45 Cardiac Rehabilitation in Congenital Heart Disease

Congenital malformations of the heart and vessels occur in 5–8 per 1000 live births, resulting in an incidence of approximately 0.7%.

Some of these malformations (10–15%) do not require correc- tion. Between 70% and 80% of defects can be cor- rected, and an increasing number of therapeutic procedures can be performed by interventional catheterization techniques, avoiding the need for open heart surgery.

Definitive therapeutic proce- dures are increasingly carried out in early infancy, to avoid long-term complications resulting from the hemodynamic burden, or from chronic cyanosis. With improved techniques and experi- ence, procedure-related mortality has been sub- stantially lowered.

In 2002, a total of 27,772 operations for the treatment of CHD were per- formed in Europe. Germany leads this statistic with 5868 operations for congenital heart defects in 2003; 4415 of those were performed using a heart–lung machine. Significantly, almost half of all operations were performed on neonates and infants. In addition, there were more than 2000 catheter interventions.

In Germany mortality from congenital cardiac malformations (operated or unoperated) has decreased by approximately 64% since 1980.

With improved survival, the focus of follow-up care has had to shift from assessment of procedure-related mortality towards assessment of long-term quality of life.

Congenital Heart Disease (CHD)

The spectrum of CHD is diverse. Defects can roughly be categorized into left-to-right shunt lesions, cyanotic lesions, obstructive lesions, and

complex lesions associated with common mixing and single ventricle physiology.

Table 45-1 and Figure 45-1 provide a list of the most frequent lesions, comprising approximately 80% of all mal- formations. For further details, see Allen et al.

The impact of a congenital cardiac malforma- tion on the development of the affected child depends on the type and severity of the mal- formation, as well as the timing and success of therapeutic measures. For some complex malformations with single ventricle physiology, only palliative solutions are available. Lesions such as tetralogy of Fallot,

atrioventricular septal defect,

and transposition of the great arteries

can be successfully corrected in infancy with good long-term outcome. Regardless of the immediate procedural outcome, long-term follow-up of patients with the entire spectrum of lesions which have been corrected or palliated shows that several new problems may appear in later life including residual valvular obstruction or insufficiency, myocardial dysfunction, and new potentially life-threatening arrhythmias related to previous surgical scars. It is mandatory therefore that all patients receive some form of life-long supervision. Depending on the degree of myocar- dial dysfunction, persistent cyanosis or dysrhyth- mias, disabilities and handicaps may exist that can have grave consequences for psychosocial and cognitive development.

Possible Complications

In complex cardiac defects with or without surgi- cal intervention, there is a complication rate of

45

Cardiac Rehabilitation in Congenital Heart Disease

Birna Bjarnason-Wehrens, Sigrid Dordel, Narayanswami Sreeram, and K. Brockmeier

361

1–5% affecting other organs (hypoxic impair- ments, infarcts, multiple organ failure), which can lead to multiple disabilities.

Neurological impair- ments caused by persistent low cardiac output, acidosis, and/or hypoxia

range from light, general, or specific failures in brain function to severe spastic tetraparesis.

Brain damage and neurodevelopmental disorders in children with CHD may also be genetically determined in addi- tion to the possibility of congenital malformations of the brain, and ischemia related to surgery.

For example, the duration of circulatory arrest during surgery

as well as the duration of a persistent low output state requiring intensive medical care after surgery are associated with these phenomena.

Disturbances of growth are a consequence of insufficient caloric intake and a simultaneous, significantly increased energy demand in infants, children, and adolescents with hemodynamically

relevant cardiac defects. Even when appropriate caloric intake is offered, problems may exist with absorption and metabolism.

Furthermore, eating disorders in infants and toddlers may be observed following long-term, intensive medical care. Extracardiac factors such as disturbed parent–child interaction may enhance distur- bances of growth.

Early definitive correction of cardiac defects provides optimum conditions for successful catch-up growth and a normalization of the physical development.

Another recently recognized, and frequently underdiagnosed problem relates to young teenagers, usually female, who present with eating disturbances associated with a disturbed body image.

Congenital heart defects are frequently found in connection with malformation syndromes and chromosomal disorders (including Williams syn- drome, Down’s syndrome, and microdeletion of chromosome 22q11), which are linked to multiple disabilities.

Accordingly, 3.2–12% of congenital heart defects are accompanied by additional chro- mosomal anomalies, while 5.4–9.5% of patients with CHD have Down’s syndrome.

The special needs of these patients have to be taken into account in their long-term treatment and in rehabilitation efforts. A microdeletion in the short arm of chromosome 22 (22q11) has a variable penetrance and is very frequently linked to CHD. Typical, but not obligatory, are substantial cognitive impairments as well as psychologically and psychiatrically relevant disorders, which may be very hard to distinguish from possible damage related to the therapeutic process.

Therefore, the diagnosis of some heart defects typically associated with microdeletion of 22q11 requires further genetic testing, so that necessary intervention methods can be applied in a timely fashion.

TABLE45-1. The most frequently diagnosed congenital heart diseases

Acyanotic vitia Cyanotic vitia

Obstructions in valves or vessels Primary left–right shunt Right–Left shunt Complex lesions

Pulmonary stenosis (PS) Ventricular septal defects (VSD) (isolated) Tetralogy of Fallot (ToF) Single ventricle physiology,

6–13% 14–16% 9–14% e.g. hypoplastic left

Coarctation of the aorta Atrial septal defects (ASD) 4–10% Transposition of the great heart syndrome (HLHS)

(CoA) 8–11% arteries (TGA) 10–11% 4–8%

Aortic stenosis (AS) 6–9% Persistent ductus arteriosus (PDA) 10–15%

Source: American Heart Association²and Mennicken et al.⁵

Without shunt 20-30%

(PS, CoA, AS) Left-right shunt

ca. 50%

(VSD, ASD, PDA)

Right-left shunt 20-30%

(ToF, TGA)

Acyanotic 70-80%

Cyanotic 20-30%

Without shunt 20-30%

With shunt 70-80%

FIGURE45-1. Classification of congenital heart defects according to defects with or without shunt and with or without cyanosis; see Table 45-1 for definitions of abbreviations. (Adapted and modified from Mennicken et al.⁵)

Possible Consequences of Congenital Heart Disease

The consequences of cardiac lesions in children are diverse and can impose stress not only on the child but also on his or her social environment (Table 45-2).

Consequences for the Patient

Numerous studies have investigated the exercise tolerance of children with various forms of CHD.

Depending on the severity of the defect, the success of corrective procedures, the presence and degree of residual sequelae, physical performance may be limited.

Even children with mild uncor- rected lesions or without residual sequelae after previous surgery may reveal a substantial reduc- tion in their physical performance. Overprotec- tion and the resulting lack of physical activity may contribute to this. Thus far the scientific focus has predominantly been on children with complex heart defects.

Relatively few studies have focused on the motor abilities of children with CHD. Bellinger et al.

demonstrated a retardation of motor development for both gross and fine motor skills at 4-year follow-up after an uncomplicated neonatal arterial switch operation for transposition of the great

arteries. The duration of total circulatory arrest (CA) was closely linked to gross motor skills, but not to fine motor skills. Distinctive limitations in fine motor skills and visual-spatial skills were observed at 8-year follow-up in the same patient cohort.

In their assessment of gross and fine motor skills of 5- to 14-year-olds, Stieh et al.

dis- covered significant deficits in motor development of children with cyanotic heart defects, as opposed to children with acyanotic CHD. In contrast to the data of Stieh, our study group found deficits in fine motor and gross motor skills for both cyanotic and acyanotic heart defects. In a study involving chil- dren with different diagnoses and varying levels of severity, 63.2% of the sample showed significant to grave deficits in gross motor skills.

Unverdorben et al.

demonstrated comparable results. They also made the interesting observation that, indepen- dent of the severity of the disease, children who were excused from physical education classes showed significantly reduced motor performance when compared to children participating in phys- ical education in school.

Numerous studies report behavioral disorders in children and adolescents with CHD, especially – but not exclusively – in those with complex heart defects. Distinctive features became apparent on emotional, social, and cognitive levels, to varying degrees.

On the emotional level, predominantly internalizing disorders such as anxiety, low frustration tolerance, increased stress, and even depressions appeared. Disturbances of self-esteem, which may either be very low or extremely exag- gerated, are also frequently observed. Particularly children who are not allowed to engage in exercise due to limited cardiac function or a perceived risk of sudden death are threatened by lowered self- esteem. Strong changes of mood, relapses to earlier stages of development, depression, and antisocial behavior have been observed especially in adoles- cents.

Additionally, children diagnosed with CHD reveal reduced social competence. Often their behavior is characterized by a tendency to retreat socially. This shyness makes building and main- taining relationships with children of the same age much harder. Numerous indicators of cognitive impairment are to be found in children with complex cardiac defects: significantly lower scores on IQ and achievement tests, learning disorders, reduced academic performance (reading, writing,

for patients and their social environment For the child:

Reduced physical performance Restrictions in physical activity

Restricted participation in normal daily activities of healthy peers Continuing dependence on care providers

Emotional disorders, mostly internalizing disorders such as anxiety, depression, etc.

Disturbances of social competence Cognitive disorders

For parents and siblings:

Stress in parent–child relationship

Difficulties with education (for instance as a result of concerns over the child having a cardiac defect)

Stress on siblings (lack of attention) Problems within the parents’ relationship

Source: Adapted and modified according to Deutsche Gesellschaft für pädiatrische Kardiologie.⁹

mathematics), speech abnormalities, attention deficit disorders, disturbances in problem-solving behavior, etc.

These disorders may be caused by neurological damage, congenital malformation syndromes, and chromosomal anomalies. Yet, learning abilities of the child can also be affected by reduced perceptual abilities, lack of concentration, and attention deficits. These can either be caused by disturbed brain function or by adverse develop- mental conditions (situation within the family, reduced experience in regard to perception and physical activity). The lack of adequate academic education related to chronic illness may also have a negative impact.

Quality of life studies have demonstrated contrasting outcomes. Some studies report no significant difference between CHD children and healthy peers while others demonstrate significantly lower quality of life, particularly in the areas of physical, social and overall function in CHD children compared to healthy controls. In a recent study where 182 parents of CHD children (54 having transposed great arteries, 55 a function- ally single ventricle and 73 complex variants of functionally biventricular disease) completed a quality of life survey concerning their children, the parents reported a significantly lower quality of life than parents of healthy controls on all subscales of the instrument: overall, physical and emotional function, social and educational functioning.

Quality of life did not correlate with socioeconomic status, number of open-heart operations, or the time since the last operation. Parents of children aged 8–12 years reported the lowest quality of life across all domains assessed. This span represents a time when surgical reintervention is common and also the time when children are first beginning to consider their own mortality and vulnerability. On comparing the diagnostic groups, parents of chil- dren with complex, functionally biventricular hearts reported the lowest scores for quality of life.

Subjects reporting lowest quality of life were found to be significantly more likely to report functional disabilities.

Consequences for the Family

The disease and the restrictions it causes (reduced physical performance, complications, continuing pharmacological treatment, operations, catheter

interventions) in connection with hospitalization and frequent outpatient visits, and the overall worries about the child, impose grave stress on parents, siblings, and the entire family environ- ment. Oftentimes, long-lasting separation of family members related to attending to the child in hospital, as well as emotional stress caused by the severe and often life-threatening heart defect of the child, also evoke psychological and somatic consequences and conflicts within the family.

Siblings suffer from lack of attention, often feel neglected, over-challenged, and misunderstood, and thus develop emotional disorders on their part. These may be eating disorders, sleeping dis- orders, regressive behavioral disorders, aggres- sion, and/or problems in academic performance.

It is crucial to approach such psychological burdens immediately and to counteract or solve conflict situations. At this point, the help of professionals (psychologists, social education workers, and social workers) who intervene at the psychosocial level is usually required.

Rehabilitation in Congenital Heart Disease

With the availability of long-term follow-up data

for the entire spectrum of cardiac defects, it is

becoming clear that life-long, qualified care –

which may include rehabilitation measures – is

required for affected children, adolescents, and

adults. The decision on whether rehabilitation

measures are required, and at which point and to

what extent they are necessary, has to be made on

an individual basis. Most frequently rehabilitation

has to be initiated directly after surgery. However,

rehabilitation measures may also be indicated

several years after original intervention. While

extensive rehabilitation is currently being offered

for adult patients with coronary artery disease,

such measures are not widely available to children

with CHD.

Outpatient rehabilitation measures

are often not accepted because of the long dis-

tances between patients’ homes and the rehabilita-

tion institutions. Inpatient care is very rarely

offered and can only be carried out if at least

one parent is present in order to avoid a painful

and potentially long-term separation of the child

from family.

However, a parent accompanying

the child throughout inpatient rehabilitation significantly raises the costs of such therapy.

Rehabilitation for this group of patients has to be structured in three phases. Each phase involves somatic, educative, psychological, and social ele- ments, which are managed by an interdisciplinary rehabilitation team.

Rehabilitation Goals

According to the WHO charter for children, every child has the right to an appropriate and undis- turbed physical, mental, and emotional develop- ment. The main goals of rehabilitative measures are to eliminate or minimize impairments, dis- abilities, and handicaps linked to the disease and to prevent possible secondary effects. Other general rehabilitation goals are:

– Promotion of self-management and self- responsibility in terms of helping to self-help.

– Promotion of equal participation in social life and prevention or counteraction of possible discrimination. In this respect, it is particularly important to ensure and/or reestablish the affected person’s integration into school, educa- tion, job, family, and society.

– Enhancement of the overall quality of life.

– Reduction of disease-related morbidity.

The specific rehabilitation goals are formulated from the patient’s individual situation (age and stage of life, severity of the disease, time-span from the intervention, postoperative sequelae, co-mor- bidity, family and social situation, etc.). As a conse- quence of the diversity and complexity of cardiac defects and their effects on the whole life situation, the need for rehabilitation varies substantially, as do the corresponding rehabilitation goals. As an example, the general development of a child’s personality is not only affected by medical and therapeutic interventions and/or improvement of physical fitness, but is also significantly influenced by emotional, psychosocial, and cognitive aspects of development. On the other hand, in adolescents education and coping strategies may be the main focus. This may involve providing extensive infor- mation about the cardiac defect, a personal history of the disease and its prognosis, past interventions and their consequences for heart and body, requirement for long-term medication, future

diagnostic or therapeutic procedures, and the necessity of hospital attendance for regular follow- up. Furthermore, support in terms of planning a future life independent from the parents, job train- ing, choice of employment, sexuality, and family planning can be of great importance. Especially in adolescence, promoting acceptance of the disease can constitute an essential rehabilitation goal, as restricted acceptance may result in inefficient disease management.

A specific rehabilitation goal can also be catch- ing up with family problems caused by the child’s disease. Such problems may impact on the child/adolescent’s development, their healing process,and/or their disease management.In some circumstances, this may require the integration of the whole family in the rehabilitation process.

Phases of Rehabilitation

The phase structure of rehabilitation in CHD is illustrated in Figure 45-2. Rehabilitation phase I includes treatment in a hospital or a cardiologic center for children. Here, the main focus is placed on somatic treatment including medical care and nursing. If surgery is performed on older children, adolescents, and adults, physiotherapeutic care is prioritized in order to achieve early mobilization.

The most important goals are pain relief, throm- bosis prophylaxis, stabilization of the circulatory system, as well as the management of existing neu- rological deficits.

In neonates, infants, and chil- dren, it is crucial for the attending doctor to provide information, counseling, and assistance to the family. Extensive information and advice offered to the parents constitutes the fundament of an adequate management of the child’s heart defect. Hereby, parents also receive help in dealing with their unexpectedly difficult situation. Grief about the child being chronically ill, concerns about the future, fear of losing the child, and other worries should be addressed. Counseling by a psy- chological expert, a social education worker, and/or a representative of the appropriate reli- gious society may be necessary or at least helpful, especially in severe and life-threatening diseases.

Moreover, additional information and support

offered by parents of other affected children con-

tributes tremendously to the efficacy of these

measures. Such self-help groups offer a great deal of emotional and social support, which is crucial at this point.

Many parent-support groups for chil- dren with specific cardiac lesions currently have their own internet websites, from which useful information concerning a particular therapeutic procedure, its outcome, and the possible complica- tions are readily available. Encouraging parents to access these sites improves the quality of commu- nication between parents and care providers, and also provides parents with a realistic view of the future, as seen from their perspective. Information and education about disease and rehabilitation should be provided to the parents in the course of several interviews, often going over ground which has previously been covered. At the time of diag- nosis, the decision to have the child operated on and the operation itself are sources of great stress to the parents. At this point, they may not fully comprehend or accept detailed information.

Therefore, it is crucial to take sufficient time and patience for parents’ education. Communication

can furthermore be enhanced by means of infor- mation booklets. As parents are not only the most important persons for the child to relate to but are also responsible for their everyday care, they are an important part of the rehabilitation team.

For older children, adolescents, and young adults, age- appropriate information and education should be provided to the patients themselves. If needed, consultation with a (child-) psychologist and/or a social education worker should be available.

After surgical or interventional correction of a heart defect in a neonate or an infant, early reha- bilitation is usually not necessary, as the patient is only discharged from hospital when it is evident that the parents are able to care for the child at home. As a result, rehabilitation phases I and II merge. After children are released from hospital, their further care is provided by a specialist. In this phase, external nursing services are recom- mended to support the parents. This may at first be used on a daily basis. With increasing time from the operation, the frequency and intensity of

(days or weeks)

post operative, or post-interventional care in the operating center, or in the cardiological section for children in an hospital

Rehabilitation phase II (weeks or months)

rehabilitation immediately after intervention

Outpatient

•thorough medical care provided by pediatric cardiologist / operating center

• external care If necessary:

• physiotherapy

• psychosocial care / treatment

• family-oriented rehabilitation

• children’s heart group (CHG)

Inpatient

•patient (child / adolescents / adult)

• infant / child accompanied by one parent

• family-oriented rehabilitation

Rehabilitation phase III (years)

long-term care at patient’s residence

•long-term outpatient medical care provided by pediatric cardiologist / pediatrician / family doctor

• children’s heart group (CHG)

If necessary: psychosocial care / treatment, physiotherapy, nursing

FIGURE45-2. Organization and phases of rehabilitation in patients with congenital heart defects.

these services are reduced. Especially in regard to complex cardiac defects, extensive rehabilitation measures may become necessary at a later point in life. If early rehabilitation happens to be required after surgery (phase II), it is best pursued in a specifically designed and equipped in- or out- patient institution. Here, resources for all neces- sary therapeutic measures are available, ready to be employed by an interdisciplinary rehabilitation team. However, more frequently this phase is per- formed either in an outpatient setting or at the patient’s home, directed by a children’s heart center, pediatric cardiologist, or pediatrician. If needed, outpatient physiotherapy and/or psy- chosocial and psychomotor treatment are addi- tionally integrated into the care program.

The transition to phase III rehabilitation is smooth. If necessary, it includes continuous, regular medical treatment at home, which is covered by a pediatric cardiologist sufficiently experienced in the care of grown-ups with CHD.

If needed, these measures can be sustained through the promotion of psychomotor skills in a children’s heart group and, at later ages, in an adult heart group.

The children’s heart group (CHG) is a medically prescribed, supervised outpatient therapy option for children with heart defects and is led by a qualified exercise/sport therapist. Children in need of this therapy are given the opportunity to be physically active in a medically supervised,

“protected area.” Here, potentially existing psy- chomotor deficits can be identified and treated.

Simultaneously, conditions for a thorough inte- gration into physical activity of peers (as, for instance, physical education at school) are estab- lished. For most children, temporally limited par- ticipation (90–120 sessions or units) is sufficient.

For children who, as a result of the severity of their disease, urgently require medical supervision during physical activity, longer participation (possibly for years) is desirable and practical in order to provide means for them to be physically active at all. CHGs meet once or twice a week for 60–90-minute sessions. To provide adequate indi- vidual attention, group sizes should be small (up to 10 children) and children should all be of approximately the same age. In the CHG, children gain knowledge about their physical limitations;

they learn to become aware of their physical reac-

tions to high load and learn how to respond accordingly. The fun aspect of engaging in physi- cal activity together with other children is partic- ularly important. To the extent that the heart defect permits it, children ought to be encouraged to participate in physical activity with their peers, both in leisure time and at school. Participation in a CHG can also help to minimize parents’

concerns and anxiety about their child being physically active and can thereby reduce overpro- tection. Consulting by the physician and the exer- cise/sport therapist along with the exchange of ideas with other parents can also provide valuable input and support for the family.

In both phase II and phase III, regular phone calls and/or email contact, along with visits from a health professional, may serve as means of con- tinuing care for the patient and his family. Such measures could well be supported by continuous provision of information bulletins. The contact with the care team could further be improved through the implementation of a telephone hotline, which makes advice and assistance avail- able for parents and patients. Such measures are primarily meant to serve as additional options within the care system. They are particularly important when circumstances do not allow for a patient’s regular participation in therapy sessions and/or information meetings.

Need for Rehabilitation

It would be wrong to limit the need for rehabilita- tion to certain diagnoses and/or cardiac surgical interventions. In this respect, an urgent need for rehabilitation may as well exist due to behavioral disorders in children and adolescents with rela- tively mild heart defects. The need for rehabilita- tion can result from somatic, educative, and psychosocial, but also from family-related reasons, regardless of the patient’s age or diagnosis

(Table 45-3). The indication for rehabilitation is provided by a pediatric cardiologist/pediatrician, possibly in association with a child neurologist and/or a child psychiatrist. The indication has to be determined and justified based on detailed medical diagnosis.

If necessary, diagnostic data from other subspe-

cialists (for instance child psychologists, social

education workers, pediatric physiotherapists)

must be considered. Only based on such detailed diagnostics can rehabilitation goals be formulated and recommendations for duration and setting (outpatient or inpatient) be given (Table 45-4). By means of an extensive interdisciplinary diagnostic approach,hidden deficits may be uncovered.More- over, immediate intervention usually proves to be easier and less expensive than the treatment of avoidable long-term consequences.

Family-Oriented Rehabilitation

If possible, younger children should be accompa- nied by a parent while going through the rehabil- itation process. This goes especially for inpatient care. For a chronically ill child, the relationship with the family is of utmost importance for posi- tive management of the disease and constructive coping. However, as a consequence of the extraor- dinary amount of stress the chronic disease imposes on the family, a family-oriented rehabi- litation including all family members may be indicated.

Regardless of the severity of the disease, family- oriented rehabilitation is required if:

– The family is unable to care for the child in a manner that will guarantee a successful healing process.

– The family cannot provide sufficient support, for instance as a result of anxiety, or if medical

and/or psychosocial factors affecting other family members negatively impact on the healing process of the primary patient.

– The disease has caused a breakdown in the family with resulting medical and psychosocial complications in other family members. This sit- uation may occur in conjunction with life- threatening heart defects, multiple disabilities, or additional stressors.

The decision for family- oriented rehabilitation has to be made and justified on the basis of medical and/or psy- chosocial diagnostics, which include the entire family.

Family-oriented rehabilitation must be under- stood as medical/psychosocial care which aims at individual medical and psychotherapeutic mea- sures for both the primary patient and other family members. The integration of the family into the medical care setting is required due to the complex somatic and psychosocial interaction, disturbed social behavior, anxiety, and/or learning disorders of the patient. In the best-case scenario, it is carried out as inpatient treatment.

As a consequence of specific developmental circum- stances, inpatient treatment of children requires a duration of at least 4 to 6 weeks. For adolescents and adults, a minimum of 4 weeks is required.

Independent of patients’ age, need for rehabilitation may exist:

– after surgery with intra- or postoperative complications, or in case of extended convalescence

– for disturbed psychomotor development due to the severity of the defect or because of complex malformation syndromes – for optimization or controlled reduction of pharmacologic therapy – after heart transplantation

– for patients’ and parents’ education (for instance about medication use and individual dosage as, for example, with warfarin (Marcumar) after prosthetic valve replacement

– in case of inappropriately low (subjective) performance despite successful correction of the heart defect

– in case of insufficient acceptance and management of the disease – to guide adolescents and adults regarding their future choice of

education and career

– in special cases, especially in adolescents and young adults, as a means to prepare for future cardiac surgical or interventional procedures Source: Adapted and modified according to Deutsche Gesellschaft für pädiatrische Kardiologie.⁹

TABLE45-4. Categories of support: patients (parents) of all cat- egories need examination(s) by experts to investigate a potential benefit from rehabilitation. Patients from the first category may require repeated examination of their psychosocial status. Patients from categories two and three usually need only one examination of their psychosocial status

Rehabitation obligatory

Severe forms of congenital heart disease – complex congenital heart disease:

– palliative surgery (Fontan type palliation)

– congenital heart disease without possible definitive treatment – after surgery/intervention with major residual defects – severe congestive heart disease/cardiomyopathy – after heart transplantation

Rehabilitation recommended

Less severe forms of congenital heart disease:

– after successful surgery – after successful intervention – with minor residual defects

Rehabilitation recommended under special, e.g. psychosocial, conditions Congenital heart disease with marginal hemodynamic significance (e.g.):

– small left-to-right shunts – insignificant semilunar valve stenosis

TABLE45-5. Differentiated illustration of therapy areas and the therapeutic team involved in rehabilitation measures for children and adolescents with congenital heart defects

Medical care-related, and physiotherapeutic area Psychosocial area Psychomotor area

Diagnosis: Diagnosis: Diagnosis:

– general physical examination Psychological diagnosis: Especially diagnosis of:

– laboratory diagnostics – behavioral anomalies – physical fitness

– ECG – developmental delays – motor skills

– spirometry – emotional disorders – perceptual skills, etc.

– 24-hour ECG – inadequate disease

– long-term measurement of blood pressure management Personnel:

– Sonography – social nonconformism – (child) physiotherapist**

– Echocardiography, – family-related problems – occupational therapist

– SaO2monitoring – exercise/sport therapist

– incremental ergometry Personnel: – psychomotor therapist

– cycle- (spiro-) ergometry/treadmill-(spiro-) ergometry – child psychiatrist**

if necessary, including transcutaneus oximetry – (child-) psychologist Therapy offers:

– social education workers – ergotherapy

Personnel: – educator (teacher)** – perceptual training to promote

– pediatric cardiologist (in charge) – art therapist sensory development

– pediatrician – music therapist* – training of fine motor skills

– child neurologist** – remedial teacher* – concentration exercises

– (children’s nurse)** – training of social competence

– (child-)physiotherapist** Therapy offers:

– masseur and balneotherapist** Counseling and group counseling, Psychomotor and sport therapy, for

– dietary assistant** for instance as a parents’ circle instance:

– promotion of perception and

Therapy: Family counseling and life-coaching: movement

Nursing, medical treatment, and therapy are adjusted – individual therapy – improvement of body coordination, to individual needs. Goals of all therapy subsequent – couple therapy*** endurance, strength, speed and

to hospitalization are for instance: – family therapy*** flexibility

– improvement of physical performance – relaxation methods – improvement of motor skills

– improvement of ventilation and lung function – play therapy** – development of a realistic self-

– optimization of antiarrhythmic therapy – art therapy* evaluation

– treatment of perioperative complications – music therapy* – improvement of social skills – treatment of extracardiac complications – social consulting, including – advice for autonomous physical

– general recovery school and job-related advice** activity in daily life

– age-specific pedagogical – introduction to different sports

Physical therapy, for example: attendance – motivation for autonomous, life-long

– specific. neurophysiological/-kinesio-logical – education in specific classes** physical activity physiotherapy (according to Bobath, Vojta, – remedial pedagogy* – parent–child gymnastics**

Brunkow, and others)** – leisure pedagogy* – advice for movement-oriented leisure

– ventilation therapy** with the whole family

– inhalation therapy**

– electrotherapy**

– massages, medicinal baths**

– dietary prescriptions/advice**

– therapy for eating disorders**

*Facultative, **by means of consulting services, if necessary, ***family-oriented therapy.

Source: Modified and completed according to Deutsche Gesellschaft für pädiatrische Kardiologie⁹and Rosendahl and van der Mei.³⁰

Content of Rehabilitation

The rehabilitation process has to be individualized, age-appropriate, and oriented to the specific needs.

Great value is placed on the development and pro-

motion of the patient’s competence – and that of his

family – in dealing with the disease and the result-

ing life situation. In this respect, the treatment is

meant as an aid to self-help. Table 45-5 illustrates

and differentiates the most important therapy areas.

The Impact of Physical Activity

Children have a basic need for physical activity.

Their perceptual and motor experience not only determines their physical and motor development but also decisively impacts on their emotional, psychosocial, and cognitive development. In con- trast, physical inactivity in childhood is abnormal – regardless of whether it is due to physical, emo- tional, psychosocial, or cognitive factors. Physical activity and sports should therefore be recom- mended and encouraged for all youth.

Oftentimes, a cardiac disease means a restric- tion of the affected child’s perceptual and motor experience. Complex and severe heart defects may – at least temporarily – cause reduced symptom- limited exercise tolerance, and therefore require a certain amount of rest. Times of inpatient ex- aminations or corrective operations are always periods of more or less strict immobilization.

Depending on their duration and the child’s age and mental stability, they can lead to develop- mental stagnation or regression. Anxiety and worries about the ill child often cause parents to become overprotective. Anxiety, or at least great uncertainty, exists especially in regard to the danger one might expose a child to by allowing them to engage in physical activity. This is often –

unnecessarily – also the case with children whose physical capacities are grossly normal. An existing deficit could be easily compensated through specific motor training and would make further inactivity redundant. Figure 45-3 shows the network of possible causes and effects of physical inactivity in children with heart disease.

Considering the high relevance of physical activ- ity and sports for current day social awareness,par- ticipation in physical activity together with healthy peers improves quality of life for children and ado- lescents. Particularly for them, physical activity and sports play an important social and socializing role. They experience an exclusion from sports and/or a restriction of their activity as extremely unpleasant. Accordingly, when asked about their disadvantages in comparison to peers, 62 children and adolescents with CHD put their physical restrictions in first place, even ahead of life expectancy and opportunities for employment.

Recommendations for Physical Activity

With improved life expectancy, growing atten- tion is given to the question of whether and to what extent physical activity should be

Congenital heart disease

Anxiety Lack of

information Possible reduced

functional capacity

Overprotection

Social isolation

Deficiency of perceptual and motor

experience

Reduced physical activity

Increased overprotection

Impaired perceptional

and motor development Reduced radius

of action

Impaired psycho social development:

self-concept, social behavior,

motivation etc.

FIGURE45-3. A network of possible causes and effects of physical inactivity in children with CHD.

recommended in order to improve the quality of life. Numerous groups of experts have provided recommendations concerning exercise for chil- dren with CHD.

Additionally, recommenda- tions for the implementation of medically supervised heart groups have been published in Germany.

These recommendations can con- tribute to avoiding unnecessary exclusion of chil- dren and adolescents with heart disease from physical activity and sport. Moreover, they can minimize children’s, parents’, and teachers’ inse- curity in regard to the affected child’s physical abilities.

In keeping with these recommendations, all young people with CHD who fulfill the necessary requirements should have the opportunity to par- ticipate in physical activity and, if needed, take part in specially adapted programs of physical education. For the assessment of aptitude and classification, the primary heart defect is less important than the current clinical status and potentially deleterious residual defects (Table 45-6).

For many of the affected children, no restriction of physical activity and sport is recommended.

This group includes all children and adolescents whose heart defects were definitively corrected in infancy or early childhood (patent ductus arteriosus, small atrial septal defect, ventricular septal defect), who do not have symptom-limited reduction of exercise capacity (group I.1). Even in patients with moderate residual defects (group I.2) (such as moderate aortic valve disease), normal load can be permitted in physical education and physical activities in leisure time. This also applies to children and adolescents whose cardiac defects do not require surgery (group II, for instance small septal defects or insignificant valvular stenosis).

Patient groups I.1, I.2, and II do need temporary participation in remedial programs and/or adapted physical education if a restriction of physical fitness and/or psychomotor deficits exists. In this context the indication for participa- tion in special groups may also result from psy- chosocial reasons.

Despite the reduction in mortality and improved hemodynamic outcomes of surgery and interventional catheterization, a considerable

number of affected children and adolescents have hemodynamically significant residual defects, which may impair their expectancy and quality of life. For them, participation in special groups is most recommended. For patients with significant findings, complex heart defects subsequent to pal- liative interventions, inoperable heart defects, chronic cardiomyopathy, complex arrhythmia, or after heart transplantation, participation in phys- ical activity cannot generally be advocated. Here, a decision for each individual patient has to be made in consultation with the attending pediatric cardiologist.

Patients with complex heart defects after pal- liative operations (I.4) represent a special group.

In a great number of them (I.4a), a separation of the systemic and pulmonary circulations can be performed and thus no cyanosis persists.

However, some patients remain cyanotic (I.4b).

For these groups, and for children receiving anticoagulant therapy or with implanted devices (pacemakers, ICDs) or at a risk of sudden death, special and sometimes individual recommenda- tions have to be made.

TABLE45-6. Classification according to current cardiac situation and postoperative clinical findings

Group I: patients after heart surgical/catheter interventional operations 1. No residual sequelae (complete correction)

2. With moderate residual sequelae 3. With significant residual sequelae

4. Patients with complex heart defects after palliative interventions:

(a) such as the Fontan operation or the Mustard operation for TGA, where separation of systemic and pulmonary circulation has been achieved

(b) patients in whom the two circulatory systems have not been separated (e.g. aortopulmonary shunt operation) Group II: patients with heart defects not requiring operation

1. Shunt lesions with insignificant left-to-right shunt such as small atrial or ventricular septal defect

2. Insignificant valvular defects/anomalies such as congenital bicuspid aortic valve

Group III: patients with inoperable heart defects Group IV: patients with chronic cardiomyopathy Group V: patients with complex arrhythmia Group VI: patients after heart transplantation

Source: Adapted and modified according to Deutsche Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen.³⁵

specific danger of sudden death. They should par- ticipate in physical activity (indoors and out- doors) with their peers in an unrestricted fashion, as far as possible. This applies to play and guided activity in kindergarten, school, and/or sports clubs. Participation in specific, possibly medically supervised programs for the promotion of motor abilities can help to limit motor deficits and prepare and support the integration of children into their peer group.

Results of empirical studies show that physical and motor performance of children and adoles- cents with CHD can be enhanced through regular engagement in autonomous or supervised physi- cal activity. Furthermore emotional, psychosocial, and cognitive developmental processes can also be positively influenced.

Figure 45-4 illustrates how diverse, possibly negative consequences of CHD can be compensated through the improve- ment of motor abilities and skills.

The content of special motor training programs primarily aims at improvement of perceptual and motor development in order to compensate for existing deficits. Positive experience of one’s own body, its functions, and capabilities constitutes the basis for developing a positive self-image, which in turn helps children with CHD to cope with their disease and the possible restrictions connected

activity may result from the following:

• acute myocarditis

• children/adolescents with heart defects which acutely require surgery

• significant coarctation and/or heart failure NYHA class III/IV (preoperative)

• severe pulmonary hypertension

• severe cyanosis

• complex arrhythmia

• severe cardiomyopathy, obstructive hyper- trophic cardiomyopathy.

Required Preliminary Examinations

Prior to starting a physical training program, a thorough cardiological examination has to be performed in order to classify diagnosis and severity of the disease (Table 45-7). The objective of this examination is to determine the patient’s individual symptom-limited cardiac capacity and the risk of exercise-related sudden cardiac death associated with the individual’s specific disease.

Improvement of Motor Development

Improvement of physical activity in children with CHD should start as early as possible. In this way deficits in perceptual and motor experience and their negative consequences can be minimized. It is a special aim of motor interventions in children with CHD to develop individual perception of potential limitations and establish the boundaries of their exertional tolerance. In connection with acquiring age-appropriate knowledge about the disease-specific situation and the resulting symptom-limited capacity, this leads to a realistic self-estimation. In combination with this positive self-concept, emotional and psychosocial stability as well as a proper social integration, a realistic self-evaluation represents the most efficient pro- tection from overload in daily life, physical activ- ity and sport.

Children need to be provided with the oppor- tunity to act out their basic need for physical activity and should only be stopped if there is a

TABLE45-7. Required (preliminary) examinations prior to ini- tialization physical training

Initial examination

Precise knowledge of patient’s clinical history General physical examination

ECG at rest Echocardiography

Ergometry*(spiroergometry, if needed), especially in case of cyanotic vitia with transcutaneous O2measurement 6-minute running test, if needed with ECG monitoring (as an alternative for younger children) Long-term ECG

Facultative: Stress echocardiography*

Control check-ups (at least yearly) Clinical history

General clinical examination ECG at rest

Echocardiography Endurance testing*

*Starting at age 5 to 6.

Source: Adapted and modified according to Deutsche Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen.³⁵

with it. Within the children’s special group, based on differentiated body perception, children develop awareness of strain and learn to have the confidence to take breaks during group activities as often as needed.

Moreover, all age-appropriate forms of activity should be made available for children with CHD.

At preschool and elementary school age, these are diverse coordinative tasks involving gross and fine motor skills. Specific resistance and endurance training is neither necessary nor efficient at the ages of 8 to 10. Improved strength and cardiovas- cular performance at this age result from improved motor coordination. Yet, should chil- dren exhibit muscular imbalance resulting from a lack of movement or unbalanced load (for instance frequent sitting), special compensation could be indicated.

Already at preschool and school age, but espe- cially in adolescence, sport-specific skills are acquired and increasingly improved through diverse and varied physical activities depending on interests and available resources. An important goal is to offer insight into the diversity of physi- cal activity and sports available to all young people. This will help them obtain specific skills and knowledge and thereby enable and motivate them to participate with their peers in physical activities and choose an appropriate lifetime-

sport. Special attention has to be given to the danger of abdominal strain. Already at preschool age, children with specific risk factors should learn to avoid breath-holding during exercise. The Valsalva maneuver can lead to dangerous blood pressure peaks. Lowered cardiac output during straining as well as post-pressor bradycardia may result in significant arrhythmia and even ventric- ular fibrillation. A rapid fall in blood pressure after straining at maximal workload sometimes leads to syncope, even in healthy persons.

The specific behavior patterns in youth often cause adolescents with CHD to consciously disre- gard their body signals in order to avoid the

“embarrassment” that a necessary physical break would cause. By doing this, they expose them- selves to potential danger. Prevention of this danger can – besides appeals to the adolescent’s rationality – only be achieved through an early stabilization of personality and the improvement of self-responsibility and self-confidence.

Summary

Progress in the treatment of CHD has led to a dra- matic reduction of mortality. More and more chil- dren with CHD reach adulthood, which causes morbidity within this population to be a growing

Congenital heart disease

Anxiety Lack of

information

Overprotection

Social isolation Deficiency of

perceptual and motor experience Reduced physical activity

Improved motor abilities and

skills Expanded radius of

action Improved psycho social situation:

competence of behavior, self-assessment,

anxiety etc.

Increased physical activity Possible decreased functional capability

Psychomotor training

FIGURE45-4. Compensation of negative consequences of CHD by means of goal-oriented improvement of motor development.

problem that demands special expertise. Preven- tive diagnostics and treatment have to be initiated early, aiming to find deficits and alleviate them through the use of specific measures. We expect CHD to be accompanied by deficits in the fields of motor skills, cognition, and emotion (not only in the person affected but also in their social environment). However, even with less complex heart defects, deficits exist to a currently as yet unknown extent. This is the reason for rehabilitative intervention in CHD, targeting a long-tem reduction of morbidity and an en- hancement of the patient’s quality of life. Consid- ering the financial outlay currently targeted towards invasive therapeutic measures, an increased expenditure of time and finances directed towards optimizing the quality of life of this patient group by institution of appropriate rehabilitation measures in a timely manner is justified.

References

1. Allen DH, Gutgesell HP, Clark EB, et al. Moss and Adams’ Heart Disease in Infants, Children, and Adolescents. Including the Fetus and Young Adults, 6th edn, Vols 1 and 2. Philadelphia: Lippincott Williams & Wilkins; 2001.

2. American Heart Association. Cardiac Disease in Children: Statistics. Available at: http://www.

americanheart.org/presenter.jhtml?identifier=4498.

3. Bruckenberger E. Herzbericht 2003. Hanover:

Eigenverlag; 2004.

4. Deanfield J, Thaulow E, Warnes C, et al. Manage- ment of grown up congenital heart disease. The Task Force on the Management of Grown Up Con- genital Heart disease of the European Society of Cardiology. European Heart Journal 2003;24:1035–

1084.

5. Mennicken U, Franz Ch, Hirsch H. Angeborene Herzfehler. In: Siegenthaler W, Kaufmann H, Horn- borste H, et al., eds. Lehrbuch der Inneren Medizin.

Stuttgart: Thieme; 1992:99–130.

6. Norgaard MA, Lauridsen P, Helvind M, et al.

Twenty-to-thirty-seven-year-follow-up after repair for tetralogy of Fallot. Eur J Cardiothorac Surg 1999;16:125–130.

7. Schaffer R, Berdat P, Stolle B, et al. Surgery of the complete atrioventricular canal: relationship between age at operation, mitral regurgitation, size of the ventricular septum defect, additional mal-

formations and early postoperative outcome. Car- diology 1999;91:231–235.

8. Hutter PA, Kreb DL, Mantel SF, et al. Twenty-five years’ experience with the arterial switch operation.

Thorac Cardiovasc Surg 2002;124:790–797.

9. Deutsche Gesellschaft für pädiatrische Kardiologie.

Rehabilitation bei angeborenen und erworbenen Herzerkrankungen im Kindes- und Jugendalter.

Leitlinien zur Diagnostik und Therapie in der Pädiatrischen Kardiologie (2003);1–7. AMWF online http:/www.uni-düsseldorf.de AWMF/11/

pkard031.htm, 30.05.2005.

10. Wernovsky G, Newburger J. Neurologic and devel- opmental morbidity in children with complex con- genital heart disease. J Pediatr 2003;142:6–8.

11. Bellinger DC, Wypij D, duPlessis AJ, et al. Neurode- velopmental status at eight years in children with dextro-transposition of the great arteries: The Boston Circulatory Arrest Trial. J Thorac Cardio- vasc Surg 2003;126:1385–1396.

12. Wypij D, Newburger J, Rappaport LA, et al. The effect of duration of deep hypothermic circulatory arrest in infant heart surgery on late neurodevel- opment: The Boston Circulatory Arrest Trial. J Thorac Cardiovasc Surg 2003;126:1397–1403.

13. Newburger J, Wypij D, Bellinger DC, et al. Length of stay after infant heart surgery is related to cognitive outcome at age 8 years. J Pediatr 2003;143:67–73.

14. Dunbar-Masterson C, Wyoij D, Bellinger DC, et al.

General health status of children with D-transposi- tion of the great arteries after the arterial switch operation. Circulation 2001;104(Suppl I):I-138–I- 142.

15. Singer H. Einfluss angeborener Herzfehler auf die Entwicklung von Kindern und Jugendlichen. In:

Bjarnason-Wehrens B, Dordel S, eds. Motorische Förderung von Kindern mit angeborenen Herzfehlern. Sankt Augustin: Academiaverlag;

2001:9–25.

16. Abad-Sinden A, Sutphen JL. Growth and nutrition.

In: Allen HD, Gutgesell HP, Eclard EB, et al., eds.

Moss and Adams’ Heart Disease in Infants and Ado- lescents, 6th edn, Vol 1. Philadelphia: Lippincott Williams & Wilkins; 2001:325–332.

17. Clark EB. Etiology of congenital cardiovascular malformations: epidemiology and genetics. In:

Allen HD, Gutgesell HP, Eclard EB, et al., eds. Moss and Adams’ Heart Disease in Infants and Adoles- cents, 6th edn, Vol 1. Philadelphia: Lippincott Williams & Wilkins; 2001:64–79.

18. Fredriksen PM, Ingjer F, Nystad W, et al. A compar- ison of VOpeak between patients with CHD and healthy subjects all aged 8–17 years. Eur J Appl Physiol 1999;80:409–416.

28. Ammani Prasad S, Main E. Paediatrics. In: Pryor JA, Ammani-Prasad S. Physiotherapy for Respiratory and Cardiac Problems. Adults and Paediatrics, 3rd edn. Edinburgh: Churchill Livingstone; 2002:

425–455.

29. Kendall L, Sloper P, Lewin RJP, et al. The view of parents concerning the planning of services for rehabilitation of families of children with congeni- tal cardiac disease. Cardiol Young 2003;13:20–27.

30. Rosendahl W, van der Mei SH. Family-orientated rehabilitation in patients with congenital heart disease. Kinder- und Jugendarzt 2000;31:665–671.

31. Sport and European Union, European Community, Administrative Department, January 2000:4–5.

32. Ratzmann U, Schneider P, Richter H. Psychologis- che Untersuchung bei Familien, Kindern und Jugendlichen nach Operation angeborener Herzfehler (Fallotsche Tetralogie und Aoertenisth- musstenose). Kinderärztl Praxis 1991;59:107–110.

33. Graham TP, Driscoll DJ, Gersony WM, et al. Task Force 2: congenital heart disease. J Am Coll Cardiol 2005;45:1326–1333.

34. Mitchell JH, Maron BJ, Epstein SE. Sixteenth Bethesda Conference: Cardiovascular abnormali- ties in the athlete: Recommendations regarding eligibility for competition. J Am Coll Cardiol 1985;6:29–30.

35. Deutsche Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkran-kungen.

Empfehlungen zur Leitung von Kinderherzgruppen (KHG). Herz/Kreisl 2000;32:414–418.

36. Longmuir PE, Tremblay MS, Goode RC. Postopera- tive exercise training develops normal levels of physical activity in a group of children following cardiac surgery. Pediatr Cardiol 1990;11:126–130.

37. Fredriksen PM, Kahrs N, Blaasvaer S, et al. Effect of physical training in children and adolescents with congenital heart disease. Cardiol Young 2000;10:

107–114.

38. Bjarnason-Wehrens B, Dordel S. Motorische Förderung von Kindern mit angeborenen Herzfehlern. Sankt Augustin: Academia; 2001.

19. Bellinger DC, Wypij D, Kuban KC, et al. Develop- ment and neurological status of children at 4 years of age after heart surgery with hypothermic circu- latory arrest or low-flow cardiopulmonary bypass.

Circulation 1999;100:526–532.

20. Stieh H, Kramer HH, Harding P, et al. Gross and fine motor development is impaired in children with cyanotic congenital heart disease. Neuropediatrics 1998;30:77–82.

21. Dordel S, Bjarnason-Wehrens B, Lawrens W, et al.

Efficiency of psychomotor training of children with (partly-) corrected congenital heart disease. Z Sportmed 1999;50:41–46.

22. Unverdorben M, Singer H, Trägler M, et al.

Reduzierte koordinative Leistungs-fähigkeit – nicht nur ein medizinisches Problem? Herz/Kreisl 1997;

29:1881–1884.

23. Hassberg D, Döttling-Ulrich J. Psychologische Aspekte von Patienten mit angeborenen Her- zfehlern und ihren Familien. In: Apitz J, ed. Pädia- trische Kardiologie. Darmstadt: Steinkopff; 2001:

803–807.

24. Kunick I. Die psychosoziale Situation des herzoperierten Kindes und Jugendlichen. In:

Schmalz AA, Singer H, eds. Herzoperierte Kinder und Jugendliche. Ein Leitfaden zur Langzeit- betreuung in Klinik und Praxis. Stuttgart:

Wissenschaftlich Verlagsgesellschaft; 1995:99–

108.

25. Mussatto K, Tweddell J. Quality of life following surgery for congenital cardiac malformations in neonates and infants. Cardiol Young 2005;15(Suppl 1):174–178.

26. Lawoko S, Soares JJF. Distress and hoplessness among parents of children with congenital heart disease, parents of children with other diseases and parents of healthy children. J Psychosom Res 2002;52:193–208.

27. Calzolari A, Giordano U, Di Giacinto B, et al. Exer- cise and sports participation after surgery for con- genital heart disease: the European perspective. Ital Heart J 2001;2:736–739.