Canadian Journal of Cardiology

Negative Impact of Obesity on Ventricular Size and Function and Exercise Performance in Children and Adolescents With Repaired Tetralogy of Fallot



      Up to 25% of children with congenital heart disease are obese, which may have negative physiologic consequences for patients with repaired tetralogy of Fallot (rTOF).


      Patients with rTOF who underwent cardiac magnetic resonance (CMR) imaging and cardiopulmonary exercise testing from 2007 to 2018 were reviewed. Complex rTOF patients were excluded. Obese patients (body mass index [BMI] ≥ 95th percentile) were compared with normal-weight patients (BMI < 85th percentile). CMR data were indexed to actual body surface area (aBSA), height, and BSA assuming ideal body weight (iBSA).


      We compared 32 obese patients matched with 64 normal-weight patients. Obese vs normal-weight patients had significantly lower right (RV; median 45% [interquartile range 42%-48%] vs 52% [47%-55%]; P < 0.0001) and left (LV; 52% [47%-56%] vs 56% [54%-60%]; P < 0.0001) ventricular ejection fractions (EFs). There were no statistically significant differences regarding aBSA-indexed volumes of the RV or LV at either end-diastole (EDV) or end-systole (ESV). However, when indexed to either height or iBSA, obese patients had significantly greater RVEDV and LVEDV, greater LV mass, and higher RV and LV stroke volumes. Obese patients had lower peak oxygen consumption and oxygen consumption at anaerobic threshold. These results did not change after adjusting for degree of pulmonary regurgitation.


      Obesity is associated with increased biventricular size, decreased biventricular EFs, and impaired exercise performance after rTOF. These data suggest a potential role for cardiac rehabilitation for weight management and to optimize fitness.



      Jusqu'à 25 % des enfants atteints de cardiopathie congénitale sont obèses, ce qui peut avoir des conséquences physiologiques néfastes pour les patients atteints de tétralogie de Fallot réparée (rTOF pour repaired tetralogy of Fallot).


      Les patients atteints de rTOF qui ont subi une résonance magnétique cardiaque (RMC) et des tests d'effort cardiopulmonaire de 2007 à 2018 ont été examinés. Les patients ayant subi une rTOF complexe ont été exclus. Les patients obèses (indice de masse corporelle [IMC] ≥ 95e percentile) ont été comparés aux patients de poids normal (IMC < 85e percentile). Les données de RMC ont été indexées en fonction de la surface corporelle avérée (aBSA pour actual body surface area), de la taille et de la surface corporelle en supposant un poids corporel idéal (iBSA pour ideal body surface area).


      Nous avons comparé 32 patients obèses à 64 patients de poids normal. Par rapport aux patients de poids normal, les patients obèses avaient des fractions d'éjection (FE) ventriculaire droite (VD) et gauche (VG) significativement plus faibles [FE ventriculaire droite (FEVD) 45 % (écart interquartile 42-48) contre 52 % (47-55), P < 0.0001; et FEVG 52 % (47-56) contre 56 % (54-60), P < 0.0001, respectivement]. Aucune différence statistiquement significative n'a été constatée concernant les volumes du VD ou du VG indexés sur l'aBSA, que ce soit en fin de diastole (VFD) ou en fin de systole. Cependant, lorsqu'ils étaient indexés sur la taille ou sur l'iBSA, les patients obèses présentaient des VFD-VD et VFD-VG significativement plus élevés, une masse du VG plus importante et des volumes systoliques du VD et du VG plus élevés. Les patients obèses présentaient une consommation maximale d'oxygène plus faible et une consommation d'oxygène au seuil anaérobie réduite. Ces résultats n'ont pas varié après ajustement en fonction du degré d’insuffisance pulmonaire.


      L'obésité est associée à une augmentation de la taille des deux ventricules, à une diminution de la FE des deux ventricules et à une diminution des performances à l'effort après un rTOF. Ces données suggèrent un rôle potentiel de la réadaptation cardiaque pour la gestion du poids et pour une optimisation de la condition physique.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Tamayo C.
        • Manlhiot C.
        • Patterson K.
        • Lalani S.
        • McCrindle B.W.
        Longitudinal evaluation of the prevalence of overweight/obesity in children with congenital heart disease.
        Can J Cardiol. 2015; 31: 117-123
        • Centers for Disease Control and Prevention
        Prevalence of childhood obesity in the United States, 2011-2014.
        (Available at:) (Accessed August 6, 2020)
        • Pinto N.M.
        • Marino B.S.
        • Wernovsky G.
        • et al.
        Obesity is a common comorbidity in children with congenital and acquired heart disease.
        Pediatrics. 2007; 120: e1157-e1164
        • Kuczmarski R.J.
        • Ogden C.L.
        • Grummer-Strawn L.M.
        • et al.
        CDC growth charts: United States.
        Adv Data. 2000; : 1-27
        • Centers for Disease Control and Prevention
        About child & teen BMI.
        (Available at:) (Accessed August 6, 2020)
        • Haycock G.B.
        • Schwartz G.J.
        • Wisotsky D.H.
        Geometric method for measuring body surface area: a height-weight formula validated in infants, children, and adults.
        J Pediatr. 1978; 93: 62-66
        • Phillips S.
        • Edlbeck A.
        • Kirby M.
        • Goday P.
        Ideal body weight in children.
        Nutr Clin Pract. 2007; 22: 240-245
        • Kang I.S.
        • Redington A.N.
        • Benson L.N.
        • et al.
        Differential regurgitation in branch pulmonary arteries after repair of tetralogy of Fallot: a phase-contrast cine magnetic resonance study.
        Circulation. 2003; 107: 2938-2943
        • Bergstralh E.J.
        • Kosanke J.L.
        Computerized matching of cases to controls. Technical report no. 56. April 1995. Rochester, MN: Mayo Foundation.
        (Available at:) (Accessed August 6, 2020)
        • Ogden C.L.
        • Carroll M.D.
        • Kit B.K.
        • Flegal K.M.
        Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010.
        JAMA. 2012; 307: 483-490
        • Stefan M.A.
        • Hopman W.M.
        • Smythe J.F.
        Effect of activity restriction owing to heart disease on obesity.
        Arch Pediatr Adolesc Med. 2005; 159: 477-481
        • Longmuir P.E.
        • Brothers J.A.
        • de Ferranti S.D.
        • et al.
        Promotion of physical activity for children and adults with congenital heart disease: a scientific statement from the American Heart Association.
        Circulation. 2013; 127: 2147-2159
        • Maskatia S.A.
        • Spinner J.A.
        • Nutting A.C.
        • et al.
        Impact of obesity on ventricular size and function in children, adolescents and adults with tetralogy of Fallot after initial repair.
        Am J Cardiol. 2013; 112: 594-598
        • Fogel M.A.
        • Pawlowski T.
        • Keller M.S.
        • et al.
        The cardiovascular effects of obesity on ventricular function and mass in patients after tetralogy of Fallot repair.
        J Pediatr. 2015; 167: 325-330.e1
        • Chahal H.
        • McClelland R.L.
        • Tandri H.
        • et al.
        Obesity and right ventricular structure and function: the MESA—Right Ventricle study.
        Chest. 2012; 141: 388-395
        • Otto M.E.
        • Belohlavek M.
        • Romero-Corral A.
        • et al.
        Comparison of cardiac structural and functional changes in obese otherwise healthy adults with versus without obstructive sleep apnea.
        Am J Cardiol. 2007; 99: 1298-1302
        • Sasson Z.
        • Rasooly Y.
        • Bhesania T.
        • Rasooly I.
        Insulin resistance is an important determinant of left ventricular mass in the obese.
        Circulation. 1993; 88: 1431-1436
        • Chiu H.C.
        • Kovacs A.
        • Blanton R.M.
        • et al.
        Transgenic expression of fatty acid transport protein 1 in the heart causes lipotoxic cardiomyopathy.
        Circ Res. 2005; 96: 225-233
        • Shibata R.
        • Ouchi N.
        • Ito M.
        • et al.
        Adiponectin-mediated modulation of hypertrophic signals in the heart.
        Nat Med. 2004; 10: 1384-1389
        • Tansey D.K.
        • Aly Z.
        • Sheppard M.N.
        Fat in the right ventricle of the normal heart.
        Histopathology. 2005; 46: 98-104
        • Hock J.
        • Hacker A.L.
        • Reiner B.
        • et al.
        Functional outcome in contemporary children and young adults with tetralogy of Fallot after repair.
        Arch Dis Child. 2019; 104: 129-133
        • Fredriksen P.M.
        • Therrien J.
        • Veldtman G.
        • et al.
        Aerobic capacity in adults with tetralogy of Fallot.
        Cardiol Young. 2002; 12: 554-559
        • Takken T.
        • Giardini A.
        • Reybrouck T.
        • et al.
        Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic and Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology.
        Eur J Prev Cardiol. 2012; 19: 1034-1065
        • Longmuir P.E.
        • McCrindle B.W.
        Physical activity restrictions for children after the Fontan operation: disagreement between parent, cardiologist, and medical record reports.
        Am Heart J. 2009; 157: 853-859
        • Duppen N.
        • Kapusta L.
        • de Rijke Y.B.
        • et al.
        The effect of exercise training on cardiac remodelling in children and young adults with corrected tetralogy of Fallot or Fontan circulation: a randomized controlled trial.
        Int J Cardiol. 2015; 179: 97-104
        • Stout K.K.
        • Daniels C.J.
        • Aboulhosn J.A.
        • et al.
        2018 AHA/ACC guideline for the management of adults with congenital heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        Circulation. 2019; 139: e637-e697
        • Maximova K.
        • Kuhle S.
        • Davidson Z.
        • Fung C.
        • Veugelers P.J.
        Cardiovascular risk-factor profiles of normal and overweight children and adolescents: insights from the Canadian Health Measures Survey.
        Can J Cardiol. 2013; 29: 976-982
        • Ghai A.
        • Silversides C.
        • Harris L.
        • Webb G.D.
        • Siu S.C.
        • Therrien J.
        Left ventricular dysfunction is a risk factor for sudden cardiac death in adults late after repair of tetralogy of Fallot.
        J Am Coll Cardiol. 2002; 40: 1675-1680
        • Geva T.
        • Sandweiss B.M.
        • Gauvreau K.
        • Lock J.E.
        • Powell A.J.
        Factors associated with impaired clinical status in long-term survivors of tetralogy of Fallot repair evaluated by magnetic resonance imaging.
        J Am Coll Cardiol. 2004; 43: 1068-1074

      Linked Article