Improving preventive cardiology in congenital heart disease: lessons from the QUALIREHAB trial

Background Medical advances have reduced morbidity and mortality in congenital heart disease (CHD); however, maximum oxygen uptake (VO2max) and ventilatory anaerobic threshold (VAT), decline more rapidly in CHD patients compared to the general population, impairing cardiopulmonary fitness and health-related quality of life (HRQoL) (1,2). The QUALIREHAB randomized controlled trial showed positive effects of a hybrid cardiac rehabilitation program on physical health, mental health and HRQoL in youth with CHD (Amedro et al., Eur Heart J, 2024) (3). We analyzed parameters associated with the intervention’s magnitude. Methods A post-hoc analysis was conducted using data from e-Case Report Forms, medical records and interviews with pediatric cardiologists, specialist nurses, adapted physical activity educators and psychologists. Efficacy was defined as a 3.5 mL/kg/min increase in VO2max at 3 or 12 months a 4.3-point increase in HRQoL questionnaire. The parameters associated with poorer outcomes were evaluated using multivariate analysis. Results Data from 70 participants (intervention group) and 10 professionals were analyzed. Analyses found that the moderate intensity of exercise training (VAT interval training) could have been exceeded in most patients and a one-hour cycloergometer was too long. Many patients and professionals expressed a need for more playful sessions and less center-based reinforcement sessions (adherence: 88% for home-based and 77% for center-based). The intervention had a positive effect on mental health (-2.4 points in depression and -2.3 points in anxiety outcomes), but patients expressed the importance to involve their relatives. Parameters associated with lower efficacy included: cardiac surgery or catheterization for VO2max change at 3 months (AUC = 0.79), low VAT and female gender for VO2max change at 12 months (AUC = 0.83), and low VAT for HRQoL change at 12 months (AUC = 0.69). Conclusion QUALIREHAB showed positive results but could benefit from a more tailored rehabilitation approach to maximize intervention magnitude, particularly for female patients, with high-intensity, playful activities, home-based sessions and stronger mental health support.