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Dhont S, Stassen J, Herbots L, Hoedemakers S, Bekhuis Y, Jasaityte R, Stroobants S, Petit T, Bakelants E, Falter M, Ferreira SM, Claessen G, Nijst P, Vandervoort PM, Bertrand PB, Verwerft J. Exercise pulmonary hypertension by the mPAP/CO slope in primary mitral regurgitation. Eur Heart J Cardiovasc Imaging 2024; 25:530-538. [PMID: 37976175 DOI: 10.1093/ehjci/jead313] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023] Open
Abstract
AIMS Exercise-induced pulmonary hypertension (PH), defined by a mean pulmonary arterial pressure over cardiac output (mPAP/CO) slope >3 mmHg/L/min, has important diagnostic and prognostic implications. The aim of this study is to investigate the value of the mPAP/CO slope in patients with more than moderate primary mitral regurgitation (MR) with preserved ejection fraction and no or discordant symptoms. METHODS AND RESULTS A total of 128 consecutive patients were evaluated with exercise echocardiography and cardiopulmonary testing. Clinical outcome was defined as the composite of mitral valve intervention, new-onset atrial fibrillation, cardiovascular hospitalization, and all-cause mortality. The mean age was 63 years, 61% were male, and the mean LVEF was 66 ± 6%. The mPAP/CO slope correlated with peak VO2 (r = -0.52, P < 0.001), while the peak systolic pulmonary artery pressure (sPAP) did not (r = -0.06, P = 0.584). Forty-six per cent (n = 59) had peak exercise sPAP ≥60 mmHg, and 37% (n = 47) had mPAP/CO slope >3 mmHg/L/min. Event-free survival was 55% at 1 year and 46% at 2 years, with reduced survival in patients with mPAP/CO slope >3 mmHg/L/min (hazard ratio, 4.9; 95% confidence interval, 2.9-8.2; P < 0.001). In 53 cases (41%), mPAP/CO slope and peak sPAP were discordant: patients with slope >3 mmHg/L/mmHg and sPAP <60 mmHg (n = 21) had worse outcome vs. peak sPAP ≥60 mmHg and normal slope (n = 32, log-rank P = 0.003). The mPAP/CO slope improved predictive models for outcome, incremental to resting and exercise sPAP, and peak VO2. CONCLUSION Exercise PH defined by the mPAP/CO slope >3 mmHg/L/min is associated with decreased exercise capacity and a higher risk of adverse events in significant primary MR and no or discordant symptoms. The slope provides a greater prognostic value than single sPAP measures and peak VO2.
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Affiliation(s)
- Sebastiaan Dhont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Synaps Park 1, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
| | - Jan Stassen
- Department of Cardiology, Jessa Hospital, 3500 Hasselt, Belgium
| | - Lieven Herbots
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, 3500 Hasselt, Belgium
| | - Sarah Hoedemakers
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, 3500 Hasselt, Belgium
| | - Youri Bekhuis
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, 3500 Hasselt, Belgium
| | - Ruta Jasaityte
- Department of Cardiology, Jessa Hospital, 3500 Hasselt, Belgium
| | | | - Thibault Petit
- Department of Cardiology, Ziekenhuis Oost-Limburg, Synaps Park 1, 3600 Genk, Belgium
| | - Elise Bakelants
- Department of Cardiology, Imeldaziekenhuis, 2820 Bonheiden, Belgium
| | - Maarten Falter
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, 3500 Hasselt, Belgium
| | - Sara Moura Ferreira
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, 3500 Hasselt, Belgium
| | - Guido Claessen
- Department of Cardiology, Jessa Hospital, 3500 Hasselt, Belgium
| | - Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg, Synaps Park 1, 3600 Genk, Belgium
| | - Pieter M Vandervoort
- Department of Cardiology, Ziekenhuis Oost-Limburg, Synaps Park 1, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
| | - Philippe B Bertrand
- Department of Cardiology, Ziekenhuis Oost-Limburg, Synaps Park 1, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
| | - Jan Verwerft
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, 3500 Hasselt, Belgium
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Aggeli C, Polytarchou K, Varvarousis D, Kastellanos S, Tousoulis D. Stress ECHO beyond coronary artery disease. Is it the holy grail of cardiovascular imaging? Clin Cardiol 2018; 41:1600-1610. [PMID: 30315566 DOI: 10.1002/clc.23094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/03/2018] [Accepted: 10/10/2018] [Indexed: 01/06/2023] Open
Abstract
Stress echocardiography (SE) is a very useful method in clinical practice, because it offers important information of both the patient's functional status and hemodynamic changes during stress. Therefore, SE provides strong diagnostic and prognostic data in a wide spectrum of cardiovascular diseases. This review summarizes the clinical applications of SE in conditions beyond coronary artery disease (CAD) and highlights practical recommendations and key issues for each condition that need further investigation. SE is an established method for the evaluation of symptomatic and asymptomatic patients with valvular heart disease (VHD) and cardiomyopathies, and provides important information regarding prognosis and management of patients with congenital heart disease, pulmonary hypertension or diastolic dysfunction. Moreover, when one or multiple VHD and cardiomyopathy or CAD coexist in one patient, SE is a very useful clinical tool for the evaluation of etiology and symptomatology.
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Affiliation(s)
- Constantina Aggeli
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Kali Polytarchou
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece.,1st Department of Cardiology, Evagelismos General Hospital of Athens, Athens, Greece
| | - Dimitrios Varvarousis
- 2nd Department of Cardiology, General Hospital of Nikea-Piraeus "Agios Panteleimon", Piraeus, Greece
| | - Stellios Kastellanos
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Dimitrios Tousoulis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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Del Rio JM, Grecu L, Nicoara A. Right Ventricular Function in Left Heart Disease. Semin Cardiothorac Vasc Anesth 2018; 23:88-107. [DOI: 10.1177/1089253218799345] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Right ventricular (RV) function is an independent prognostic factor for short- and long-term outcomes in cardiac surgical patients. Patients with mitral valve (MV) disease are at increased risk of RV dysfunction before and after MV operations. Yet RV function is not part of criteria for decision making or risk stratification in this setting. The role of MV disease in the development of pulmonary hypertension (PHTN) and the ultimate impact of PHTN on RV function have been well described. Nonetheless, there are other mechanisms by which MV disease and MV surgery affect RV performance. Research suggests that PHTN may not be the most important determinant of RV dysfunction. Both RV dysfunction and PHTN have independent prognostic significance. This review explores the unique anatomic and functional features of the RV and the pathophysiologic and prognostic implications of RV dysfunction in patients with MV disease in the perioperative period.
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Affiliation(s)
- J. Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
| | - Loreta Grecu
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
| | - Alina Nicoara
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
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Beaudry RI, Samuel TJ, Wang J, Tucker WJ, Haykowsky MJ, Nelson MD. Exercise cardiac magnetic resonance imaging: a feasibility study and meta-analysis. Am J Physiol Regul Integr Comp Physiol 2018; 315:R638-R645. [PMID: 29949409 DOI: 10.1152/ajpregu.00158.2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cardiac stress testing improves detection and risk assessment of heart disease. Magnetic resonance imaging (MRI) is the clinical gold-standard for assessing cardiac morphology and function at rest; however, exercise MRI has not been widely adapted for cardiac assessment because of imaging and device limitations. Commercially available magnetic resonance ergometers, together with improved imaging sequences, have overcome many previous limitations, making cardiac stress MRI more feasible. Here, we aimed to demonstrate clinical feasibility and establish the normative, healthy response to supine exercise MRI. Eight young, healthy subjects underwent rest and exercise cinematic imaging to measure left ventricular volumes and ejection fraction. To establish the normative, healthy response to exercise MRI we performed a comprehensive literature review and meta-analysis of existing exercise cardiac MRI studies. Results were pooled using a random effects model to define the left ventricular ejection fraction, end-diastolic, end-systolic, and stroke volume responses. Our proof-of-concept data showed a marked increase in cardiac index with exercise, secondary to an increase in both heart rate and stroke volume. The change in stroke volume was driven by a reduction in end-systolic volume, with no change in end-diastolic volume. These findings were entirely consistent with 17 previous exercise MRI studies (226 individual records), despite differences in imaging approach, ergometer, or exercise type. Taken together, the data herein demonstrate that exercise cardiac MRI is clinically feasible, using commercially available exercise equipment and vendor-provided product sequences and establish the normative, healthy response to exercise MRI.
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Affiliation(s)
- Rhys I Beaudry
- Department of Kinesiology, University of Texas at Arlington , Arlington, Texas
| | - T Jake Samuel
- Department of Kinesiology, University of Texas at Arlington , Arlington, Texas
| | - Jing Wang
- College of Nursing and Health Innovation, University of Texas at Arlington , Arlington, Texas
| | - Wesley J Tucker
- Department of Kinesiology, University of Texas at Arlington , Arlington, Texas
| | - Mark J Haykowsky
- College of Nursing and Health Innovation, University of Texas at Arlington , Arlington, Texas
| | - Michael D Nelson
- Department of Kinesiology, University of Texas at Arlington , Arlington, Texas
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