Cardiovascular Rehabilitation Program in Pediatric and Young Adult Patients With Congenital Heart Disease: Single-Center 4-Year Experience
Year: 2026
Type: article
Abstract: Congenital heart defect (CHD) affect 9 in 1000 live births worldwide. Due to medical advancements, there are more adults than children with CHD in the United States. However, patients with CHD face a 36% lifetime risk of premature cardiovascular disease1,2 and lifestyle-related risks contributing to declining life expectancy.2 Physical activity is a key modifiable factor in cardiovascular disease prevention, but perceived exercise intolerance, clinician-imposed limits, and caregiver overprotection often restrict participation. Cardiovascular rehabilitation (CR), a supervised program combining exercise and education, is well-studied in adults but remains underdeveloped for pediatric patients with CHD. Despite proven safety and long-term benefits for children, few structured CR programs exist for children with CHD in the United States,3,4 with no established standard.5 Established in 2020, our pediatric CR program is a pioneering initiative for patients with CHD. This article outlines its key components, early results, and lessons learned over 4 years. METHODS This retrospective cohort study included pediatric and young adult patients with CHD who completed a CR program at a midwestern academic children’s hospital (2020–2024) with institutional review board approval and waiver of consent (Supplemental Digital Content 1, available at: https://links.lww.com/JCRP/A666). Inclusion criteria were CHD diagnosis, age >6 years, abnormal exercise capacity (<80% predicted peak oxygen uptake [V̇O₂peak]), and commitment to rehabilitation. Exclusion criteria were life-threatening arrhythmias, severe ventricular dysfunction (ejection fraction <40%), pulmonary hypertension (>40 mm Hg), inflammatory cardiac disease, hypotensive response to exercise, pregnancy, or physical disabilities. Demographic data collected included birthdate, gender, height, weight, body surface area, body mass index, heart rate, diagnosis, cardiac surgical intervention, and prior medical history. CARDIOVASCULAR REHABILITATION PROGRAM PROTOCOL Baseline Assessment Cardiopulmonary Exercise Stress Test Patients undergo pulmonary function testing and breath-by-breath metabolic measurements using the Ultima Cardio Gas exchange system. The Corival CPX Bicycle Stress Ergometer assesses exercise capacity, starting with a 2-minute warm-up at 0 watts, followed by a gradual workload increase (0.25 watts/kg). Patients pedal at 65 to 75 revolutions/min until exhaustion, reaching a respiratory exchange ratio >1.0 and target heart rate ≥(220 − age)*0.85 beats/min. Borg exertion scores and physiological parameters (V̇O₂, carbon dioxide production, ventilation, oxygen saturation, blood pressure, and heart rate) are continuously monitored. Muscle Endurance Test Patients perform push-ups, squats, crunches, and overhead presses to measure strength in chest, legs, shoulders, and core, with repetitions recorded for individualized baselines. Cardiovascular Rehabilitation Program The program includes 30 structured, 1-hour sessions over 15 weeks, held twice weekly with one-on-one training led by exercise physiologists. Patients commit to attending at least 75% of supervised sessions. The program integrates cardiovascular training, strength exercises, and education, with each session featuring a warm-up, 30 minutes of exercise, a cool-down, and periodic education (Supplemental Digital Content 2, available at: https://links.lww.com/JCRP/A667 and Supplemental Digital Content 3, available at: https://links.lww.com/JCRP/A668). Safety measures include oxygen, pulse oximetry, and an external defibrillator. Training Components Cardiovascular training includes treadmill walking, biking, and stair climbing to improve endurance. Sessions are personalized using cardiopulmonary exercise stress test (CPX) data, with target heart rates (60%–85% of heart rate reserve) set by the Karvonen formula. Intensity progresses from 60% in early weeks to >85% in high-intensity sessions, enhancing circulation, stamina, and heart health. Electrocardiogram monitoring and Borg scale assessments ensure safety. Muscle strength training follows a linear periodization model, using body weight, medicine balls, dumbbells, and bands to increase intensity while reducing volume. Education covers cardiovascular health, nutrition, stress management, and exercise techniques, with dietitian guidance and psychosocial support promoting mental well-being. Patients are encouraged to exercise at home twice weekly after 3 weeks, though adherence is not monitored. Midpoint and completion questionnaires help refine individual programs and guide future improvements. Completion Assessment Final assessments included CPX and muscle endurance tests, following the baseline protocol (Supplemental Digital Content 4, available at: https://links.lww.com/JCRP/A669 and Supplemental Digital Content 5, available at: https://links.lww.com/JCRP/A670). STATISTICAL ANALYSES Continuous variables were tested for normality and reported as mean ± SD or median (IQR). Paired Student t tests compared pre- and post-rehabilitation data, with P <.05 considered significant. SPSS v24 was used for statistical analysis. RESULTS A total of 16 pediatric and young adult patients with CHD (age 10.2–20.6 years) completed the CR program without any serious adverse cardiovascular events. Demographic, exercise capacity, and muscle endurance test data are shown in Table 1. Table 1 - Demographic, CPX, and Muscle Endurance Test Data in 16 Pediatric and Young Adult Patients With CHD Attending Cardiovascular Rehabilitation, 2020–2024a Baseline Assessment Completion Assessment P Value Demographic data Sex, male/female 12/4 Race/ethnicity 14 White/2 Hispanic Age, yr 15.5 ± 2.5 15.8 ± 2.5 .716 Weight, kg 75.9 ± 20.8 75.8 ± 19.9 .847 Height, cm 165.9 ± 12.0 166.1 ± 12.0 .424 Body surface area, m2 1.84 ± 0.31 1.85 ± 0.30 .703 BMI, kg/m2 27.3 ± 6.5 27.2 ± 6.1 .655 CPX data Exercise time, min 9.5 ± 1.9 10.9 ± 2.1 <.001 Absolute V̇O2peak, mL/min 1782.8 ± 541.2 2031.4 ± 669.5 .003 Relative V̇O2peak, mL/kg/min 24.0 ± 5.7 27.3 ± 8.0 .004 % predicted V̇O2 peak, % 61.3 ± 12.6 68.9 ± 14.9 .007 O2 pulse, mL/beats/min 10.8 ± 3.5 11.6 ± 3.7 .078 SpO2, % 92.5 ± 11.4 92.7 ± 11.6 .767 Maximum HR, beats/min 171.8 ± 22.7 177.6 ± 16.7 .227 Resting blood pressure, mm Hg 113.2 ± 14.7 111 ± 15.1 .389 Maximum blood pressure, mm Hg 148.4 ± 31.3 151.9 ± 25.5 .533 Muscle endurance test data Push-ups, n 10.9 ± 5.7 25.1 ± 9.8 <.001 Squats, n 21.7 ± 9.5 35 ± 9.2 <.001 Crunches, n 30.4 ± 8.9 57.1 ± 16.4 <.001 Overhead press, n 17.4 ± 5.1 38.6 ± 11.2 <.001 aData are presented as n or mean ± SD.Abbreviations: BMI, body mass index; CHD, congenital heart defect; CPX, cardiopulmonary exercise stress test; HR, heart rate; SpO2, oxygen saturation; V̇O2, oxygen uptake. Patient body mass index was tracked for up to 26 months, showing no significant changes. However, a declining trend was observed from baseline to short-term (5 ± 1.6 months) and long-term follow-up (15.8 ± 5.8 months) (27.3 vs 27 vs 26.3 kg/m2, P =.378 and.115, respectively). No significant changes were observed in resting and maximal exercise blood pressure, heart rate, oxygen pulse, or oxygen saturation. However, absolute V̇O2peak, relative V̇O2peak, percent predicted V̇O2peak, and exercise time significantly improved following the CR program. Muscle endurance also showed significant increases, demonstrated by higher repetition counts. DISCUSSION In the present study, we evaluated the safety and effectiveness of a 15-week CR program for pediatric and young adult patients with CHD. Participants completed 30 supervised sessions with no reported adverse cardiovascular events, supporting the safety of structured, personalized rehabilitation in this population.6,7 Significant improvements in V̇O₂peak confirmed the program’s effectiveness in enhancing cardiorespiratory fitness, a key predictor of long-term survival in patients with CHD. These findings align with Barranco study, which showed that CR programs improved inspiratory muscle strength in children with CHD without adverse events.8 Additionally, increased muscle resistance enhanced mobility, posture, and functional independence, benefiting daily activities and overall quality of life. A major strength of this study is its structured, one-on-one supervised, and individualized design, allowing close monitoring throughout rehabilitation. However, limitations include unmonitored home-based exercise, which may have contributed to improvements, and the quasi-experimental design with a small sample size, requiring remedial statistical analysis. Larger, randomized studies are needed to validate these findings. To improve accuracy, future research should incorporate wearable activity trackers to distinguish supervised versus independent exercise effects. Additionally, long-term outcomes, including morbidity, survival, psychosocial well-being, and cognitive function, should be further explored. A key future direction is the development of home-based CR programs9 or hybrid center- and home-based models, which could expand access while maintaining structured guidance and monitoring. In conclusion, this study provides foundational evidence that CR is safe and effective for children and young adults with CHD, improving V̇O₂peak, muscle strength, and overall health. As pediatric CR evolves, it has the potential to become an integral part of long-term CHD management, offering better outcomes and improved quality of life.
Institutions: University of Nebraska Medical Center, University of Virginia
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W7128360218
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