Lower Child Opportunity Index is Associated with Lower Exercise Capacity Post-Fontan Palliation

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Karolcik, Li Wang, Maya I. Ragavan, Arvind K. Hoskoppal, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4993172/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Dec, 2024 Read the published version in Pediatric Cardiology → Version 1 posted 7 You are reading this latest preprint version Abstract Background The Child Opportunity Index (COI) is a validated measurement that uses a composite index of 29 indicators of social determinants of health linked to the US Census. Patients post-Fontan palliation for single ventricle often have reduced exercise capacity compared to the general population. Our hypothesis is that COI levels are directly associated with exercise capacity and inversely with late outcomes. Methods A retrospective, single-center study was performed, including 99 patients post-Fontan procedure who had cardiac magnetic resonance imaging at our institution from January 2010 to July 2023, of which 78 had undergone an exercise test. Univariate analysis was performed with Pearson correlational testing and multivariable linear regression was then used to evaluate independent predictors of % predicted VO 2 . Results The mean age and sex were not different between the low and high COI groups (24.1 ± 8.5 y vs 22.5 ± 9.7 y; 34.5% vs 29.3% female). Patients with low COI had lower peak VO2 (25.7 vs 31.0 L/min/kg 2 , p = 0.002) and % predicted peak VO2 (61.9 vs 71.4%, p = 0.003). At follow up post-Fontan (mean of 17.9 ± 7.4 y) there was one mortality and two heart transplants. There were more interventions in the low COI group (1.5 vs 0.9 intervention occurrence/patient, p = 0.038). There was no difference in hospital admissions or significant comorbidities between COI groups. Conclusion Lower COI was associated with worse exercise capacity in Fontan patients and may negatively impact the need for late interventions. This highlights the need for efforts to provide community resources to promote equity in cardiac outcomes. Fontan Exercise capacity Social determinants of Health Child opportunity index Adult congenital heart disease Introduction Multiple studies have shown the association of singular measures of socioeconomic status and racial disparities with outcomes following congenital heart surgery and that these factors may limit equitable access to care. 1 – 6 Additionally, it is well-understood that social determinants of health (SDOH) impact resource utilization and that this association has multiple components which has made this relationship challenging to measure. 7 – 9 Many previous studies have looked into geographic information linked to public data sources using singular metrics of SDOH like household income, but this approach doesn’t account for the multifactorial relationship. 2 , 4 – 6 An emerging tool to address this problem of multiple influences on SDOH is the Child Opportunity Index (COI). 10 COI is a validated approach that uses a composite index of 29 indicators of SDOH linked to the US Census (Table 1 ) 11 . Developers of the COI took the aggregate of the nationally normed, overall index z-scores from the census tract level allowing it to be applied to the ZIP code level. These ZIP code level z-scores are categorized into very low, low, moderate, high, and very high categories. 12 , 13 Table 1 Breakdown of the 29 different indicators of SDOH that factor into the COI divided by the three main domains. Education Domain Early childhood education enrollment High school graduation rates Math proficiency (3rd grade) Reading proficiency (3rd grade) Advanced placement (AP) course participation Proximity to early childhood education centers Proximity to high-quality schools Health and Environment Domain Access to healthy food outlets Access to green spaces/parks Access to health care facilities Access to physical activity facilities Air pollution (PM2.5 concentration) Housing vacancy rate Lead exposure risk Proximity to toxic waste sites Walkability index Water contamination risk Social and Economic Domain Adult educational attainment Employment rate Median household income Neighborhood poverty rate Public assistance receipt rate Single-parent households Unemployment rate Violent crime rate Neighborhood homeownership rate Income inequality (Gini coefficient) Linguistic isolation Residential segregation To-date, a few relevant studies have shown COI to be independently associated with adverse outcomes in children after congenital heart surgery. 12 , 14 , 15 Within congenital heart disease (CHD), a growing population of patients have undergone Fontan palliation for complex univentricular heart malformations. For this select population many adverse outcomes are experienced post-operatively such as arrhythmia, liver cirrhosis, protein losing enteropathy, hospitalization for heart failure, heart transplantation with or without associated liver transplant exercise intolerance or death. 5 , 16 , 17 Exercise intolerance is a known prognostic factor in congenital heart disease and post-Fontan palliated patients have demonstrated worse exercise capacity compared to the general population. 18 – 20 Our investigation aimed to evaluate the association between post-Fontan patient COI and exercise capacity. Additionally, the relationship of known predictors of post-Fontan outcomes (systemic ventricle and systemic ventricle end diastolic volume) and long-term outcomes in Fontan palliated patients (number of hospitalizations, unplanned interventions, heart and/or liver transplantation, death) were investigated. Our central hypothesis was that COI z-scores are directly associated with exercise capacity and inversely related to adverse late outcomes in patients who have undergone the Fontan palliation. Methods Study Population: A retrospective, single-center study was conducted at the University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh of patients post-Fontan procedure who had cardiac magnetic resonance imaging (CMR) performed from January 2010 to July 2023. Data definitions and data dictionary of the Fontan outcomes registry by CMR (FORCE) was used. This data was part of the center’s FORCE database. A total of 3 patients living outside the United States were excluded for a total study population of 99 patients. Demographic, clinical, imaging, and CPET data were collected from patient charts. Research Electronic Data Capture (REDCap) was used to store the data for this study. This study was approved by the University of Pittsburgh Institutional Review Board and was conducted in compliance with the Health Insurance Portability and Accountability Act. The requirement for informed consent was waived due to the retrospective nature of the study. Child Opportunity Index: The Child Opportunity Index (COI) is a validated approach that uses a composite index of 29 neighborhood-level indicators of social determinants of health (SDOH) into a single composite measure linked to the US Census. Three primary domains are detailed with the COI: 1) educational; 2) health and environmental; and 3) social and economic. The educational domain represents access to early childhood education, quality of educational (primary and secondary schools), and educational resources for achievement. The health and environment domain encompasses access to healthy foods, areas for recreation, and exposure to toxic/high-risk features like industrial pollution. The social and economic domain portrays the level of employment opportunities and neighborhood economic resources like household income and home ownership. A COI level was derived based on US Census data from the publicly available COI 2.0 database 11 . Based on each patient’s zip code they were linked to unique U.S. Census data provided a scored COI level based on 29-neighborhood level indicators. All neighborhoods were ranked by COI z-score and categorized into 1 of 5 nationally normed, ranked group as follows: very low, low, moderate, high, and very high. 12,13 Based on the sample size of this study, the categorical groups were re-defined as low COI, which included the very low (n = 9), low (n = 15), and moderate groups (n = 34), or high COI, which included the high (n = 22) and very high groups (n = 19). Cardiopulmonary Exercise Testing: Patients underwent CPET by using a treadmill, following the Bruce protocol. Gas exchange was obtained at rest, during exercise, and during recovery to determine measures of oxygen uptake (VO 2 ). Since there is a known influenced of age, sex, and body weight on peak VO 2 , the percent of predicted peak VO 2 value (% predicted VO 2 ) was used due to the wide age range in this study. 21 Cardiac MRI: CMR studies were performed by using 1.5 Tesla scanners (GE Medical Systems, Milwaukee, WI, USA or Siemens AG, Munich, Germany). Briefly, ventricular assessment was performed via an electrocardiographically gated, balanced steady-state free precession (bSSFP) cine CMR in vertical and horizontal ventricular long-axis planes and a stack of slices in a ventricular short-axis plane encompassing the atrioventricular junction through the cardiac apex. Ventricular volumes and function were measured by manually tracing the endocardial and epicardial borders on each short-axis bSSFP cine slice at end-diastole (maximal volume) and end-systole (minimal volume). Analysis was performed by using commercially available software (Cvi-42, Circle Cardiovascular Imaging Inc., Calgary, AB, Canada). All CMR exams were reanalyzed by a single pediatric cardiologist with clinical experience interpreting CMR studies in the single ventricle population (TA). Clinical Outcomes: Long-term outcomes post-Fontan palliation were obtained via chart review. The primary long-term outcomes were mortality and heart transplantation. Secondarily, hospital admissions post-Fontan palliation (occurrences and total days admitted), intervention occurrences (defined by admission for intervention), New York Heart Association (NYHA) functional classification, presence of renal dysfunction, presence of Fontan-associated liver disease (FALD), and automatic implantable cardioverter defibrillator and/or pacemaker implantation were investigated. FALD was defined by the FORCE database as positive fibrosis test of significant elevated value or patients with a patient with a degree of liver fibrosis or stiffness higher than expect for a Fontan patient their age. Renal dysfunction was defined as a glomerular filtration rate < 60 mL/min/1.73 m 2 . Statistical Analysis: Categorical variables were reported as counts and percentages, while continuous variables were expressed as mean ± standard deviation. Comparison between two continuous variables was performed by using t-test, while Chi-square or Fisher’s Exact tests were used for comparing categorical variables. Correlational testing was performed by using the Pearson correlation test to evaluate the correlation with % predicted VO 2 . Missing data were omitted from the analyses and tables. Systemic ventricle was determined based on the documented predominate ventricle and were grouped as either systemic right ventricle (SRV), left systemic ventricle, or mixed. Based on low sample size of mixed systemic ventricle patients, mixed and left ventricle patients were grouped together. These values were selected based on previous studies suggesting significant association of SRV with worsen exercise capacity in post-Fontan patients. 22,23 Multivariable linear regression analysis was used to evaluate independent predictors of % predicted VO 2. Significant predictors of % predicted VO 2 from the univariate analysis were included in the multivariable analysis model. A p -value of < 0.05 was considered statistically significant. Statistical analysis was conducted by using SPSS (IBM SPSS Version 28, Armonk, NY). The corresponding author (BAK) had full access to all the data in the study and takes responsibility for its integrity and the data analysis. Results Our cohort consisted of 99 patients post-Fontan procedure who had cardiac magnetic resonance imaging (CMR) at our institution from January 2010 to July 2023. Of them 78 had undergone a CPET. There was no significant difference in baseline demographics or clinical characteristics as detailed in Table 2 between the two groups. There was no significant difference in race. In total, 1 patient had an atriopulmonary Fontan (1%), 70 patients (71%) had an extracardiac conduit Fontan, 27 (27%) had a lateral tunnel Fontan, and 1 (1%) was unknown. The most common diagnoses were hypoplastic left heart syndrome (n = 28, 28%), followed by tricuspid atresia (n = 17, 17%). Most patients had left ventricular dominance (n = 50, 51%) followed by right (n = 35, 35%), balanced or mixed (n = 13, 13%), and intermediate (n = 1, 1%). The average COI z-score was 0.008 ± 0.02. Of the population, 41 (41%) were in the low COI group with a mean overall COI z-score of -0.005 ± 0.01 and 58 (59 %) were in the high COI group with a mean overall COI z-score of 0.027 ± 0.01. COI and Exercise Capacitance: For the 78 that underwent a CPET, the mean age and sex were not different between the 2 COI groups (20.3 ± 8.6 y vs 21.2 ± 8.3 y; 31% vs 33% female). Pre-exercise heart rate (HR) and oxygen saturation by pulse oximetry (SpO 2 ) were not significantly different between the groups, which remained true at the ventilatory anaerobic threshold and peak exercise (Table 3). Patients with low COI had a lower peak VO 2 (25.7 ± 6.3 vs 31.0 ± 5.8 L/min/kg 2 , p = 0.002) and % predicted peak VO 2 (61.9 ± 13.7 vs 71.4 ± 9.3%, p = 0.003). Peak respiratory exchange ratio (RER) and ventilatory equivalent (V E /VCO 2 ) did not differ between the groups (Table 3). There was a significant positive correlation between overall COI z-scores and % of predicted peak VO 2 (r = 0.32, p = 0.013). When looking at the three main domains that contribute to COI and their association with % predicted peak VO 2 there was a correlation with the educational domain (r = 0.33, p = 0.011) and the social and economic domain (r = 0.33, p = 0.010), but not with the health and environment domain (r = 0.15, p = 0.244) (Table 4). Other Associations with Percent of Predicted VO 2 : When evaluating for other factors associated with a worse % predicted peak VO 2 , a SRV (62.4 ± 13.2% vs 68.4 ± 10.2% for systemic left ventricle or mixed ventricle, p = 0.047) and worse NYHA functional classification (66.5 ± 12.8% for class I vs 56.0 ± 14.4% for class II, p = 0.049) were identified. Higher SVEDVi by CMR (spearman’s rho = -0.25, p = 0.848) was not significantly associated with worse % predicted peak VO 2 . On multivariable analysis low COI level (9.2 ± 3.0, p = 0.004), SRV (4.3 ± 1.5, p = 0.005), and NYHA class II (9.4 ± 4.4, p = 0.039) were significantly associated with % predicted peak VO 2 (Table 5). Other Clinical Outcomes: At follow up post-Fontan (mean of 17.7 ± 7.3 y) there was one mortality (1%) and two heart transplants (2.0%). There were more intervention occurrences post-Fontan per patient in the low COI group (1.5 ± 1.5 vs 0.9 ± 0.9, p = 0.038) (Table 6). Supplemental Table 1 details the different interventions performed in the low and high COI groups. The most common interventions performed in the low and high COI groups were venous-venous or aorto-pulmonary collateral embolization (27 vs 13, respectively), Fontan fenestration device closure (13 vs 5, respectively), LPA stent implantation (8 vs 4, respectively), and Fontan conduit stent implantation (9 vs 1, respectively). There was no difference in total hospital admissions post-Fontan ( p = 0.988), total days admitted post-Fontan (p = 0.731), presence of renal dysfunction ( p = 0.376), presence of Fontan-associated liver disease (FALD) ( p = 0.314), or AICD/pacemaker implantation between COI groups ( p = 0.474) (Table 6). Discussion In this study, we evaluated the association of COI and outcomes in post-Fontan patients. It was demonstrated that lower COI was associated with worse exercise capacity in post-Fontan patients. In addition to COI, SRV and higher SVEDVi were identified to be associated with % predicted VO 2 in our cohort. On multivariable analysis, low COI is associated with lower percent of predicted VO2 by 9%. When looking at other clinical outcomes, there was higher number of intervention occurrences in the low COI group post-Fontan. Although the association of outcomes in CHD surgery with COI has previously been investigated, to our knowledge these findings post-Fontan have not been described to-date. 12,14,15 Sengupta et al. looked at the association of COI with CHD post-surgical outcomes at a large quaternary center and Duong et al. similarly looked at CHD post-surgical outcomes across 47 centers, which both showed COI not to be associated with surgical mortality in fully adjusted models but both found post-discharge survival of the lowest COI category to be significant decreased. 12,14 These findings were speculated to be observed as neighborhood effects that are more likely to be relevant out of the hospital when CHD patients are living at home and exposed to many of the factors that we discussed make up the domains of the COI. Exercise Capacity and COI: This study presents a significant relationship of lower COI with worse exercise capacity post-Fontan. It is known that better exercise capacity is associated with improved survival in patients that have undergone Fontan palliation. 24 Post Fontan, higher peak VO 2 has previously been shown to be associated with lower age, vitamin D sufficiency, absence of obesity, lower hemoglobin, and a healthier hepatic profile. 25 In our cohort, lower peak VO 2 and % predicted peak VO 2 were associated with low COI. When looking at the individual components within the COI, there were positive correlations with the educational domain and the social and economic domains, but not with the health and environmental domain. This suggests that individuals with a lower COI may have educational and socioeconomic inequities that potentially lead to lower exercise capacity. Numerous studies have previously demonstrated a significant positive association of educational achievement with exercise in pre-school, school-aged, adolescent, and adult individuals. 26-30 Likewise, physical inactivity has been previously shown to be associated with socioeconomically disadvantaged communities. 31-33 These findings most likely demonstrate importance of addressing educational and socioeconomic inequities within our post-Fontan population to improve exercise capacity and outcomes. It was surprising to see that the environmental domain was not significantly associated with predicted peak VO 2 in our post-Fontan cohort since neighborhood built characteristics like sidewalks, walkability, parks/recreational areas, and residential density have been found to impact physical activity in previous studies. 34-36 Other Associations with Percent of Predicted VO 2 : When comparing additional variables that are known to predict a worse % predicted peak VO 2 within our post-Fontan cohort, SRV was found to be associated, which was consistent with previous finding demonstrated by Tran et al. where characteristics of post-Fontan patients with higher physical performance were found to either have a left ventricle or be biventricular for their dominant ventricle. 23 CMR-derived characteristics such as SVEDVi have been found to be elevated in post-Fontan patients with worse exercise capacity, which was what was anticipated but not reproduced with our findings in our cohort. 37,38 NHYA functional classification has been previously well demonstrated to be an independent predictor of exercise capacity and specifically % predicted VO 2 . 39,40 This additional has been reproduced in the adult congenital heart disease population, so it was not surprising it was reproduced in this cohort. 41,42 When performing a multivariable analysis with COI adjusting for SRV and NHYA class II, all were significantly associated with % predicted VO 2 (Table 5). Other Clinical Outcomes: In this cohort of 99 patients post-Fontan procedure, there was only one mortality and two orthotopic heart transplants which reflects a relatively healthy group. There was no difference between the low and high COI groups post-Fontan in FALD or presence of renal dysfunction. Interestingly, there was no difference in total admissions or total days admitted post-Fontan. This differs from the findings Mayourin et al showed that lower COI was associated with a longer length of stay for patients that underwent cardiac surgery. 15 However, this study did not specifically look at the post-Fontan population as described in our study. The authors speculate that the lack of difference may reflect the nature of our surgical center. These findings likely are reflective of the mean time post-Fontan procedure of 17.7 ± 7.3 year in this study population. Notably, there were more intervention occurrences post-Fontan per patient in the low COI group. This would suggest higher disease burden and morbidity in the low COI group relative to the high COI group. This may also be related to low exercise capacity as many patients may be sent for interventions due to lower exercise capacity on an exercise test. Given this finding, this highlights the importance of identifying patients within that low COI group knowing that they are at increased risk of needing more interventions and worse exercise capacity. This stresses the importance of addressing physical activity at multiple levels as a mechanism of prevention. Individually, counseling on the importance of exercising as well as identifying any psychostressors (financial insecurity, social experiences, support network) that may limit the ability to exercise. At the community level, these findings highlight the importance of these patients’ environments, which includes access to green spaces, low-cost physical activity facilities, and safe walkable areas to encourage physical activity. Likewise, this further supports the high diagnostic value of exercise testing in this patient population, which has been described as an important tool for prognostic value for post-Fontan patients. 18-20 Initiatives to recognize these barriers and improve access to exercise in neighborhoods of lower COI may lead to improved exercise capacity and less intervention and thus overall better outcomes. Limitations: This was a retrospective study with limitations to bias secondary to missing data and patients loss to follow-up. Due to the sample size of this single-center study, there is a risk for type I error. The generalizability of our findings may also be limited given the predominantly white racial profile of the study population, which reflects the greater Pittsburgh population that serves as the main referral network for our quaternary center. Additionally, all international patients were excluded as foreign-based COI measures have not yet been developed. There are some inherent limitations of the COI, which is representative of each individual’s zip code at the time of this study’s data collection and cannot account for if a patient previously lived in a different zip code. Similarly, COI factors in the 29 different SDOH factors listed in Table 1, but the data for activity/exercise time, diet, other specific experience-based data is not readily available. Conclusion Lower COI was found to be associated with worse exercise capacity in post-Fontan patients and may negatively impact the need for late interventions. Influences of SDOH are multifactorial and the COI allows for multiple neighborhood factors are be accounted for with any patient with a US-based zip code. These results support the importance of SDOH in the Fontan population and need for increased efforts to provide community resources to address disparities to promote equity in cardiac outcomes. The impact of health-related social needs on children are well documented and screening for these factors will continue to be importance in promoting health equity. 43 Specifically, training providers for these post-Fontan patients to identify health-related social needs so they can be addressed and at the organizational level to support programs that promote resources that support at-risk individuals. The COI can be a potential tool utilized for predicting and addressing disparities in health outcomes within the post-Fontan population by early identification of at-risk individuals. Declarations Acknowledgements : None Sources of Funding : This project was supported by the division of pediatric cardiology, department of pediatrics, university of Pittsburgh school of medicine, UPMC children's hospital of Pittsburgh. The project described was supported by the National Institutes of Health through Grant Number UL1 TR001857, KL2 TR001856, and/or TL1 TR001858. Statements and Declarations: None Author Contribution B.K. helped with idea conception, study design, data acquisition, interpretation of the data, critical review of literature, writing of the manuscript, and manuscript revision; L.W. helped with study design, interpretation of the data, statistical analysis, and manuscript revision; MR helped with study design, critical review of literature, writing of the manuscript, and manuscript revision; A.K., A.S., G.A., J.K., and M.V. helped with idea conception, study design, critical review of literature, writing of the manuscript, and manuscript revision; T.A. helped with idea conception, study design, interpretation of the data, critical review of literature, writing of the manuscript, and manuscript revision; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. 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JACC Cardiovasc Imaging 13:2686–2687 Critser PJ, Truong V, Powell AW et al (2021) Cardiac magnetic resonance derived atrial function in patients with a Fontan circulation. Int J Cardiovasc Imaging 37:275–284 Williams SG, Ng LL, O'Brien RJ et al (2005) Complementary roles of simple variables, NYHA and N-BNP, in indicating aerobic capacity and severity of heart failure. Int J Cardiol 102:279–286 Zimerman A, da Silveira AD, Borges MS et al (2023) Functional assessment based on cardiopulmonary exercise testing in mild heart failure: A multicentre study. ESC Heart Fail 10:1689–1697 Bredy C, Ministeri M, Kempny A et al (2018) New York Heart Association (NYHA) classification in adults with congenital heart disease: relation to objective measures of exercise and outcome. Eur Heart J Qual Care Clin Outcomes 4:51–58 Das BB, Young ML, Niu J, Mendoza LE, Chan KC, Roth T (2019) Relation Between New York Heart Association Functional Class and Objective Measures of Cardiopulmonary Exercise in Adults With Congenital Heart Disease. Am J Cardiol 123:1868–1873 Ragavan MI, Garg A, Raphael JL (2023) Creating Healing-Centered Health Systems by Reimagining Social Needs Screening and Supports. JAMA Pediatr 177:555–556 Tables Table 1. Breakdown of the 29 different indicators of SDOH that factor into the COI divided by the three main domains. Education Domain Early childhood education enrollment High school graduation rates Math proficiency (3rd grade) Reading proficiency (3rd grade) Advanced placement (AP) course participation Proximity to early childhood education centers Proximity to high-quality schools Health and Environment Domain Access to healthy food outlets Access to green spaces/parks Access to health care facilities Access to physical activity facilities Air pollution (PM2.5 concentration) Housing vacancy rate Lead exposure risk Proximity to toxic waste sites Walkability index Water contamination risk Social and Economic Domain Adult educational attainment Employment rate Median household income Neighborhood poverty rate Public assistance receipt rate Single-parent households Unemployment rate Violent crime rate Neighborhood homeownership rate Income inequality (Gini coefficient) Linguistic isolation Residential segregation COI, childhood opportunity index; SDOH, social determinant of health Table 2. Baseline demographics and clinical characteristics of the low COI and high COI groups. Low COI High COI P value Number (n) 58 41 Mean age (y) 24.1 ± 8.5 22.5 ± 9.7 0.38 Sex Male 63.8% (37) 70.7% (29) 0.80 Female 34.5% (20) 29.3% (12) Other 1.7% (1) 0 Race White 93.0% (53) 97.6% (40) 0.39 Black 7.0% (4) 2.4% (1) Ethnicity Not Hispanic or Latino 86.2% (50) 90.2% (37) 0.86 Hispanic or Latino 1.7% (1) 0 Unspecified 12.1% (7) 9.8% (4) Cardiac diagnosis Other 36.2% (21) 22.0% (9) 0.51 HLH 25.9% (15) 31.7% (13) Tricuspid atresia 15.5% (9) 19.5% (8) DILV 8.6% (5) 7.3% (3) PA/IVS 5.2% (3) 7.3% (3) AVSD 3.4% (2) 4.9% (2) DORV 3.4% (2) 0 DIRV 0 4.9% (2) Mitral atresia 0 2.4% (1) Ebstein’s anomaly 1.7% (1) 0 Systemic ventricle morphology Right 34.5% (20) 36.6% (15) 0.85 Left 48.3% (28) 53.7% (22) Balanced or Mixed 15.5% (9) 9.8% (4) Indeterminate/Unknown 1.7% (1) 0 Data are reported as % (n) or as mean ± standard deviation. Missing data values were omitted from the table. AVSD, atrioventricular septal defect; COI, childhood opportunity index; DILV, double inlet left ventricle; DIRV, double inlet right ventricle; DORV, double outlet right ventricle; HLH, hypoplastic left heart variant; PA/IVS, pulmonary atresia with intact ventricular septum. Table 3. CPET characteristics for the low and high COI groups at pre-exercise, ventilatory anaerobic threshold, and peak. CPET Variables Low COI High COI P value Number (n) 51 27 Age at CPET (y) 20.3 ± 8.6 (51) 21.2 ± 8.3 (27) 0.68 Female sex 30.8% (51) 33.3% (27) 0.13 Pre-exercise HR (beats/min) 88.3 ± 19.0 (49) 87.4 ± 11.9 (26) 0.83 BMI 24.7 ± 5.3 (49) 24.3 ± 4.9 (26) 0.71 Pre-exercise SpO 2 (%) 92.9 ± 4.0 (46) 92.8 ± 4.6 (22) 0.93 HR at VAT (beats/min) 131.0 ± 26.8 (34) 126.2 ± 21.5 (22) 0.48 VO 2 at VAT (L/min/m 2 ) 18.0 ± 5.2 (37) 19.0 ± 4.7 (21) 0.47 Peak O 2 pulse (mL/beat) 10.1 ± 3.0 (24) 12.2 ± 3.6 (12) 0.08 Peak HR (beats/min) 165.3 ± 27.1 (49) 165.7 ± 23.5 (26) 0.95 Peak RER 1.2 ± 0.1 (42) 1.1 ± 0.1 (22) 0.07 Peak SpO 2 (%) 89.0 ± 5.3 (48) 90.6 ± 6.0 (23) 0.27 Peak VO 2 (ml/min/m 2 ) 25.7 ± 6.3 (42) 31.0 ± 5.8 (20) 0.002 % predicted peak VO 2 (%) 61.9 ± 13.7 (42) 71.4 ± 9.3 (20) 0.003 V E /VCO 2 37.9 ± 6.4 (42) 37.2 ± 6.4 (22) 0.69 Data are reported as % (n) or as mean ± standard deviation. Missing data values were omitted from the table. % predicted VO 2 , percent of predicted peak VO 2 ; BMI, body mass index; COI, childhood opportunity index; CPET, cardiopulmonary exercise test; HR, heart rate; O 2 pulse, oxygen pulse; RER, respiratory exchange ratio; SpO 2 , oxygen saturation by pulse oximetry; VAT, ventilatory anaerobic threshold; V E /VCO 2 , ventilatory equivalent; VO 2 , oxygen uptake. Table 4. Univariate components of the COI association with percent of predicted peak VO 2 . COI component Correlation coefficient (r) P-value Educational domain z-score, nationally normed 0.33 0.01 Health and environment domain z-score, nationally normed 0.15 0.24 Social and economic domain z-score, nationally normed 0.33 0.01 COI, childhood opportunity index; VO 2 , oxygen uptake. Table 5. Multivariable predictors of % predicted peak VO 2 . COI component Estimate ± Standard error P-value COI group (low) 8.7 ± 3.1 0.004 SRV morphology 7.9 ± 3.1 0.005 NYHA class II 9.4 ± 4.4 0.04 Data are reported as % (n) or as mean ± standard deviation. % predicted VO 2 , percent of predicted peak VO 2 ; COI, childhood opportunity index; NYHA, New York Heart Association; SRV, systemic right ventricle; SVEDVi, index systemic ventricle end-diastolic volume; VO 2 , oxygen uptake. Table 6. Long-term post-Fontan procedure outcomes between the low and high COI groups. Type of Outcome Low COI High COI P value Number (n) 58 41 Mortality 1.7% 0 0.40 Orthotopic heart transplantation performed 1.0% 1.0% 0.80 Intervention occurrence (mean ± SD) 1.5 ± 1.5 0.9 ± 0.9 0.04 Total admissions post-Fontan 1 (0, 2) 1 (0, 2) 0.99 Total days admitted post-Fontan (days) 2 (0, 8.8) 2 (0, 4.5) 0.73 Presence of renal dysfunction 1.7% 4.9% 0.38 Presence of FALD 67.2% 58.5% 0.31 AICD/Pacemaker Implantation 8.6% 4.9% 0.47 Data are reported as % (n), mean ± standard deviation, or median (1 st quartile, 3 rd quartile). Missing data values were omitted from the table. AICD, automatic implantable cardioverter defibrillator; FALD, Fontan-associated liver disease; SD, standard deviation). Additional Declarations No competing interests reported. Supplementary Files COIFontanSupplementalTable1.docx Cite Share Download PDF Status: Published Journal Publication published 30 Dec, 2024 Read the published version in Pediatric Cardiology → Version 1 posted Editorial decision: Revision requested 01 Oct, 2024 Reviews received at journal 29 Sep, 2024 Reviewers agreed at journal 25 Sep, 2024 Reviewers invited by journal 11 Sep, 2024 Editor assigned by journal 29 Aug, 2024 Submission checks completed at journal 29 Aug, 2024 First submitted to journal 28 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4993172","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":358932099,"identity":"7fd4b692-96b2-413c-ac41-79c51adec3c6","order_by":0,"name":"Brock A. Karolcik","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYBACCRDxgEHCwICB+QBULIEILQlgLWwwpcRpYQBq4TEgTotk+9mHDxJqLIzN2c98ky7MsWPgZ88xwKtFmifd2CDhmISZZU/uNumZ25IZJHve4Ncix5DGJpHYIGFjcACohXfbAQaDGwRskeN/BtVy/s0zsBZ7QlqkJSC2mAENZ4PYIkFAi+SMZ8wgvxhbznhmbA30C4/EmWcFeLVInE9jfPChps5wO3/yw9uF2+zk+NuTN+DVggKYgZiHeOUwLaNgFIyCUTAKMAAASrI/UGVDb+MAAAAASUVORK5CYII=","orcid":"","institution":"University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh","correspondingAuthor":true,"prefix":"","firstName":"Brock","middleName":"A.","lastName":"Karolcik","suffix":""},{"id":358932104,"identity":"4e3495b7-23ac-426e-943e-9e48d23abb13","order_by":1,"name":"Li Wang","email":"","orcid":"","institution":"University of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Wang","suffix":""},{"id":358932107,"identity":"fde4bb87-2e1e-4901-acbd-efcd19e30c28","order_by":2,"name":"Maya I. Ragavan","email":"","orcid":"","institution":"University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Maya","middleName":"I.","lastName":"Ragavan","suffix":""},{"id":358932109,"identity":"1c46e2dc-9a2e-47ea-846b-af4e10bfbc7c","order_by":3,"name":"Arvind K. Hoskoppal","email":"","orcid":"","institution":"University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Arvind","middleName":"K.","lastName":"Hoskoppal","suffix":""},{"id":358932110,"identity":"2d933764-8b18-44bc-9bd0-e5e8838d41b9","order_by":4,"name":"Anita P. Saraf","email":"","orcid":"","institution":"University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Anita","middleName":"P.","lastName":"Saraf","suffix":""},{"id":358932111,"identity":"e386a412-2046-4853-9a14-fa839447e9b4","order_by":5,"name":"Gaurav Arora","email":"","orcid":"","institution":"University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Gaurav","middleName":"","lastName":"Arora","suffix":""},{"id":358932113,"identity":"156e7e8c-0b7d-43c1-b294-433a299b8bff","order_by":6,"name":"Jacqueline Kreutzer","email":"","orcid":"","institution":"University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Jacqueline","middleName":"","lastName":"Kreutzer","suffix":""},{"id":358932117,"identity":"da6437d0-b434-48a2-9ccb-3ffa32e93c48","order_by":7,"name":"Melita L. Viegas","email":"","orcid":"","institution":"University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Melita","middleName":"L.","lastName":"Viegas","suffix":""},{"id":358932118,"identity":"339abaef-0aa8-4f9d-b06a-eb54b7877ca0","order_by":8,"name":"Tarek Alsaied","email":"","orcid":"","institution":"University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Tarek","middleName":"","lastName":"Alsaied","suffix":""}],"badges":[],"createdAt":"2024-08-28 19:13:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4993172/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4993172/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00246-024-03752-x","type":"published","date":"2024-12-30T15:57:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73093172,"identity":"be503efd-3ed5-4422-8db5-2dd27a78f1a5","added_by":"auto","created_at":"2025-01-06 16:09:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":762591,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4993172/v1/b5a464c1-28cf-447d-9d26-27d32a3c38e9.pdf"},{"id":65427804,"identity":"dbcb2547-2952-4746-9240-635cda9ffecd","added_by":"auto","created_at":"2024-09-27 09:37:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21070,"visible":true,"origin":"","legend":"","description":"","filename":"COIFontanSupplementalTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4993172/v1/a31ee8617678277609fc2241.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lower Child Opportunity Index is Associated with Lower Exercise Capacity Post-Fontan Palliation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMultiple studies have shown the association of singular measures of socioeconomic status and racial disparities with outcomes following congenital heart surgery and that these factors may limit equitable access to care.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Additionally, it is well-understood that social determinants of health (SDOH) impact resource utilization and that this association has multiple components which has made this relationship challenging to measure.\u003csup\u003e\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Many previous studies have looked into geographic information linked to public data sources using singular metrics of SDOH like household income, but this approach doesn\u0026rsquo;t account for the multifactorial relationship.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e An emerging tool to address this problem of multiple influences on SDOH is the Child Opportunity Index (COI).\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e COI is a validated approach that uses a composite index of 29 indicators of SDOH linked to the US Census (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Developers of the COI took the aggregate of the nationally normed, overall index z-scores from the census tract level allowing it to be applied to the ZIP code level. These ZIP code level z-scores are categorized into very low, low, moderate, high, and very high categories.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBreakdown of the 29 different indicators of SDOH that factor into the COI divided by the three main domains.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation Domain\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly childhood education enrollment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school graduation rates\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMath proficiency (3rd grade)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReading proficiency (3rd grade)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvanced placement (AP) course participation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximity to early childhood education centers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximity to high-quality schools\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth and Environment Domain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess to healthy food outlets\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess to green spaces/parks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess to health care facilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess to physical activity facilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAir pollution (PM2.5 concentration)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousing vacancy rate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLead exposure risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximity to toxic waste sites\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWalkability index\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWater contamination risk\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial and Economic Domain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult educational attainment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment rate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian household income\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeighborhood poverty rate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic assistance receipt rate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle-parent households\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployment rate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eViolent crime rate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeighborhood homeownership rate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome inequality (Gini coefficient)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLinguistic isolation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidential segregation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo-date, a few relevant studies have shown COI to be independently associated with adverse outcomes in children after congenital heart surgery.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Within congenital heart disease (CHD), a growing population of patients have undergone Fontan palliation for complex univentricular heart malformations. For this select population many adverse outcomes are experienced post-operatively such as arrhythmia, liver cirrhosis, protein losing enteropathy, hospitalization for heart failure, heart transplantation with or without associated liver transplant exercise intolerance or death.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Exercise intolerance is a known prognostic factor in congenital heart disease and post-Fontan palliated patients have demonstrated worse exercise capacity compared to the general population.\u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur investigation aimed to evaluate the association between post-Fontan patient COI and exercise capacity. Additionally, the relationship of known predictors of post-Fontan outcomes (systemic ventricle and systemic ventricle end diastolic volume) and long-term outcomes in Fontan palliated patients (number of hospitalizations, unplanned interventions, heart and/or liver transplantation, death) were investigated.\u003c/p\u003e \u003cp\u003eOur central hypothesis was that COI z-scores are directly associated with exercise capacity and inversely related to adverse late outcomes in patients who have undergone the Fontan palliation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Population:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective, single-center study was conducted at the University of Pittsburgh Medical Center, Children\u0026rsquo;s Hospital of Pittsburgh of patients post-Fontan procedure who had cardiac magnetic resonance imaging (CMR) performed from January 2010 to July 2023. Data definitions and data dictionary of the Fontan outcomes registry by CMR (FORCE) was used. This data was part of the center\u0026rsquo;s FORCE database. A total of 3 patients living outside the United States were excluded for a total study population of 99 patients. Demographic, clinical, imaging, and CPET data were collected from patient charts. Research Electronic Data Capture (REDCap) was used to store the data for this study. This study was approved by the University of Pittsburgh Institutional Review Board and was conducted in compliance with the Health Insurance Portability and Accountability Act. The requirement for informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eChild Opportunity Index:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Child Opportunity Index (COI) is a validated approach that uses a composite index of 29 neighborhood-level indicators of social determinants of health (SDOH) into a single composite measure linked to the US Census. Three primary domains are detailed with the COI: 1) educational; 2) health and environmental; and 3) social and economic. The educational domain represents access to early childhood education, quality of educational (primary and secondary schools), and educational resources for achievement. The health and environment domain encompasses access to healthy foods, areas for recreation, and exposure to toxic/high-risk features like industrial pollution. The social and economic domain portrays the level of employment opportunities and neighborhood economic resources like household income and home ownership.\u003c/p\u003e\n\u003cp\u003eA COI level was derived based on US Census data from the publicly available COI 2.0 database\u003csup\u003e11\u003c/sup\u003e. Based on each patient\u0026rsquo;s zip code they were linked to unique U.S. Census data provided a scored COI level based on 29-neighborhood level indicators. All neighborhoods were ranked by COI z-score and categorized into 1 of 5 nationally normed, ranked group as follows: very low, low, moderate, high, and very high.\u003csup\u003e12,13\u003c/sup\u003e Based on the sample size of this study, the categorical groups were re-defined as low COI, which included the very low (n = 9), low (n = 15), and moderate groups (n = 34), or high COI, which included the high (n = 22) and very high groups (n = 19).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCardiopulmonary Exercise Testing:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients underwent CPET by using a treadmill, following the Bruce protocol. Gas exchange was obtained at rest, during exercise, and during recovery to determine measures of oxygen uptake (VO\u003csub\u003e2\u003c/sub\u003e). Since there is a known influenced of age, sex, and body weight on peak VO\u003csub\u003e2\u003c/sub\u003e, the percent of predicted peak VO\u003csub\u003e2\u003c/sub\u003e value (% predicted VO\u003csub\u003e2\u003c/sub\u003e) was used due to the wide age range in this study.\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCardiac MRI:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCMR studies were performed by using 1.5 Tesla scanners (GE Medical Systems, Milwaukee, WI, USA or Siemens AG, Munich, Germany). Briefly, ventricular assessment was performed via an electrocardiographically gated, balanced steady-state free precession (bSSFP) cine CMR in vertical and horizontal ventricular long-axis planes and a stack of slices in a ventricular short-axis plane encompassing the atrioventricular junction through the cardiac apex. Ventricular volumes and function were measured by manually tracing the endocardial and epicardial borders on each short-axis bSSFP cine slice at end-diastole (maximal volume) and end-systole (minimal volume). Analysis was performed by using commercially available software (Cvi-42, Circle Cardiovascular Imaging Inc., Calgary, AB, Canada). All CMR exams were reanalyzed by a single pediatric cardiologist with clinical experience interpreting CMR studies in the single ventricle population (TA).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eClinical Outcomes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLong-term outcomes post-Fontan palliation were obtained via chart review. The primary long-term outcomes were mortality and heart transplantation. Secondarily, hospital admissions post-Fontan palliation (occurrences and total days admitted), intervention occurrences (defined by admission for intervention), New York Heart Association (NYHA) functional classification, presence of renal dysfunction, presence of Fontan-associated liver disease (FALD), and automatic implantable cardioverter defibrillator and/or pacemaker implantation were investigated. FALD was defined by the FORCE database as positive fibrosis test of significant elevated value or patients with a patient with a degree of liver fibrosis or stiffness higher than expect for a Fontan patient their age. Renal dysfunction was defined as a glomerular filtration rate \u0026lt; 60 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCategorical variables were reported as counts and percentages, while continuous variables were expressed as mean \u0026plusmn; standard deviation. Comparison between two continuous variables was performed by using t-test, while Chi-square or Fisher\u0026rsquo;s Exact tests were used for comparing categorical variables. Correlational testing was performed by using the Pearson correlation test to evaluate the correlation with % predicted VO\u003csub\u003e2\u003c/sub\u003e. Missing data were omitted from the analyses and tables. Systemic ventricle was determined based on the documented predominate ventricle and were grouped as either systemic right ventricle (SRV), left systemic ventricle, or mixed. Based on low sample size of mixed systemic ventricle patients, mixed and left ventricle patients were grouped together. These values were selected based on previous studies suggesting significant association of SRV with worsen exercise capacity in post-Fontan patients.\u003csup\u003e22,23\u003c/sup\u003eMultivariable linear regression analysis was used to evaluate independent predictors of % predicted VO\u003csub\u003e2.\u003c/sub\u003e Significant predictors of % predicted VO\u003csub\u003e2\u003c/sub\u003e from the univariate analysis were included in the multivariable analysis model. A \u003cem\u003ep\u003c/em\u003e-value of \u0026lt; 0.05 was considered statistically significant. Statistical analysis was conducted by using SPSS (IBM SPSS Version 28, Armonk, NY). The corresponding author (BAK) had full access to all the data in the study and takes responsibility for its integrity and the data analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur cohort consisted of 99 patients post-Fontan procedure who had cardiac magnetic resonance imaging (CMR) at our institution from January 2010 to July 2023. Of them 78 had undergone a CPET. There was no significant difference in baseline demographics or clinical characteristics as detailed in Table 2 between the two groups. There was no significant difference in race. In total, 1 patient had an atriopulmonary Fontan (1%), 70 patients (71%) had an extracardiac conduit Fontan, 27 (27%) had a lateral tunnel Fontan, and 1 (1%) was unknown. The most common diagnoses were hypoplastic left heart syndrome (n = 28, 28%), followed by tricuspid atresia (n = 17, 17%). Most patients had left ventricular dominance (n = 50, 51%) followed by right (n = 35, 35%), balanced or mixed (n = 13, 13%), and intermediate (n = 1, 1%). \u003c/p\u003e\n\u003cp\u003eThe average COI z-score was 0.008 \u0026plusmn; 0.02. Of the population, 41 (41%) were in the low COI group with a mean overall COI z-score of -0.005 \u0026plusmn; 0.01 and 58 (59 %) were in the high COI group with a mean overall COI z-score of 0.027 \u0026plusmn; 0.01. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOI and Exercise Capacitance: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the 78 that underwent a CPET, the mean age and sex were not different between the 2 COI groups (20.3 \u0026plusmn; 8.6 y vs 21.2 \u0026plusmn; 8.3 y; 31% vs 33% female). Pre-exercise heart rate (HR) and oxygen saturation by pulse oximetry (SpO\u003csub\u003e2\u003c/sub\u003e) were not significantly different between the groups, which remained true at the ventilatory anaerobic threshold and peak exercise (Table 3). \u003c/p\u003e\n\u003cp\u003ePatients with low COI had a lower peak VO\u003csub\u003e2\u003c/sub\u003e (25.7 \u0026plusmn; 6.3 vs 31.0 \u0026plusmn; 5.8 L/min/kg\u003csup\u003e2\u003c/sup\u003e, \u003cem\u003ep\u003c/em\u003e = 0.002) and % predicted peak VO\u003csub\u003e2\u003c/sub\u003e (61.9 \u0026plusmn; 13.7 vs 71.4 \u0026plusmn; 9.3%, \u003cem\u003ep\u003c/em\u003e = 0.003). Peak respiratory exchange ratio (RER) and ventilatory equivalent (V\u003csub\u003eE\u003c/sub\u003e/VCO\u003csub\u003e2\u003c/sub\u003e) did not differ between the groups (Table 3).\u003c/p\u003e\n\u003cp\u003eThere was a significant positive correlation between overall COI z-scores and % of predicted peak VO\u003csub\u003e2\u003c/sub\u003e (r = 0.32, \u003cem\u003ep\u003c/em\u003e = 0.013). When looking at the three main domains that contribute to COI and their association with % predicted peak VO\u003csub\u003e2\u003c/sub\u003e there was a correlation with the educational domain (r = 0.33, \u003cem\u003ep \u003c/em\u003e= 0.011) and the social and economic domain (r = 0.33, \u003cem\u003ep \u003c/em\u003e= 0.010), but not with the health and environment domain (r = 0.15, \u003cem\u003ep \u003c/em\u003e= 0.244) (Table 4).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eOther Associations with Percent of Predicted VO\u003csub\u003e2\u003c/sub\u003e\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eWhen evaluating for other factors associated with a worse % predicted peak VO\u003csub\u003e2\u003c/sub\u003e, a SRV (62.4 \u0026plusmn; 13.2% vs 68.4 \u0026plusmn; 10.2% for systemic left ventricle or mixed ventricle, \u003cem\u003ep\u003c/em\u003e = 0.047) and worse NYHA functional classification (66.5 \u0026plusmn; 12.8% for class I vs 56.0 \u0026plusmn; 14.4% for class II, \u003cem\u003ep\u003c/em\u003e = 0.049) were identified. Higher SVEDVi by CMR (spearman\u0026rsquo;s rho = -0.25, \u003cem\u003ep\u003c/em\u003e = 0.848) was not significantly associated with worse % predicted peak VO\u003csub\u003e2\u003c/sub\u003e. On multivariable analysis low COI level (9.2 \u0026plusmn; 3.0, \u003cem\u003ep\u003c/em\u003e = 0.004), SRV (4.3 \u0026plusmn; 1.5, \u003cem\u003ep\u003c/em\u003e = 0.005), and NYHA class II (9.4 \u0026plusmn; 4.4, \u003cem\u003ep\u003c/em\u003e = 0.039) were significantly associated with % predicted peak VO\u003csub\u003e2\u003c/sub\u003e (Table 5).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eOther Clinical Outcomes: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt follow up post-Fontan (mean of 17.7 \u0026plusmn; 7.3 y) there was one mortality (1%) and two heart transplants (2.0%). There were more intervention occurrences post-Fontan per patient in the low COI group (1.5 \u0026plusmn; 1.5 vs 0.9 \u0026plusmn; 0.9, p = 0.038) (Table 6). Supplemental Table 1 details the different interventions performed in the low and high COI groups. The most common interventions performed in the low and high COI groups were venous-venous or aorto-pulmonary collateral embolization (27 vs 13, respectively), Fontan fenestration device closure (13 vs 5, respectively), LPA stent implantation (8 vs 4, respectively), and Fontan conduit stent implantation (9 vs 1, respectively).\u003c/p\u003e\n\u003cp\u003eThere was no difference in total hospital admissions post-Fontan (\u003cem\u003ep \u003c/em\u003e= 0.988), total days admitted post-Fontan (p = 0.731), presence of renal dysfunction (\u003cem\u003ep \u003c/em\u003e= 0.376), presence of Fontan-associated liver disease (FALD) (\u003cem\u003ep\u003c/em\u003e = 0.314), or AICD/pacemaker implantation between COI groups (\u003cem\u003ep \u003c/em\u003e= 0.474) (Table 6). \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we evaluated the association of COI and outcomes in post-Fontan patients. It was demonstrated that lower COI was associated with worse exercise capacity in post-Fontan patients. In addition to COI, SRV and higher SVEDVi were identified to be associated with % predicted VO\u003csub\u003e2\u003c/sub\u003e in our cohort. On multivariable analysis, low COI is associated with lower percent of predicted VO2 by 9%. When looking at other clinical outcomes, there was higher number of intervention occurrences in the low COI group post-Fontan. Although the association of outcomes in CHD surgery with COI has previously been investigated, to our knowledge these findings post-Fontan have not been described to-date.\u003csup\u003e12,14,15\u003c/sup\u003e Sengupta \u003cem\u003eet al.\u003c/em\u003e looked at the association of COI with CHD post-surgical outcomes at a large quaternary center and Duong \u003cem\u003eet al.\u003c/em\u003e similarly looked at CHD post-surgical outcomes across 47 centers, which both showed COI not to be associated with surgical mortality in fully adjusted models but both found post-discharge survival of the lowest COI category to be significant decreased.\u003csup\u003e12,14\u003c/sup\u003e These findings were speculated to be observed as neighborhood effects that are more likely to be relevant out of the hospital when CHD patients are living at home and exposed to many of the factors that we discussed make up the domains of the COI.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExercise Capacity and COI:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study presents a significant relationship of lower COI with worse exercise capacity post-Fontan. It is known that better exercise capacity is associated with improved survival in patients that have undergone Fontan palliation.\u003csup\u003e24\u003c/sup\u003e Post Fontan, higher peak VO\u003csub\u003e2\u003c/sub\u003e has previously been shown to be associated with lower age, vitamin D sufficiency, absence of obesity, lower hemoglobin, and a healthier hepatic profile.\u003csup\u003e25\u003c/sup\u003e In our cohort, lower peak VO\u003csub\u003e2\u003c/sub\u003e and % predicted peak VO\u003csub\u003e2\u003c/sub\u003e were associated with low COI. When looking at the individual components within the COI, there were positive correlations with the educational domain and the social and economic domains, but not with the health and environmental domain. This suggests that individuals with a lower COI may have educational and socioeconomic inequities that potentially lead to lower exercise capacity. Numerous studies have previously demonstrated a significant positive association of educational achievement with exercise in pre-school, school-aged, adolescent, and adult individuals.\u003csup\u003e26-30\u003c/sup\u003e Likewise, physical inactivity has been previously shown to be associated with socioeconomically disadvantaged communities.\u003csup\u003e31-33\u003c/sup\u003e These findings most likely demonstrate importance of addressing educational and socioeconomic inequities within our post-Fontan population to improve exercise capacity and outcomes. It was surprising to see that the environmental domain was not significantly associated with predicted peak VO\u003csub\u003e2\u003c/sub\u003e in our post-Fontan cohort since neighborhood built characteristics like sidewalks, walkability, parks/recreational areas, and residential density have been found to impact physical activity in previous studies.\u003csup\u003e34-36\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOther Associations with Percent of Predicted VO\u003csub\u003e2\u003c/sub\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen comparing additional variables that are known to predict a worse % predicted peak VO\u003csub\u003e2\u003c/sub\u003e within our post-Fontan cohort, SRV was found to be associated, which was consistent with previous finding demonstrated by Tran \u003cem\u003eet al.\u003c/em\u003e where characteristics of post-Fontan patients with higher physical performance were found to either have a left ventricle or be biventricular for their dominant ventricle.\u003csup\u003e23\u003c/sup\u003e CMR-derived characteristics such as SVEDVi have been found to be elevated in post-Fontan patients with worse exercise capacity, which was what was anticipated but not reproduced with our findings in our cohort.\u003csup\u003e37,38\u003c/sup\u003e NHYA functional classification has been previously well demonstrated to be an independent predictor of exercise capacity and specifically % predicted VO\u003csub\u003e2\u003c/sub\u003e.\u003csup\u003e39,40\u003c/sup\u003e This additional has been reproduced in the adult congenital heart disease population, so it was not surprising it was reproduced in this cohort.\u003csup\u003e41,42\u003c/sup\u003e When performing a multivariable analysis with COI adjusting for SRV and NHYA class II, all were significantly associated with % predicted VO\u003csub\u003e2\u003c/sub\u003e (Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOther Clinical Outcomes:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this cohort of 99 patients post-Fontan procedure, there was only one mortality and two orthotopic heart transplants which reflects a relatively healthy group. There was no difference between the low and high COI groups post-Fontan in FALD or presence of renal dysfunction. Interestingly, there was no difference in total admissions or total days admitted post-Fontan. This differs from the findings Mayourin \u003cem\u003eet al\u003c/em\u003e showed that lower COI was associated with a longer length of stay for patients that underwent cardiac surgery.\u003csup\u003e15\u003c/sup\u003e However, this study did not specifically look at the post-Fontan population as described in our study. The authors speculate that the lack of difference may reflect the nature of our surgical center. These findings likely are reflective of the mean time post-Fontan procedure of 17.7 \u0026plusmn; 7.3 year in this study population. Notably, there were more intervention occurrences post-Fontan per patient in the low COI group. This would suggest higher disease burden and morbidity in the low COI group relative to the high COI group. This may also be related to low exercise capacity as many patients may be sent for interventions due to lower exercise capacity on an exercise test. Given this finding, this highlights the importance of identifying patients within that low COI group knowing that they are at increased risk of needing more interventions and worse exercise capacity. This stresses the importance of addressing physical activity at multiple levels as a mechanism of prevention. Individually, counseling on the importance of exercising as well as identifying any psychostressors (financial insecurity, social experiences, support network) that may limit the ability to exercise. At the community level, these findings highlight the importance of these patients\u0026rsquo; environments, which includes access to green spaces, low-cost physical activity facilities, and safe walkable areas to encourage physical activity. Likewise, this further supports the high diagnostic value of exercise testing in this patient population, which has been described as an important tool for prognostic value for post-Fontan patients.\u003csup\u003e18-20\u003c/sup\u003e Initiatives to recognize these barriers and improve access to exercise in neighborhoods of lower COI may lead to improved exercise capacity and less intervention and thus overall better outcomes. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a retrospective study with limitations to bias secondary to missing data and patients loss to follow-up. Due to the sample size of this single-center study, there is a risk for type I error. The generalizability of our findings may also be limited given the predominantly white racial profile of the study population, which reflects the greater Pittsburgh population that serves as the main referral network for our quaternary center. Additionally, all international patients were excluded as foreign-based COI measures have not yet been developed. There are some inherent limitations of the COI, which is representative of each individual\u0026rsquo;s zip code at the time of this study\u0026rsquo;s data collection and cannot account for if a patient previously lived in a different zip code. Similarly, COI factors in the 29 different SDOH factors listed in Table 1, but the data for activity/exercise time, diet, other specific experience-based data is not readily available.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLower COI was found to be associated with worse exercise capacity in post-Fontan patients and may negatively impact the need for late interventions. Influences of SDOH are multifactorial and the COI allows for multiple neighborhood factors are be accounted for with any patient with a US-based zip code. These results support the importance of SDOH in the Fontan population and need for increased efforts to provide community resources to address disparities to promote equity in cardiac outcomes. The impact of health-related social needs on children are well documented and screening for these factors will continue to be importance in promoting health equity.\u003csup\u003e43\u003c/sup\u003e Specifically, training providers for these post-Fontan patients to identify health-related social needs so they can be addressed and at the organizational level to support programs that promote resources that support at-risk individuals. The COI can be a potential tool utilized for predicting and addressing disparities in health outcomes within the post-Fontan population by early identification of at-risk individuals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/strong\u003e\u003cu\u003e:\u003c/u\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eSources of Funding\u003c/u\u003e\u003c/strong\u003e\u003cu\u003e:\u003c/u\u003e This project was supported by the division of pediatric cardiology, department of pediatrics, university of Pittsburgh school of medicine, UPMC children\u0026apos;s hospital of Pittsburgh. The project described was supported by the National Institutes of Health through Grant Number UL1 TR001857, KL2 TR001856, and/or TL1 TR001858.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eStatements and Declarations:\u003c/u\u003e\u003c/strong\u003e None\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eB.K. helped with idea conception, study design, data acquisition, interpretation of the data, critical review of literature, writing of the manuscript, and manuscript revision; L.W. helped with study design, interpretation of the data, statistical analysis, and manuscript revision; MR helped with study design, critical review of literature, writing of the manuscript, and manuscript revision; A.K., A.S., G.A., J.K., and M.V. helped with idea conception, study design, critical review of literature, writing of the manuscript, and manuscript revision; T.A. helped with idea conception, study design, interpretation of the data, critical review of literature, writing of the manuscript, and manuscript revision; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDiBardino DJ, Pasquali SK, Hirsch JC et al (2012) Effect of sex and race on outcome in patients undergoing congenital heart surgery: an analysis of the society of thoracic surgeons congenital heart surgery database. Ann Thorac Surg. ;94:2054-9; discussion 9\u0026ndash;60\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaramlou T, Hawke JL, Zafar F et al (2022) Widening our Focus: Characterizing Socioeconomic and Racial Disparities in Congenital Heart Disease. Ann Thorac Surg 113:157\u0026ndash;165\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOster ME, Strickland MJ, Mahle WT (2011) Racial and ethnic disparities in post-operative mortality following congenital heart surgery. J Pediatr 159:222\u0026ndash;226\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson BR, Fieldston ES, Newburger JW, Bacha EA, Glied SA (2018) Disparities in Outcomes and Resource Use After Hospitalization for Cardiac Surgery by Neighborhood Income. Pediatrics ;141\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtz AM, Zak V, Mahony L et al (2017) Longitudinal Outcomes of Patients With Single Ventricle After the Fontan Procedure. J Am Coll Cardiol 69:2735\u0026ndash;2744\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeterson JK, Chen Y, Nguyen DV, Setty SP (2017) Current trends in racial, ethnic, and healthcare disparities associated with pediatric cardiac surgery outcomes. Congenit Heart Dis 12:520\u0026ndash;532\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck AF, Huang B, Auger KA, Ryan PH, Chen C, Kahn RS (2016) Explaining Racial Disparities in Child Asthma Readmission Using a Causal Inference Approach. JAMA Pediatr 170:695\u0026ndash;703\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColvin JD, Zaniletti I, Fieldston ES et al (2013) Socioeconomic status and in-hospital pediatric mortality. Pediatrics 131:e182\u0026ndash;e190\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFieldston ES, Zaniletti I, Hall M et al (2013) Community household income and resource utilization for common inpatient pediatric conditions. 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Health Aff (Millwood) 39:1693\u0026ndash;1701\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChild Opportunity Index (2023) 2.0 ZIP Code data, retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.diversitydatakids.org/dataset/coi20_zipcodes-child-opportunity-index-2-0-zip-code-data?_external=True\u003c/span\u003e\u003cspan address=\"https://data.diversitydatakids.org/dataset/coi20_zipcodes-child-opportunity-index-2-0-zip-code-data?_external=True\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSengupta A, Gauvreau K, Bucholz EM, Newburger JW, Del Nido PJ, Nathan M (2022) Contemporary Socioeconomic and Childhood Opportunity Disparities in Congenital Heart Surgery. 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Eur Heart J 31:3073\u0026ndash;3083\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandes SM, McElhinney DB, Khairy P, Graham DA, Landzberg MJ, Rhodes J (2010) Serial cardiopulmonary exercise testing in patients with previous Fontan surgery. Pediatr Cardiol 31:175\u0026ndash;180\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyers J, Kaminsky LA, Lima R, Christle JW, Ashley E, Arena R (2017) A Reference Equation for Normal Standards for VO(2) Max: Analysis from the Fitness Registry and the Importance of Exercise National Database (FRIEND Registry). Prog Cardiovasc Dis 60:21\u0026ndash;29\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowell AW, Chin C, Alsaied T et al (2020) The Unique Clinical Phenotype and Exercise Adaptation of Fontan Patients With Normal Exercise Capacity. Can J Cardiol 36:1499\u0026ndash;1507\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTran DL, Celermajer DS, Ayer J et al (2021) The Super-Fontan Phenotype: Characterizing Factors Associated With High Physical Performance. Front Cardiovasc Med 8:764273\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhuchi H, Negishi J, Noritake K et al (2015) Prognostic value of exercise variables in 335 patients after the Fontan operation: a 23-year single-center experience of cardiopulmonary exercise testing. Congenit Heart Dis 10:105\u0026ndash;116\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinreb SJ, Dodds KM, Burstein DS et al (2020) End-Organ Function and Exercise Performance in Patients With Fontan Circulation: What Characterizes the High Performers? J Am Heart Assoc 9:e016850\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTomporowski PD, Davis CL, Miller PH, Naglieri JA (2008) Exercise and Children's Intelligence, Cognition, and Academic Achievement. Educ Psychol Rev 20:111\u0026ndash;131\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang T, Tarp J, Domazet SL et al (2015) Associations of Adiposity and Aerobic Fitness with Executive Function and Math Performance in Danish Adolescents. J Pediatr 167:810\u0026ndash;815\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastelli DM, Hillman CH, Buck SM, Erwin HE (2007) Physical fitness and academic achievement in third- and fifth-grade students. J Sport Exerc Psychol 29:239\u0026ndash;252\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKantomaa MT, Stamatakis E, Kankaanpaa A et al (2013) Physical activity and obesity mediate the association between childhood motor function and adolescents' academic achievement. Proc Natl Acad Sci U S A 110:1917\u0026ndash;1922\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKari JT, Viinikainen J, Bockerman P et al (2020) Education leads to a more physically active lifestyle: Evidence based on Mendelian randomization. Scand J Med Sci Sports 30:1194\u0026ndash;1204\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRawal LB, Smith BJ, Quach H, Renzaho AMN (2020) Physical Activity among Adults with Low Socioeconomic Status Living in Industrialized Countries: A Meta-Ethnographic Approach to Understanding Socioecological Complexities. J Environ Public Health 2020:4283027\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore GF, Littlecott HJ (2015) School- and family-level socioeconomic status and health behaviors: multilevel analysis of a national survey in wales, United Kingdom. J Sch Health 85:267\u0026ndash;275\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlthoff T, Sosic R, Hicks JL, King AC, Delp SL, Leskovec J (2017) Large-scale physical activity data reveal worldwide activity inequality. Nature 547:336\u0026ndash;339\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHajna S, Ross NA, Brazeau AS, Belisle P, Joseph L, Dasgupta K (2015) Associations between neighbourhood walkability and daily steps in adults: a systematic review and meta-analysis. BMC Public Health 15:768\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDing D, Nguyen B, Learnihan V et al (2018) Moving to an active lifestyle? A systematic review of the effects of residential relocation on walking, physical activity and travel behaviour. Br J Sports Med 52:789\u0026ndash;799\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarmeniemi M, Lankila T, Ikaheimo T, Koivumaa-Honkanen H, Korpelainen R (2018) The Built Environment as a Determinant of Physical Activity: A Systematic Review of Longitudinal Studies and Natural Experiments. Ann Behav Med 52:239\u0026ndash;251\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsaied T, Critser PJ, Azcue N, St Clair N, Powell AJ, Rathod RH (2020) CMR-Derived Ventricular Global Function Index in Patients Late After the Fontan Operation. JACC Cardiovasc Imaging 13:2686\u0026ndash;2687\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCritser PJ, Truong V, Powell AW et al (2021) Cardiac magnetic resonance derived atrial function in patients with a Fontan circulation. Int J Cardiovasc Imaging 37:275\u0026ndash;284\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams SG, Ng LL, O'Brien RJ et al (2005) Complementary roles of simple variables, NYHA and N-BNP, in indicating aerobic capacity and severity of heart failure. Int J Cardiol 102:279\u0026ndash;286\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimerman A, da Silveira AD, Borges MS et al (2023) Functional assessment based on cardiopulmonary exercise testing in mild heart failure: A multicentre study. ESC Heart Fail 10:1689\u0026ndash;1697\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBredy C, Ministeri M, Kempny A et al (2018) New York Heart Association (NYHA) classification in adults with congenital heart disease: relation to objective measures of exercise and outcome. Eur Heart J Qual Care Clin Outcomes 4:51\u0026ndash;58\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas BB, Young ML, Niu J, Mendoza LE, Chan KC, Roth T (2019) Relation Between New York Heart Association Functional Class and Objective Measures of Cardiopulmonary Exercise in Adults With Congenital Heart Disease. Am J Cardiol 123:1868\u0026ndash;1873\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRagavan MI, Garg A, Raphael JL (2023) Creating Healing-Centered Health Systems by Reimagining Social Needs Screening and Supports. JAMA Pediatr 177:555\u0026ndash;556\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eBreakdown of the 29 different indicators of SDOH that factor into the COI divided by the three main domains.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eEarly childhood education enrollment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eHigh school graduation rates\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eMath proficiency (3rd grade)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eReading proficiency (3rd grade)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAdvanced placement (AP) course participation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eProximity to early childhood education centers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eProximity to high-quality schools\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth and Environment Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAccess to healthy food outlets\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAccess to green spaces/parks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAccess to health care facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAccess to physical activity facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAir pollution (PM2.5 concentration)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eHousing vacancy rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eLead exposure risk\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eProximity to toxic waste sites\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eWalkability index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eWater contamination risk\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial and Economic Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eAdult educational attainment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eEmployment rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eMedian household income\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eNeighborhood poverty rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003ePublic assistance receipt rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eSingle-parent households\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eUnemployment rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eViolent crime rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eNeighborhood homeownership rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eIncome inequality (Gini coefficient)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eLinguistic isolation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eResidential segregation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCOI, childhood opportunity index; SDOH, social determinant of health\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Baseline demographics and clinical characteristics of the low COI and high COI groups.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow COI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh COI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age (y)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e24.1\u0026nbsp;\u0026plusmn;\u0026nbsp;8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e22.5\u0026nbsp;\u0026plusmn;\u0026nbsp;9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 609px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e63.8% (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e70.7% (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e34.5% (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e29.3% (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e1.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 609px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e93.0% (53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e97.6% (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Black\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e7.0% (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e2.4% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 609px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003eNot Hispanic or Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e86.2% (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e90.2% (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Hispanic or Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e1.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Unspecified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e12.1% (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e9.8% (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 609px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u003c/strong\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e36.2% (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e22.0% (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"10\" valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; HLH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e25.9% (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e31.7% (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; Tricuspid atresia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e15.5% (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e19.5% (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; DILV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e8.6% (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e7.3% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; PA/IVS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e5.2% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e7.3% (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; AVSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e3.4% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e4.9% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; DORV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e3.4% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;DIRV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e4.9% (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Mitral atresia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e2.4% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; Ebstein\u0026rsquo;s anomaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e1.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 609px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystemic ventricle morphology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e Right\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e34.5% (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e36.6% (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; Left\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e48.3% (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e53.7% (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u0026nbsp; Balanced or Mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e15.5% (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e9.8% (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eIndeterminate/Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e1.7% (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are reported as % (n) or as mean \u0026plusmn; standard deviation. Missing data values were omitted from the table. AVSD, atrioventricular septal defect; COI, childhood opportunity index; DILV, double inlet left ventricle; DIRV, double inlet right ventricle; DORV, double outlet right ventricle; HLH, hypoplastic left heart variant; PA/IVS, pulmonary atresia with intact ventricular septum.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eCPET characteristics for the low and high COI groups at pre-exercise, ventilatory anaerobic threshold, and peak.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCPET Variables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow COI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh COI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003eAge at CPET (y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e20.3 \u0026plusmn; 8.6 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e21.2 \u0026plusmn; 8.3 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003eFemale sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e30.8% (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e33.3% (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003ePre-exercise HR (beats/min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e88.3 \u0026plusmn; 19.0 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e87.4 \u0026plusmn; 11.9 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e24.7 \u0026plusmn; 5.3 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e24.3 \u0026plusmn; 4.9 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003ePre-exercise SpO\u003csub\u003e2\u003c/sub\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e92.9 \u0026plusmn; 4.0 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e92.8 \u0026plusmn; 4.6 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003eHR at VAT (beats/min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e131.0 \u0026plusmn; 26.8 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e126.2 \u0026plusmn; 21.5 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003eVO\u003csub\u003e2\u003c/sub\u003e at VAT (L/min/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e18.0 \u0026plusmn; 5.2 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e19.0 \u0026plusmn; 4.7 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003ePeak O\u003csub\u003e2\u003c/sub\u003e pulse (mL/beat)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e10.1 \u0026plusmn; 3.0 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e12.2 \u0026plusmn; 3.6 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003ePeak HR (beats/min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e165.3 \u0026plusmn; 27.1 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e165.7 \u0026plusmn; 23.5 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003ePeak RER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 0.1 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e1.1 \u0026plusmn; 0.1 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003ePeak SpO\u003csub\u003e2\u003c/sub\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e89.0 \u0026plusmn; 5.3 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e90.6 \u0026plusmn; 6.0 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003ePeak VO\u003csub\u003e2\u003c/sub\u003e (ml/min/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e25.7 \u0026plusmn; 6.3 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e31.0 \u0026plusmn; 5.8 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003e% predicted peak VO\u003csub\u003e2\u003c/sub\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e61.9 \u0026plusmn; 13.7 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e71.4 \u0026plusmn; 9.3 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.0476%;\"\u003e\n \u003cp\u003eV\u003csub\u003eE\u003c/sub\u003e/VCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e37.9 \u0026plusmn; 6.4 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.8571%;\"\u003e\n \u003cp\u003e37.2 \u0026plusmn; 6.4 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4762%;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are reported as % (n) or as mean \u0026plusmn; standard deviation. Missing data values were omitted from the table.\u0026nbsp;% predicted VO\u003csub\u003e2\u003c/sub\u003e,\u0026nbsp;percent of\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003epredicted peak VO\u003csub\u003e2\u003c/sub\u003e; BMI, body mass index;\u0026nbsp;COI, childhood opportunity index; CPET, cardiopulmonary exercise test; HR, heart rate; O\u003csub\u003e2\u003c/sub\u003e pulse, oxygen pulse; RER, respiratory exchange ratio; SpO\u003csub\u003e2\u003c/sub\u003e, oxygen saturation by pulse oximetry; VAT, ventilatory anaerobic threshold; V\u003csub\u003eE\u003c/sub\u003e/VCO\u003csub\u003e2\u003c/sub\u003e, ventilatory equivalent; VO\u003csub\u003e2\u003c/sub\u003e, oxygen uptake.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eUnivariate components of the COI association with percent of predicted peak VO\u003csub\u003e2\u003c/sub\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38.0952%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOI component\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorrelation coefficient (r)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5238%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38.0952%;\"\u003e\n \u003cp\u003eEducational domain z-score, nationally normed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.381%;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5238%;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38.0952%;\"\u003e\n \u003cp\u003eHealth and environment domain z-score, nationally normed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.381%;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5238%;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38.0952%;\"\u003e\n \u003cp\u003eSocial and economic domain z-score, nationally normed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.381%;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.5238%;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCOI, childhood opportunity index;\u0026nbsp;VO\u003csub\u003e2\u003c/sub\u003e, oxygen uptake.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u003c/strong\u003e Multivariable predictors of % predicted peak VO\u003csub\u003e2\u003c/sub\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOI component\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimate \u0026plusmn; Standard error \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40%;\"\u003e\n \u003cp\u003eCOI group (low)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.381%;\"\u003e\n \u003cp\u003e8.7 \u0026plusmn; 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40%;\"\u003e\n \u003cp\u003eSRV morphology\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.381%;\"\u003e\n \u003cp\u003e7.9 \u0026plusmn; 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40%;\"\u003e\n \u003cp\u003eNYHA class II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.381%;\"\u003e\n \u003cp\u003e9.4 \u0026plusmn; 4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.619%;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are reported as % (n) or as mean \u0026plusmn; standard deviation. %\u0026nbsp;predicted VO\u003csub\u003e2\u003c/sub\u003e,\u0026nbsp;percent of\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003epredicted peak VO\u003csub\u003e2\u003c/sub\u003e;\u0026nbsp;COI, childhood opportunity index; NYHA, New York Heart Association; SRV, systemic right ventricle; SVEDVi, index systemic ventricle end-diastolic volume;\u0026nbsp;VO\u003csub\u003e2\u003c/sub\u003e, oxygen uptake.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6.\u0026nbsp;\u003c/strong\u003eLong-term post-Fontan procedure outcomes between the low and high COI groups.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow COI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh COI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003eMortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003eOrthotopic heart transplantation performed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003eIntervention occurrence (mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e1.5 \u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e0.9 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003eTotal admissions post-Fontan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e1 (0, 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e1 (0, 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003eTotal days admitted post-Fontan (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2 (0, 8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e2 (0, 4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003ePresence of renal dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e4.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003ePresence of FALD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e67.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e58.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.9615%;\"\u003e\n \u003cp\u003eAICD/Pacemaker Implantation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e8.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e4.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5385%;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are reported as % (n), mean \u0026plusmn; standard deviation, or median (1\u003csup\u003est\u003c/sup\u003e quartile, 3\u003csup\u003erd\u003c/sup\u003e quartile). Missing data values were omitted from the table. AICD, automatic implantable cardioverter defibrillator; FALD, Fontan-associated liver disease; SD, standard deviation).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Fontan, Exercise capacity, Social determinants of Health, Child opportunity index, Adult congenital heart disease","lastPublishedDoi":"10.21203/rs.3.rs-4993172/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4993172/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe Child Opportunity Index (COI) is a validated measurement that uses a composite index of 29 indicators of social determinants of health linked to the US Census. Patients post-Fontan palliation for single ventricle often have reduced exercise capacity compared to the general population. Our hypothesis is that COI levels are directly associated with exercise capacity and inversely with late outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective, single-center study was performed, including 99 patients post-Fontan procedure who had cardiac magnetic resonance imaging at our institution from January 2010 to July 2023, of which 78 had undergone an exercise test. Univariate analysis was performed with Pearson correlational testing and multivariable linear regression was then used to evaluate independent predictors of % predicted VO\u003csub\u003e2\u003c/sub\u003e.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age and sex were not different between the low and high COI groups (24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5 y vs 22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 y; 34.5% vs 29.3% female). Patients with low COI had lower peak VO2 (25.7 vs 31.0 L/min/kg\u003csup\u003e2\u003c/sup\u003e, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) and % predicted peak VO2 (61.9 vs 71.4%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003). At follow up post-Fontan (mean of 17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 y) there was one mortality and two heart transplants. There were more interventions in the low COI group (1.5 vs 0.9 intervention occurrence/patient, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.038). There was no difference in hospital admissions or significant comorbidities between COI groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eLower COI was associated with worse exercise capacity in Fontan patients and may negatively impact the need for late interventions. This highlights the need for efforts to provide community resources to promote equity in cardiac outcomes.\u003c/p\u003e","manuscriptTitle":"Lower Child Opportunity Index is Associated with Lower Exercise Capacity Post-Fontan Palliation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-27 09:37:20","doi":"10.21203/rs.3.rs-4993172/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-01T15:42:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-29T16:26:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308116018883103343934020337211740381913","date":"2024-09-25T12:53:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-11T16:10:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-29T08:06:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-29T08:05:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Cardiology","date":"2024-08-28T19:12:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ddc9c9b1-e677-49aa-96f4-70c112fd8d27","owner":[],"postedDate":"September 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T15:59:30+00:00","versionOfRecord":{"articleIdentity":"rs-4993172","link":"https://doi.org/10.1007/s00246-024-03752-x","journal":{"identity":"pediatric-cardiology","isVorOnly":false,"title":"Pediatric Cardiology"},"publishedOn":"2024-12-30 15:57:07","publishedOnDateReadable":"December 30th, 2024"},"versionCreatedAt":"2024-09-27 09:37:20","video":"","vorDoi":"10.1007/s00246-024-03752-x","vorDoiUrl":"https://doi.org/10.1007/s00246-024-03752-x","workflowStages":[]},"version":"v1","identity":"rs-4993172","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4993172","identity":"rs-4993172","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}