1
|
Kriechbaum SD, Birmes J, Wiedenroth CB, Adameit MSD, Gruen D, Vietheer J, Richter MJ, Guth S, Roller FC, Rademann M, Fischer-Rasokat U, Rolf A, Liebetrau C, Hamm CW, Keller T, Rieth AJ. Exercise MR-proANP unmasks latent right heart failure in CTEPH. J Heart Lung Transplant 2022; 41:1819-1830. [PMID: 36210266 DOI: 10.1016/j.healun.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/31/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The present study was designed to investigate the dynamics of right atrial pressure (RAP) and mid-regional pro-atrial natriuretic peptide (MR-proANP) during physical exercise in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and to determine whether these parameters might serve as a tool to measure exercise-dependent atrial stress as an indicator of right heart failure. METHODS This prospective observational cohort study included 100 CTEPH patients who underwent right heart catheterization during physical exercise (eRHC). Blood samples for MR-proANP measurement were taken prior, during, and after eRHC. MR-proANP levels were correlated to RAP levels at rest, at peak exercise (eRAP), and during recovery. RAP at rest ≤7 mmHg was defined as normal and eRAP >15 mmHg as suggestive of right heart failure. RESULTS During eRHC mean RAP increased from 6 mmHg (standard deviation, SD 4) to 16 mmHg (SD 7; p < 0.001). MR-proANP levels and dynamics correlated with RAP at rest (rs = 0.61; p < 0.001) and at peak exercise (rs = 0.66; p < 0.001). Logistic regression analysis revealed the peak MR-proANP level (B = 0.058; p = 0.004) and the right atrial area (B = 0.389; p < 0.001) to be associated with eRAP dynamics. A peak MR-proANP level ≥139 pmol/L (AUC = 0.81) and recovery level ≥159 pmol/L (AUC = 0.82) predicted an eRAP >15 mmHg. Physical exercise unmasked right heart failure in 39% of patients with normal RAP at rest; these patients were also characterized by a more distinct increase in MR-proANP levels (p = 0.005) and higher peak (p < 0.001) and recovery levels (p < 0.001). CONCLUSIONS RAP and MR-proANP dynamics unmask manifest and latent right heart failure in CTEPH patients.
Collapse
Affiliation(s)
- Steffen D Kriechbaum
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany.
| | - Judith Birmes
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany
| | - Christoph B Wiedenroth
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Miriam S D Adameit
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Dimitri Gruen
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - J Vietheer
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany
| | - Manuel J Richter
- Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany; Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Stefan Guth
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Fritz C Roller
- Justus Liebig University Giessen, Department of Radiology, Giessen, Germany
| | - Matthias Rademann
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Ulrich Fischer-Rasokat
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Andreas Rolf
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany; Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Christoph Liebetrau
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany; Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Christian W Hamm
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany; Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Till Keller
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany; Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Andreas J Rieth
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany
| |
Collapse
|
2
|
Lichtblau M, Bader PR, Saxer S, Berlier C, Schwarz EI, Hasler ED, Furian M, Grünig E, Bloch KE, Ulrich S. Right Atrial Pressure During Exercise Predicts Survival in Patients With Pulmonary Hypertension. J Am Heart Assoc 2020; 9:e018123. [PMID: 33146048 PMCID: PMC7763735 DOI: 10.1161/jaha.120.018123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/30/2020] [Indexed: 12/29/2022]
Abstract
Background We investigated changes in right atrial pressure (RAP) during exercise and their prognostic significance in patients assessed for pulmonary hypertension (PH). Methods and Results Consecutive right heart catheterization data, including RAP recorded during supine, stepwise cycle exercise in 270 patients evaluated for PH, were analyzed retrospectively and compared among groups of patients with PH (mean pulmonary artery pressure [mPAP] ≥25 mm Hg), exercise-induced PH (exPH; resting mPAP <25 mm Hg, exercise mPAP >30 mm Hg, and mPAP/cardiac output >3 Wood Units (WU)), and without PH (noPH). We investigated RAP changes during exercise and survival over a median (quartiles) observation period of 3.7 (2.8-5.6) years. In 152 patients with PH, 58 with exPH, and 60 with noPH, median (quartiles) resting RAP was 8 (6-11), 6 (4-8), and 6 (4-8) mm Hg (P<0.005 for noPH and exPH versus PH). Corresponding peak changes (95% CI) in RAP during exercise were 5 (4-6), 3 (2-4), and -1 (-2 to 0) mm Hg (noPH versus PH P<0.001, noPH versus exPH P=0.027). RAP increase during exercise correlated with mPAP/cardiac output increase (r=0.528, P<0.001). The risk of death or lung transplantation was higher in patients with exercise-induced RAP increase (hazard ratio, 4.24; 95% CI, 1.69-10.64; P=0.002) compared with patients with unaltered or decreasing RAP during exercise. Conclusions In patients evaluated for PH, RAP during exercise should not be assumed as constant. RAP increase during exercise, as observed in exPH and PH, reflects hemodynamic impairment and poor prognosis. Therefore, our data suggest that changes in RAP during exercise right heart catheterization are clinically important indexes of the cardiovascular function.
Collapse
Affiliation(s)
- Mona Lichtblau
- Department of PulmonologyUniversity Hospital ZürichZürichSwitzerland
| | - Patrick R. Bader
- Department of PulmonologyUniversity Hospital ZürichZürichSwitzerland
- Institute of Intensive Care MedicineUniversity Hospital ZürichZürichSwitzerland
| | - Stéphanie Saxer
- Department of PulmonologyUniversity Hospital ZürichZürichSwitzerland
| | - Charlotte Berlier
- Department of PulmonologyUniversity Hospital ZürichZürichSwitzerland
| | - Esther I. Schwarz
- Department of PulmonologyUniversity Hospital ZürichZürichSwitzerland
| | | | - Michael Furian
- Department of PulmonologyUniversity Hospital ZürichZürichSwitzerland
| | - Ekkehard Grünig
- Centre for Pulmonary HypertensionThoraxklinik Heidelberg gGmbH at Heidelberg University HospitalHeidelbergGermany
| | - Konrad E. Bloch
- Department of PulmonologyUniversity Hospital ZürichZürichSwitzerland
| | - Silvia Ulrich
- Department of PulmonologyUniversity Hospital ZürichZürichSwitzerland
| |
Collapse
|
3
|
Ruijsink B, Velasco Forte MN, Duong P, Asner L, Pushparajah K, Frigiola A, Nordsletten D, Razavi R. Synergy in the heart: RV systolic function plays a key role in optimizing LV performance during exercise. Am J Physiol Heart Circ Physiol 2020; 319:H642-H650. [PMID: 32762556 DOI: 10.1152/ajpheart.00256.2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The right ventricle (RV) is often overlooked in the evaluation of cardiac performance and treatment of left ventricular (LV) heart diseases. However, recent evidence suggests the RV may play an important role in maintaining systemic cardiac function and delivering stroke volume (SV). We used exercise cardiac magnetic resonance and biomechanical modeling to investigate the role of the RV in LV stroke volume regulation. We studied SV augmentation during exercise by pharmacologically inducing negative chronotropy (sHRi) in healthy volunteers and investigating training-induced SV augmentation in endurance athletes. SV augmentation during exercise after sHRi is achieved differently in the two ventricles. In the RV, the larger SV is driven by increasing contraction down to lower end-systolic volume (ESV; P < 0.001). In the LV, SV augmentation is achieved through an increase in end-diastolic volume (EDV; P < 0.001), avoiding contraction to a lower ESV. The same mechanism underlies the enhanced SV response observed in athletes. Changes in atrial area during SV augmentation suggest that the improved LV EDV response is sustained by the larger RV contractions. Using our biomechanical model, we explain this behavior by showing that the RV systolic function-driven regulation of LV SV optimizes the energetic cost of LV contraction and leads to minimization of the total costs of biventricular contraction. In conclusion, this work provides mechanistic understanding of the pivotal role of the RV in optimizing LV SV during exercise. It demonstrates why optimizing RV function needs to become a key part of therapeutic strategies in patients and training for athletes.NEW & NOTEWORTHY The right ventricle appears to have an important impact on maintaining systemic cardiac function and delivering stroke volume. However, its exact role in supporting left ventricular function has so far been unclear. This study demonstrates a new mechanism of ventricular interaction that provides mechanistic understanding of the key importance of the right ventricle in driving cardiac performance.
Collapse
Affiliation(s)
- B Ruijsink
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom.,Departments of Paediatric Cardiology and Adult Congenital Cardiology, Guy's and Saint Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - M N Velasco Forte
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom.,Departments of Paediatric Cardiology and Adult Congenital Cardiology, Guy's and Saint Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - P Duong
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom.,Departments of Paediatric Cardiology and Adult Congenital Cardiology, Guy's and Saint Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - L Asner
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
| | - K Pushparajah
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom.,Departments of Paediatric Cardiology and Adult Congenital Cardiology, Guy's and Saint Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - A Frigiola
- Departments of Paediatric Cardiology and Adult Congenital Cardiology, Guy's and Saint Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - D Nordsletten
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom.,Department of Biomedical Engineering and Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - R Razavi
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom.,Departments of Paediatric Cardiology and Adult Congenital Cardiology, Guy's and Saint Thomas' National Health Service Foundation Trust, London, United Kingdom
| |
Collapse
|