise. The department here has been undertaking a project with others at Bristol using new MRI techniques to measure blood flow during exercise using MRI. This project has developed from a collaboration between Dr Turner, Dr Szantho and Professor Michael Frenneaux. Dr Mark Hamilton and Dr Gergely Szantho have undertaken a great deal of development work to validate this technique. It is important as many patients only have symptoms during exercise and so assessing the heart during exercise appears to us to be a better way to evaluate the causes of these symptoms, than only assessing the patient at rest.
It is hoped that we could use this tool in the future to understand the response of the pumping chambers of the heart and blood flow through the pulmonary arteries during exercise. This may help us to understand the causes of exercise intolerance in our patients, and identify those who may benefit from early surgery or catheter treatments.
Described above are a few of our exercise and sport focused research projects in congenital heart disease, some aiming to improve our understanding and others aiming to increase the fitness of our patients. Either way our department has a commitment to improve the quality of life of our patients through exercise.
We would like to acknowledge some our collaborators in our research projects, particularly, Professor Craig Williams who is director of the Children’s Exercise Research Centre at the University of Exeter, Dr Guido Pieles, NIHR Lecturer in Congenital Heart Disease who is leading on some of our exercise physiology work (particularly the project involving Manchester United and University Rowers) and Professor Ashley Cooper, Department of Exercise and Health, University of Bristol. We would also like to acknowledge the help of Dr Chris Gillet and Mr Dan Wilson on the Nike Fuelband study. Also our thanks to Dr Mark Hamilton for his support on all our MRI work at Bristol.
By Dr Reza Ashrafi, Dr Graham Stuart, Dr Mark Turner, Consultant Cardiologist
Bristol Congenital Cardiac Centre