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J Thorac Cardiovasc Surg 2007;134:1207-1212
© 2007 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Coronary artery pattern and age impact exercise performance late after the arterial switch operation

Sara K. Pasquali, MD, Bradley S. Marino, MD, MPP, MSCE, Michael G. McBride, PhD, Gil Wernovsky, MD, Stephen M. Paridon, MD*

The Cardiac Center at The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pa.

Presented in part at the American College of Cardiology 2006 Scientific Sessions, Atlanta, Georgia.

Received for publication March 28, 2007; revisions received May 16, 2007; accepted for publication June 5, 2007.

* Address for reprints: Stephen M. Paridon, MD, Associate Professor of Pediatrics, Director of Exercise Physiology Program, The Children’s Hospital of Philadelphia, 2nd Floor Main, 34th St. and Civic Center Blvd, Philadelphia, PA 19104. (Email: paridon{at}email.chop.edu).

Objective: The impact of coronary artery pattern on exercise performance after the arterial switch operation is unknown. The purpose of this study was to evaluate the relationship between coronary artery pattern and exercise performance late after the arterial switch operation.

Methods: Patients who underwent the arterial switch operation and were referred for exercise stress testing between January of 1996 and April of 2005 were included. Univariate and multivariate analyses were performed to identify risk factors for lower maximum heart rate and percent of predicted peak oxygen consumption.

Results: Fifty-three patients were included; 72% were male. The median age at the arterial switch operation was 5 days (1 day to 3.6 years); 32% had concurrent ventricular septal defect repair. The time from the arterial switch operation to exercise stress testing was 14.1 years (7.7–20.6 years). There were 37 patients with the usual coronary artery pattern, and 16 patients (30%) with variant coronary artery patterns. At exercise stress testing, there was no difference in respiratory exchange ratio (1.16 ± 0.1 for both), indicating similar effort. Compared with patients with the usual coronary artery pattern, patients with variant coronary artery patterns had a significantly lower maximum heart rate (177 ± 16 beats/min [89% predicted] vs 186 ± 11 beats/min [93% predicted], respectively, P = .04). Percent of predicted peak oxygen consumption was not significantly different between patients with the usual coronary pattern and patients with variant coronary artery patterns (89% ± 20% vs 80% ± 17%, respectively, P = .12). In multivariate analysis, variant coronary artery patterns (P = .03) and ventricular septal defect (P = .004) were predictors of significantly lower maximum heart rate and were associated with a trend toward lower percent of predicted peak oxygen consumption (P < .09). Longer follow-up time was the strongest predictor of lower percent of predicted peak oxygen consumption (P < .001).

Conclusions: Variant coronary artery patterns are associated with chronotropic impairment, and longer follow-up time is the strongest predictor of diminished aerobic capacity late after arterial switch operation.

Abbreviations and Acronyms ASO = arterial switch operation; EST = exercise stress test; RER = respiratory exchange ratio; TGA = transposition of the great arteries; VO2 = peak oxygen consumption; VSD = ventricular septal defect






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