Enalapril does not enhance exercise capacity in patients after fontan procedure

Background: Angiotensin-converting enzyme inhibitors improve exercise capacity in adults with congestive heart failure by decreasing systemic vascular resistance and improving ventricular diastolic function. Patients who have undergone the Fontan procedure have decreased cardiac output, increased systemic vascular resistance, abnormal diastolic function, and decreased exercise capacity compared with normal people. Methods and Results: To test the hypothesis that afterload reduction therapy alters hemodynamic variables and augments exercise capacity in patients after a Fontan procedure, we compared the results of graded exercise with maximal effort from 18 subjects (14.5±6.2 years of age, 4 to 19 years after Fontan procedure) in a randomized, double-blind, placebo-controlled crossover trial using enalapril (0.2 to 0.3 mg · kg^-1 · d^-1, maximum 15 mg). Each treatment was administered for 10 weeks. Diastolic filling patterns at rest were assessed by Doppler determination of the systemic atrioventricular valve flow velocity at the conclusion of each therapy. No difference was detected in resting heart rate, blood pressure, or cardiac index. Diastolic filling patterns were also similar. Exercise duration was not different (6.4±2.6 [enalapril] versus 6.7±2.6 minutes [placebo]). The mean percent increase in cardiac index from rest to maximum exercise was slightly but significantly decreased in subjects after 10 weeks of enalapril therapy (102±34% [enalapril] versus 125±34% [placebo]; P<.02). At maximal exercise, cardiac index (3.5±0.9 [enalapril] versus 3.8±0.9 L · min^-1 · m² [placebo]), oxygen consumption (18.3±9 [enalapril] versus 20.5±7 mL · min^-1 · kg^{- 1} [placebo]), minute ventilation (57.5±17 [enalapril] versus 55.4±19 L/min [placebo]), and total work (247±181 [enalapril] versus 261±197 W [placebo]) were not different. Conclusions: We conclude that enalapril administration for 10 weeks does not alter abnormal systemic vascular resistance, resting cardiac index, diastolic function, or exercise capacity in patients who have undergone a Fontan procedure.