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Ozemek C, Hardwick J, Bonikowske A, Christle J, German C, Reddy S, Arena R, Faghy M. How to interpret a cardiorespiratory fitness assessment - Key measures that provide the best picture of health, disease status and prognosis. Prog Cardiovasc Dis 2024; 83:23-28. [PMID: 38417770 DOI: 10.1016/j.pcad.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 02/25/2024] [Indexed: 03/01/2024]
Abstract
Graded exercise testing is a widely accepted tool for revealing cardiac ischemia and/or arrhythmias in clinical settings. Cardiopulmonary exercise testing (CPET) measures expired gases during a graded exercise test making it a versatile tool that helps reveal underlying physiologic abnormalities that are in many cases only present with exertion. It also characterizes one's health status and clinical trajectory, informs the therapeutic plan, evaluates the efficacy of therapy, and provides submaximal and maximal information that can be used to tailor an exercise intervention. Practitioners can also modify the mode and protocol to allow individuals of all ages, fitness levels, and most disease states to perform a CPET. When used to its full potential, CPET can be a key tool used to optimize care in primary and secondary prevention settings.
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Affiliation(s)
- Cemal Ozemek
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA.
| | - Joel Hardwick
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Amanda Bonikowske
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey Christle
- Division of Cardiovascular Medicine, Stanford University, School of Medicine, Stanford, CA, USA
| | - Charles German
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Satyajit Reddy
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Mark Faghy
- Human Sciences Research Centre, College of Science and Engineering, University of Derby, UK
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2
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Leite GW, Alcantara Zimmermann ND, Alves JL, Salge JM, de Albuquerque ALP. The Relevance of Dysautonomia on Exercise Responses. Ann Am Thorac Soc 2023; 20:1813-1818. [PMID: 38038599 DOI: 10.1513/annalsats.202303-219cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 10/14/2023] [Indexed: 12/02/2023] Open
Affiliation(s)
- Guilherme Ward Leite
- Pneumologia-Incor, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brasil
| | - Natalia de Alcantara Zimmermann
- Pneumologia-Incor, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brasil
| | - José Leonidas Alves
- Pneumologia-Incor, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brasil
| | - João Marcos Salge
- Pneumologia-Incor, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brasil
| | - André Luis Pereira de Albuquerque
- Pneumologia-Incor, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brasil
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Cunha G, Apostolo A, De Martino F, Salvioni E, Matavelli I, Agostoni P. Exercise oscillatory ventilation: the past, present, and future. Eur J Prev Cardiol 2023; 30:ii22-ii27. [PMID: 37819229 DOI: 10.1093/eurjpc/zwad205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/22/2023] [Accepted: 06/12/2023] [Indexed: 10/13/2023]
Abstract
Exercise oscillatory ventilation (EOV) is a fascinating event that can be appreciated in the cardiopulmonary exercise test and is characterized by a cyclic fluctuation of minute ventilation, tidal volume, oxygen uptake, carbon dioxide production, and end-tidal pressure for oxygen and carbon dioxide. Its mechanisms stem from a dysregulation of the normal control feedback of ventilation involving one or more of its components, namely, chemoreflex delay, chemoreflex gain, plant delay, and plant gain. In this review, we intend to breakdown therapeutic targets according to pathophysiology and revise the prognostic value of exercise oscillatory ventilation in the setting of heart failure and other diagnoses.
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Affiliation(s)
- Gonçalo Cunha
- Cardiology department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, 2790-134 Carnaxide, Portugal
| | - Anna Apostolo
- Heart failure department, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | | | - Irene Matavelli
- Heart failure department, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Piergiuseppe Agostoni
- Heart failure department, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Dos Santos Ribeiro G, Beltrame T, Fernando Deresz L, Hansen D, Agostoni P, Karsten M. Software development to standardize the clinical diagnosis of exercise oscillatory ventilation in heart failure. J Clin Monit Comput 2023; 37:1247-1253. [PMID: 36735189 DOI: 10.1007/s10877-023-00976-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is characterized by periodic oscillations of minute ventilation during cardiopulmonary exercise testing (CPET). Despite its prognostic value in chronic heart failure (HF), its diagnosis is complex due to technical limitations. An easier and more accurate way of EOV identification can contribute to a better approach and clinical diagnosis. This study aims to describe a software development to standardize the EOV diagnosis from CPET's raw data in heart failure patients and test its reliability (intra- and inter-rater). METHODS The software was developed in the "drag-and-drop" G-language using LabVIEW®. Five EOV definitions (Ben-Dov, Corrà, Kremser, Leite, and Sun definitions), two alternative approaches, one smoothing technique, and some basic statistics were incorporated into the interface to visualize four charts of the ventilatory response. EOV identification was based on a set of criteria verified from the interaction between amplitude, cycle length, and oscillation time. Two raters analyzed the datasets. In addition, repeated measurements were verified after six months using about 25% of the initial data. Cohen's kappa coefficient (κ) was used to investigate the reliability. RESULTS Overall, 391 tests were analyzed in duplicate (inter-rater reliability) and 100 tests were randomized for new analysis (intra-rater reliability). High inter-rater (κ > 0.80) and intra-rater (κ > 0.80) reliability of the five EOV diagnoses were observed. CONCLUSION The present study proposes novel semi-automated software to detect EOV in HF, with high inter and intra-rater agreements. The software project and its tutorial are freely available for download.
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Affiliation(s)
- Gustavo Dos Santos Ribeiro
- Programa de Pós-Graduação em Ciências da Reabilitação, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Thomas Beltrame
- Samsung R&D Institute Brazil - SRBR, Universidade Federal de São Carlos (UFSCAR), Campinas, SP, Brazil
| | - Luís Fernando Deresz
- Departamento de Educação Física, Universidade Federal de Juiz de Fora (UFJF), Governador Valadares, MG, Brazil
| | - Dominique Hansen
- Faculty of Rehabilitation Sciences, Hasselt University (UHASSELT), BIOMED/REVAL, Hasselt, Belgium
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences of Community Health, Cardiovascular Section, University of Milano, Milano, Italy
| | - Marlus Karsten
- Programa de Pós-Graduação em Ciências da Reabilitação, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
- Departamento de Fisioterapia, Universidade do Estado de Santa Catarina (UDESC), Florianópolis, SC, Brazil
- Programa de Pós-Graduação em Fisioterapia, UDESC, Florianópolis, SC, Brazil
- Centro de Ciências da Saúde e do Esporte, UDESC, Rua Pascoal Simone 358, CEP 88080-350, Florianópolis, SC, Brazil
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Goulart CDL, Silva RN, Agostoni P, Franssen FME, Myers J, Arena R, Borghi-Silva A. Exercise oscillatory ventilation in patients with coexisting chronic obstructive pulmonary disease and heart failure: Clinical implications. Respir Med 2023; 217:107332. [PMID: 37356636 DOI: 10.1016/j.rmed.2023.107332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is considered an important variable for predicting poor prognosis in patients with heart failure (HF) with reduced left ventricular ejection fraction (HFrEF). However, there are no studies evaluating EOV presence in the coexistence chronic obstructive pulmonary disease (COPD) and HFrEF. AIMS I) To compare the clinical characteristics of participants with coexisting HFrEF-COPD with and without EOV during cardiopulmonary exercise testing (CPET); and II) to identify the impact of EOV on mortality during follow-up for 35 months. METHODS 50 stable HFrEF-COPD (EF<50%) participants underwent CPET and were followed for 35 months. The parametric Student's t-test, chi-square tests, linear regression model and Kaplan-Meier analysis were applied. RESULTS We identified 13 (26%) participants with EOV and 37 (74%) without EOV (N-EOV) during exercise. The EOV group had worse cardiac function (LVEF: 30 ± 6% vs. N-EOV 40 ± 9%, p = 0.007), worse pulmonary function (FEV1: 1.04 ± 0.7 L vs. N-EOV 1.88 ± 0.7 L, p = 0.007), a higher mortality rate [7 (54%) vs. N-EOV 8 (27%), p = 0.02], higher minute ventilation/carbon dioxide production (V̇˙E/ V̇˙ CO2) slope (42 ± 7 vs. N-EOV 36 ± 8, p = 0.04), reduced peak ventilation (L/min) (26.2 ± 16.7 vs. N-EOV 40.3 ± 16.4, p = 0.01) and peak oxygen uptake (mlO2 kg-1 min-1) (11.0 ± 4.0 vs. N-EOV 13.5 ± 3.4 ml●kg-1●min-1, p = 0.04) when compared with N-EOV group. We found that EOV group had a higher risk of mortality during follow-up (long-rank p = 0.001) than patients with N-EOV group. CONCLUSION The presence of EOV is associated with greater severity of coexisting HFrEF and COPD and a reduced prognosis. Assessment of EOV in participants with coexisting HFrEF-COPD, as a biomarker for both clinical status and prognosis may therefore be warranted.
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Affiliation(s)
- Cássia da Luz Goulart
- Cardiopulmonary Physiotherapy Laboratory, Physiotherapy Department, Federal University of Sao Carlos, UFSCar, Sao Carlos, SP, Brazil
| | - Rebeca Nunes Silva
- Cardiopulmonary Physiotherapy Laboratory, Physiotherapy Department, Federal University of Sao Carlos, UFSCar, Sao Carlos, SP, Brazil
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, 20138, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy
| | - Frits M E Franssen
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jonathan Myers
- Division of Cardiovascular Medicine, VA Palo Alto Health Care System, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Audrey Borghi-Silva
- Cardiopulmonary Physiotherapy Laboratory, Physiotherapy Department, Federal University of Sao Carlos, UFSCar, Sao Carlos, SP, Brazil.
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Sakellaropoulos SG, Steinberg BS. Hypertrophic Cardiomyopathy: A Cardiovascular Challenge Becoming a Contemporary Treatable Disease. Cardiol Res 2023; 14:243-249. [PMID: 37559708 PMCID: PMC10409543 DOI: 10.14740/cr1514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/30/2023] [Indexed: 08/11/2023] Open
Abstract
Hypertrophic cardiomyopathy is one of the most common genetic inherited diseases of myocardium, which is caused by mutation in genes encoding proteins for the cardiac sarcomere. It is the most frequent cause of sudden death in young people and trained athletes. All diagnostic methods, including heart catheterization, transthoracic and transesophageal echocardiography, magnetic resonance imaging, genetic counseling and tissue biopsy are required for risk and therapy stratification and should be individualized depending on phenotype and genotype. Current therapy has not been tested adequately. Beta-blockers and verapamil can cause hypotension which can make hypertrophic cardiomyopathy worse. Disopyramide has been inadequately studied, and mavacamten was only studied in small trials. More definitive trials are currently ongoing. Novel invasive and noninvasive diagnostics, medical therapies, interventional and surgical approaches tend to influence the natural history of the disease, favoring a better future for this patient population.
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Magrì D, Palermo P, Salvioni E, Mapelli M, Gallo G, Vignati C, Mattavelli I, Gugliandolo P, Maruotti A, Di Loro PA, Fiori E, Sciomer S, Agostoni P. Influence of exertional oscillatory breathing and its temporal behavior in patients with heart failure and reduced ejection fraction. Int J Cardiol 2023:S0167-5273(23)00659-9. [PMID: 37164295 DOI: 10.1016/j.ijcard.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/12/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Exertional oscillatory breathing (EOV) represents an emerging prognostic marker in heart failure (HF) patients, however little is known about EOV meaning with respect to its disappearance/persistence during cardiopulmonary exercise test (CPET). The present single-center study evaluated EOV clinical and prognostic impact in a large cohort of reduced ejection fraction HF patients (HFrEF) and, contextually, if a specific EOV temporal behavior might be an addictive risk predictor. METHODS AND RESULTS Data from 1.866 HFrEF patients on optimized medical therapy were analysed. The primary cardiovascular (CV) study end-point was cardiovascular death, heart transplantation or LV assistance device (LVAD) implantation at 5-years. For completeness a secondary end-point of total mortality at 5- years was also explored. EOV presence was identified in 251 patients (13%): 142 characterized by EOV early cessation (Group A) and 109 by EOV persistence during the whole CPET (Group B). The entire EOV Group showed worse clinical and functional status than NoEOV Group (n = 1.615) and, within the EOV Group, Group B was characterized by a more severe HF. At CV survival analysis, EOV patients showed a poorer outcome than the NoEOV Group (events 27.1% versus 13.1%, p < 0.001) both unpolished and after matching for main confounders. Instead, no significant differences were found between EOV Group A and B with respect to CV outcome. Conversely the analysis for total mortality failed to be significant. CONCLUSIONS Our analysis, albeit retrospective, supports the inclusion of EOV into a CPET-centered clinical and prognostic evaluation of the HFrEF patients. EOV characterizes per se a more advanced HFrEF stage with an unfavorable CV outcome. However, the EOV persistence, albeit suggestive of a more severe HF, does not emerge as a further prognostic marker.
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Affiliation(s)
- Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, "Sapienza" University, Rome, Italy
| | | | | | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.; Dept. of Clinical sciences and Community health, Cardiovascular Section, University of Milano, Milan, Italy
| | - Giovanna Gallo
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, "Sapienza" University, Rome, Italy
| | | | | | | | - Antonello Maruotti
- Dipartimento di Giurisprudenza, Economia, Politica e Lingue Moderne - Libera Università Maria Ss Assunta; Department of Mathematics, University of Bergen, Norway; School of Computing, University of Portsmouth, United Kingdom
| | | | - Emiliano Fiori
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, "Sapienza" University, Rome, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza" University, Rome, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.; Dept. of Clinical sciences and Community health, Cardiovascular Section, University of Milano, Milan, Italy..
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Cunha GJL, Maltês S, Rocha BML, Nina D, Aguiar C, Andrade MJ, Moreno L, Durazzo A, Mendes M, Agostoni P. Beyond exercise oscillatory ventilations: the prognostic impact of loop gain in heart failure. Eur J Prev Cardiol 2023; 30:zwad021. [PMID: 36707994 DOI: 10.1093/eurjpc/zwad021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/07/2023] [Accepted: 01/24/2023] [Indexed: 01/29/2023]
Abstract
Exercise oscillatory ventilation (EOV) is a strong prognostic marker in patients with heart failure (HF) and left ventricular (LV) dysfunction. This phenomenon can be explained through a single quantitative measurement of ventilatory instability, the loop gain. Therefore, we aimed to evaluate whether loop gain could be a better tool than subjective EOV evaluation to identify HF patients with a higher risk of major cardiovascular complications. This was a single-center retrospective study that included patients with left ventricular ejection fraction (LVEF) ≤ 50% consecutively referred for cardiopulmonary exercise testing (CPET) from 2016-2020. Loop gain was measured through computational evaluation of the minute ventilation graph. Of the 250 patients included, the 66 that presented EOV also had higher values of loop gain, when compared to patients without EOV. Those with both EOV and higher loop gain had more severe HF, with higher NT-proBNP and VE/VCO2 slope as well as lower peak VO2 and LVEF. On multivariable analysis, loop gain was strongly correlated with the composite endpoint of cardiovascular death, urgent heart transplantation, urgent left ventricular assist device implantation or HF hospitalization, even after correcting for peak VO2, LVEF, VE/VCO2 slope and NT-proBNP. Presence of EOV was not prognostically significant in this analysis. Loop gain is an objective parameter that quantifies ventilatory instability and showed to have a strong prognostic value in a cohort of patients with HF and LVEF ≤ 50%, outperforming the classification of EOV.
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Affiliation(s)
- Gonçalo J L Cunha
- Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Sérgio Maltês
- Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Bruno M L Rocha
- Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | | | - Carlos Aguiar
- Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Maria J Andrade
- Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Luís Moreno
- Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Anaí Durazzo
- Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Miguel Mendes
- Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
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Neder JA, Phillips DB, O'Donnell DE, Dempsey JA. Excess ventilation and exertional dyspnoea in heart failure and pulmonary hypertension. Eur Respir J 2022; 60:13993003.00144-2022. [PMID: 35618273 DOI: 10.1183/13993003.00144-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023]
Abstract
Increased ventilation relative to metabolic demands, indicating alveolar hyperventilation and/or increased physiological dead space (excess ventilation), is a key cause of exertional dyspnoea. Excess ventilation has assumed a prominent role in the functional assessment of patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We herein provide the key pieces of information to the caring physician to 1) gain unique insights into the seeds of patients' shortness of breath and 2) develop a rationale for therapeutically lessening excess ventilation to mitigate this distressing symptom. Reduced bulk oxygen transfer induced by cardiac output limitation and/or right ventricle-pulmonary arterial uncoupling increase neurochemical afferent stimulation and (largely chemo-) receptor sensitivity, leading to alveolar hyperventilation in HFrEF, PAH and small-vessel, distal CTEPH. As such, interventions geared to improve central haemodynamics and/or reduce chemosensitivity have been particularly effective in lessening their excess ventilation. In contrast, 1) high filling pressures in HFpEF and 2) impaired lung perfusion leading to ventilation/perfusion mismatch in proximal CTEPH conspire to increase physiological dead space. Accordingly, 1) decreasing pulmonary capillary pressures and 2) mechanically unclogging larger pulmonary vessels (pulmonary endarterectomy and balloon pulmonary angioplasty) have been associated with larger decrements in excess ventilation. Exercise training has a strong beneficial effect across diseases. Addressing some major unanswered questions on the link of excess ventilation with exertional dyspnoea under the modulating influence of pharmacological and nonpharmacological interventions might prove instrumental to alleviate the devastating consequences of these prevalent diseases.
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Affiliation(s)
- J Alberto Neder
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Dept of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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10
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Haouzi P. Revisiting the effects of the reciprocal function between alveolar ventilation and CO 2 partial pressure (PACO2) on PACO2 homeostasis at rest and in exercise. J Appl Physiol (1985) 2022; 133:913-916. [PMID: 35511724 PMCID: PMC9829475 DOI: 10.1152/japplphysiol.00058.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/04/2022] [Accepted: 05/02/2022] [Indexed: 01/21/2023] Open
Affiliation(s)
- Philippe Haouzi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
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11
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Belli-Marin JFC, Bocchi EA, Ayub-Ferreira S, Junior NC, Guimarães GV. Effects of β-blocker therapy on exercise oscillatory ventilation in reduced ejection fraction heart failure patients: A case series study. Biomed Pharmacother 2022; 152:113106. [PMID: 35665667 DOI: 10.1016/j.biopha.2022.113106] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/03/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is an abnormal breathing pattern that occurs in ~20% of patients with heart failure (HF) and is associated with poor prognosis and exercise intolerance. β-blockers (βb) are prescribed for most HF patients; however, their effect on EOV remains unclear. We evaluated the effect of βb on EOV in HF patients with reduced ejection fraction (HFrEF). METHODS Fifteen patients diagnosed with HF, ejection fraction < 45%, aged from 18 to 65 years, were included before starting βb therapy. Patients underwent clinical evaluation, cardiopulmonary exercise testing, echocardiography, laboratory exams (norepinephrine levels, B type natriuretic peptide) at baseline and after βb therapy optimized for six months. Presence of exercise oscillatory breathing was determined by two experienced observers who were blinded to the moment of the test (pre or post). RESULTS Fifteen patients (1 female), aged 49.5 ± 2.5 years, with HFrEF, NYHA I-III enrolled in the study. The etiologies of the HFrEF were idiopathic (n = 8) and hypertensive (n = 7). LVEF increased after βb therapy from 25.9 ± 2.5% to 33 ± 2.6%, P = 0.02; peak VO2 did not significantly change (21.8 ± 1.7 vs 24.7 ± 1.9, P = 0.4); VE/VCO2 slope changed from 32.1 ± 10.6-27.5 ± 9.1, P = 0.03. Before βb initiation, nine patients (60%) had EOV, but only two (13%) did after optimized therapy. McNemar test was used to evaluate the significance of the association between the two moments (P = 0.02). CONCLUSION In patients with HF, medical therapy with βb can reverse EOV. This may explain why these patients experience symptom improvement after βb therapy.
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Affiliation(s)
| | - Edimar Alcides Bocchi
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Silvia Ayub-Ferreira
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Nelson Carvas Junior
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Guilherme Veiga Guimarães
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
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12
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Ribeiro GDS, Deresz LF, Salvioni E, Hansen D, Agostoni P, Karsten M. Sensitivity and specificity of different exercise oscillatory ventilation definitions to predict 2-year major adverse cardiovascular outcomes in chronic heart failure patients. Int J Cardiol 2022; 360:39-43. [PMID: 35623479 DOI: 10.1016/j.ijcard.2022.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) shows a four-fold greater risk of adverse events. This study aims to analyze the sensitivity and specificity of three EOV diagnostic definitions to predict adverse outcomes at a 2-year follow-up and to compare its EOV prevalence and relations with the patient's profile. METHODS Cardiopulmonary exercise tests from 233 heart failure patients were analyzed. Two blinded reviewers used a semiautomated software to identify EOV cases pattern according to the definitions of Ben-Dov, Corrà, and Leite. Data were grouped in EOV-positive or EOV-negative according to each definition. Baseline characteristics, EOV prevalence, relative risk, sensitivity, and specificity to predict 2-years of major adverse cardiovascular outcomes were analyzed. RESULTS The Corrà definition led to the best prediction of 2-year major cardiovascular adverse outcomes (HR 2.46 [1.16 to 5.25]; p = 0.019, AUC = 0.618; p = 0.007). EOV prevalence was 17.2%, 17.2%, and 9.4% applying Ben-Dov, Corrà, and Leite definition, respectively. The main clinical differences between EOV-positive and EOV-negative patients were: MECKI score and VE/VCO2 slope (all definitions), and BNP levels (Ben-Dov and Leite). BNP levels were correlated with amplitude (rho = 0.255; p = 0.033) and cycle length (rho = 0.388; p = 0.002). CONCLUSION Corrà definition was the only one that exhibited the capacity to predict major adverse cardiovascular outcomes at a 2-year follow-up. Regardless of its definition, EOV was more often prevalent in patients with a greater MECKI score and VE/VCO2 slope values.
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Affiliation(s)
- Gustavo Dos Santos Ribeiro
- Programa de Pós-Graduação em Ciências da Reabilitação, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Luís Fernando Deresz
- Departamento de Educação Física, Universidade Federal de Juiz de Fora (UFJF), Governador Valadares, Brazil
| | | | - Dominique Hansen
- Hasselt University (UHASSELT), Faculty of Rehabilitation Sciences, BIOMED/REVAL, Hasselt, Belgium; Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences of Community Health, Cardiovascular Section, University of Milano, Milano, Italy
| | - Marlus Karsten
- Programa de Pós-Graduação em Ciências da Reabilitação, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil; Departamento de Fisioterapia, Universidade do Estado de Santa Catarina (UDESC), Florianópolis, Brazil; Programa de Pós-Graduação em Fisioterapia, UDESC, Florianópolis, Brazil.
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13
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Corrà U, Piepoli MF, Giordano A, Doni F, Magini A, Bonomi A, Salvioni E, Lagioia R, Limongelli G, Paolillo S, Magrì D, Filardi PP, Sinagra G, Scardovi AB, Metra M, Senni M, Scrutinio D, Raimondo R, Emdin M, Cattadori G, Parati G, Re F, Cicoira M, Minà C, Correale M, Frigerio M, Perna E, Bussotti M, Battaia E, Guazzi M, Bandera F, Badagliacca R, Lenarda AD, Maggioni A, Passino C, Sciomer S, Pacileo G, Mapelli M, Vignati C, Clemenza F, Lombardi C, Agostoni P. Revisiting a Prognosticating Algorithm from Cardiopulmonary Exercise Testing in Chronic Heart Failure (from the MECKI Score Population). Am J Cardiol 2022; 180:65-71. [DOI: 10.1016/j.amjcard.2022.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 11/01/2022]
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14
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da Luz Goulart C, Agostoni P, Salvioni E, Kaminsky LA, Myers J, Arena R, Borghi-Silva A. Exercise Oscillatory Breathing in Heart Failure with reduced ejection fraction: clinical implication. Eur J Prev Cardiol 2022; 29:1692-1698. [PMID: 35708730 DOI: 10.1093/eurjpc/zwac116] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/22/2022] [Accepted: 06/01/2022] [Indexed: 01/26/2023]
Abstract
AIM I) to evaluate the impact of exertional oscillatory ventilation (EOV) in patients with heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) during cardiopulmonary exercise testing (CPET) compared with patients without EOV (N-EOV); II) to identify the influence of EOV persistence (P-EOV) and EOV disappearance (D-EOV) during CPET on the outcomes of mortality and hospitalization in HFrEF patients; and III) to identify further predictors of mortality and hospitalization in patients with P-EOV. METHODS AND RESULTS 315 stable HFrEF patients underwent CPET and were followed for 35 months. We identified 202 patients N-EOV and 113 patients with EOV. Patients with EOV presented more symptoms (NYHA III: 35% vs. N-EOV 20%, p < 0.05), worse cardiac function (LVEF: 28 ± 6 vs. N-EOV 39 ± 1, p < 0.05), higher minute ventilation/carbon dioxide production (V̇E/V̇CO2 slope: 41 ± 11 vs. N-EOV 37 ± 8, p < 0.05) and a higher rate of deaths (26% vs. N-EOV 6%, p < 0.05) and hospitalization (29% vs. N-EOV 9%, p < 0.05). P-EOV patients had more severe HFrEF (NYHA IV: 23% vs D-EOV: 9%, p < 0.05), had worse cardiac function (LVEF: 24 ± 5 vs. D-EOV: 34 ± 3, p < 0.05) and had lower peak oxygen consumption (V̇O2) (12.0 ± 3.0 vs D-EOV: 13.3 ± 3.0 mlO2.kg-1.min-1, p < 0.05). Among P-EOV, other independent predictors of mortality were V̇E/V̇CO2 slope ≥36 and V̇O2 peak ≤12 mlO2.kg-1.min-1; a V̇E/V̇CO2 slope≥34 was a significant predictor of hospitalization. Kaplan-Meier survival analysis showed that, HFrEF patients with P-EOV had a higher risk of mortality and higher risk of hospitalization (p < 0.05) than patients with D-EOV and N-EOV. CONCLUSION In HFrEF patients, EOV persistence during exercise had a strong prognostic role. In P-EOV patients V̇E/V̇CO2 ≥36 and V̇O2 peak ≤12 mlO2.kg-1.min-1, had a further additive negative prognostic role.
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Affiliation(s)
- Cássia da Luz Goulart
- Cardiopulmonary Physiotherapy Laboratory, Physiotherapy Department, Federal University of Sao Carlos, UFSCar, Rodovia Washington Luis, KM 235, Monjolinho, CEP: 13565-905, Sao Carlos, SP, Brazil
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan20138, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy
| | | | | | - Jon Myers
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Audrey Borghi-Silva
- Cardiopulmonary Physiotherapy Laboratory, Physiotherapy Department, Federal University of Sao Carlos, UFSCar, Rodovia Washington Luis, KM 235, Monjolinho, CEP: 13565-905, Sao Carlos, SP, Brazil
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15
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Chuang ML, Tsai CF, Ueng KC, Weng JH, Tsai MF, Lo CH, Chen GB, Sia SK, Chuang YT, Wu TC, Kao PF, Hsieh MJ. The Impact of Oxygen Pulse and Its Curve Patterns on Male Patients with Heart Failure, Chronic Obstructive Pulmonary Disease, and Healthy Controls-Ejection Fractions, Related Factors and Outcomes. J Pers Med 2022; 12:703. [PMID: 35629127 PMCID: PMC9146512 DOI: 10.3390/jpm12050703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 12/04/2022] Open
Abstract
Oxygen pulse (O2P) is a function of stroke volume and cellular oxygen extraction and O2P curve pattern (O2PCP) can provide continuous measurements of O2P. However, measurements of these two components are difficult during incremental maximum exercise. As cardiac function is evaluated using ejection fraction (EF) according to the guidelines and EF can be obtained using first-pass radionuclide ventriculography, the aim of this study was to investigate associations of O2P%predicted and O2PCP with EF in patients with heart failure with reduced or mildly reduced ejection fraction (HFrEF/HFmrEF) and chronic obstructive pulmonary disease (COPD), and also in normal controls. This was a prospective observational cross-sectional study. Correlations of resting left ventricular EF, dynamic right and left ventricular EFs and outcomes with O2P% and O2PCP across the three participant groups were analyzed. A total of 237 male subjects were screened and 90 were enrolled (27 with HFrEF/HFmrEF, 30 with COPD and 33 normal controls). O2P% and the proportions of the three types of O2PCP were similar across the three groups. O2P% reflected dynamic right and left ventricular EFs in the control and HFrEF/HFmrEF groups, but did not reflect resting left ventricular EF in all participants. O2PCP did not reflect resting or dynamic ventricular EFs in any of the subjects. A decrease in O2PCP was significantly related to nonfatal cardiac events in the HFrEF/HFmrEF group (log rank test, p = 0.01), whereas O2P% and O2PCP did not predict severe acute exacerbations of COPD. The findings of this study may clarify the utility of O2P and O2PCP, and may contribute to the currently used interpretation algorithm and the strategy for managing patients, especially those with HFrEF/HFmrEF. (Trial registration number NCT05189301.).
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Affiliation(s)
- Ming-Lung Chuang
- Division of Pulmonary Medicine and Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan; (G.-B.C.); (T.-C.W.)
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan; (C.-F.T.); (K.-C.U.); (J.-H.W.); (S.-K.S.); (Y.-T.C.); (P.-F.K.)
| | - Chin-Feng Tsai
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan; (C.-F.T.); (K.-C.U.); (J.-H.W.); (S.-K.S.); (Y.-T.C.); (P.-F.K.)
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
| | - Kwo-Chang Ueng
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan; (C.-F.T.); (K.-C.U.); (J.-H.W.); (S.-K.S.); (Y.-T.C.); (P.-F.K.)
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
| | - Jui-Hung Weng
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan; (C.-F.T.); (K.-C.U.); (J.-H.W.); (S.-K.S.); (Y.-T.C.); (P.-F.K.)
- Department of Nuclear Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Ming-Fong Tsai
- Department of Nuclear Medicine, Chiayi Chang Gung Memorial Hospital, Chang Gung Medical Foundation, Chiayi 61301, Taiwan;
| | - Chien-Hsien Lo
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
- Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Gang-Bin Chen
- Division of Pulmonary Medicine and Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan; (G.-B.C.); (T.-C.W.)
| | - Sung-Kien Sia
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan; (C.-F.T.); (K.-C.U.); (J.-H.W.); (S.-K.S.); (Y.-T.C.); (P.-F.K.)
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
| | - Yao-Tsung Chuang
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan; (C.-F.T.); (K.-C.U.); (J.-H.W.); (S.-K.S.); (Y.-T.C.); (P.-F.K.)
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
| | - Tzu-Chin Wu
- Division of Pulmonary Medicine and Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan; (G.-B.C.); (T.-C.W.)
| | - Pan-Fu Kao
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan; (C.-F.T.); (K.-C.U.); (J.-H.W.); (S.-K.S.); (Y.-T.C.); (P.-F.K.)
- Department of Nuclear Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Meng-Jer Hsieh
- Department of Respiratory Therapy, Chang Gung University, Taoyuan 33303, Taiwan
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang Gung Memorial Hospital, Chang Gung Medical Foundation, Chiayi 61301, Taiwan
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16
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Kulej-Lyko K, Niewinski P, Tubek S, Ponikowski P. Contribution of Peripheral Chemoreceptors to Exercise Intolerance in Heart Failure. Front Physiol 2022; 13:878363. [PMID: 35492596 PMCID: PMC9046845 DOI: 10.3389/fphys.2022.878363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/29/2022] [Indexed: 01/08/2023] Open
Abstract
Peripheral chemoreceptors (PChRs), because of their strategic localization at the bifurcation of the common carotid artery and along the aortic arch, play an important protective role against hypoxia. Stimulation of PChRs evokes hyperventilation and hypertension to maintain adequate oxygenation of critical organs. A relationship between increased sensitivity of PChRs (hyperreflexia) and exercise intolerance (ExIn) in patients with heart failure (HF) has been previously reported. Moreover, some studies employing an acute blockade of PChRs (e.g., using oxygen or opioids) demonstrated improvement in exercise capacity, suggesting that hypertonicity is also involved in the development of ExIn in HF. Nonetheless, the precise mechanisms linking dysfunctional PChRs to ExIn remain unclear. From the clinical perspective, there are two main factors limiting exercise capacity in HF patients: subjective perception of dyspnoea and muscle fatigue. Both have many determinants that might be influenced by abnormal signalling from PChRs, including: exertional hyperventilation, oscillatory ventilation, ergoreceptor oversensitivity, and augmented sympathetic tone. The latter results in reduced muscle perfusion and altered muscle structure. In this review, we intend to present the milieu of abnormalities tied to malfunctioning PChRs and discuss their role in the complex relationships leading, ultimately, to ExIn.
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Affiliation(s)
- Katarzyna Kulej-Lyko
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
- *Correspondence: Katarzyna Kulej-Lyko,
| | - Piotr Niewinski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
| | - Stanislaw Tubek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
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18
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Ministro G, Castaño JB, Barboza CA, Moura EG, Ferreira-Melo SE, Mostarda CT, Fattori A, Moreno-Junior H, Rodrigues B. ACUTE TRANSCRANIAL DIRECT CURRENT STIMULATION (tDCS) IMPROVES VENTILATORY VARIABILITY AND AUTONOMIC MODULATION IN RESISTANT HYPERTENSIVE PATIENTS. Respir Physiol Neurobiol 2021; 297:103830. [PMID: 34915178 DOI: 10.1016/j.resp.2021.103830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/29/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
Here, we assessed the impact of one session of transcranial direct current stimulation (tDCS) or SHAM (20 min, each) on ventilatory responses to cardiopulmonary exercise test, central and peripheral blood pressure (BP), and autonomic modulation in resistant hypertensive (RHT) patients. RHT subjects (n = 13) were randomly submitted to SHAM and tDCS crossing sessions (1 week of "washout"). Patients and a technician who set the tDCS/Sham room up were both blind. After brain stimulation, patients were submitted to a cardiopulmonary exercise test to evaluate ventilatory and cardiovascular response to exercise. Hemodynamic (Finometer®, Beatscope), and autonomic variables were measured at baseline (before tDCS/Sham) and after incremental exercise. RESULTS: Our study shows that tDCS condition improved heart rate recovery, VO2 peak, and vagal modulation (after cardiopulmonary exercise test); attenuated the ventilatory variability response, central and peripheral blood pressure well as sympathetic modulation (after cardiopulmonary exercise test) in comparison with SHAM. These data suggest that acute tDCS sessions prevented oscillatory ventilation behavior during the cardiopulmonary exercise test and mitigated the increase of systolic blood pressure in RHT patients. After the exercise test, tDCS promotes better vagal reentry and improved autonomic modulation, possibly reducing central blood pressure and aortic augmentation index compared to SHAM. Brazilian Registry of Clinical Trials (ReBEC): https://ensaiosclinicos.gov.br/rg/RBR-8n7c9p.
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Affiliation(s)
- Gabriela Ministro
- Laboratory of Cardiovascular Investigation & Exercise, School of Physical Education, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Javier B Castaño
- Laboratory of Cardiovascular Investigation & Exercise, School of Physical Education, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Catarina A Barboza
- Laboratory of Cardiovascular Investigation & Exercise, School of Physical Education, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Eliezer G Moura
- Laboratory of Cardiovascular Investigation & Exercise, School of Physical Education, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Silvia E Ferreira-Melo
- Laboratory of Cardiovascular Pharmacology & Hypertension, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | | | - André Fattori
- Department of Clinical Medicine, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Heitor Moreno-Junior
- Laboratory of Cardiovascular Pharmacology & Hypertension, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Bruno Rodrigues
- Laboratory of Cardiovascular Investigation & Exercise, School of Physical Education, University of Campinas (UNICAMP), Campinas, SP, Brazil; Laboratory of Cardiovascular Pharmacology & Hypertension, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil.
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19
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Segreti A, Verolino G, Crispino SP, Agostoni P. Listing Criteria for Heart Transplant: Role of Cardiopulmonary Exercise Test and of Prognostic Scores. Heart Fail Clin 2021; 17:635-646. [PMID: 34511211 DOI: 10.1016/j.hfc.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patients with advanced heart failure (AdHF) have a reduced quality of life and poor prognosis. A heart transplant (HT) is an effective treatment for such patients. Still, because of a shortage of donor organs, the final decision to place a patient without contraindications on the HT waiting list is based on detailed risk-benefit analysis. Cardiopulmonary exercise tests (CPETs) play a pivotal role in guiding selection in patients with AdHF considered for an HT. Furthermore, several validated multivariable predicting scores obtained through various techniques, including the CPETs, are available and part of the decision-making process for HT listing.
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Affiliation(s)
- Andrea Segreti
- Unit of Cardiovascular Science, Campus Bio-Medico University of Rome, Rome, Italy.
| | - Giuseppe Verolino
- Unit of Cardiovascular Science, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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20
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Cazco MDP, Lorenzi-Filho G. Síndrome de apnea obstructiva del sueño y sus consecuencias cardiovasculares. REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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21
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Neder JA, Phillips DB, Marillier M, Bernard AC, Berton DC, O'Donnell DE. Clinical Interpretation of Cardiopulmonary Exercise Testing: Current Pitfalls and Limitations. Front Physiol 2021; 12:552000. [PMID: 33815128 PMCID: PMC8012894 DOI: 10.3389/fphys.2021.552000] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 03/01/2021] [Indexed: 12/12/2022] Open
Abstract
Several shortcomings on cardiopulmonary exercise testing (CPET) interpretation have shed a negative light on the test as a clinically useful tool. For instance, the reader should recognize patterns of dysfunction based on clusters of variables rather than relying on rigid interpretative algorithms. Correct display of key graphical data is of foremost relevance: prolixity and redundancy should be avoided. Submaximal dyspnea ratings should be plotted as a function of work rate (WR) and ventilatory demand. Increased work of breathing and/or obesity may normalize peak oxygen uptake (V̇O2) despite a low peak WR. Among the determinants of V̇O2, only heart rate is measured during non-invasive CPET. It follows that in the absence of findings suggestive of severe impairment in O2 delivery, the boundaries between inactivity and early cardiovascular disease are blurred in individual subjects. A preserved breathing reserve should not be viewed as evidence that "the lungs" are not limiting the subject. In this context, measurements of dynamic inspiratory capacity are key to uncover abnormalities germane to exertional dyspnea. A low end-tidal partial pressure for carbon dioxide may indicate either increased "wasted" ventilation or alveolar hyperventilation; thus, direct measurements of arterial (or arterialized) PO2 might be warranted. Differentiating a chaotic breathing pattern from the normal breath-by-breath noise might be complex if the plotted data are not adequately smoothed. A sober recognition of these limitations, associated with an interpretation report free from technicalities and convoluted terminology, is crucial to enhance the credibility of CPET in the eyes of the practicing physician.
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Affiliation(s)
- J Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen's University and Kingston General Hospital, Kingston, ON, Canada
| | - Devin B Phillips
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen's University and Kingston General Hospital, Kingston, ON, Canada
| | - Mathieu Marillier
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen's University and Kingston General Hospital, Kingston, ON, Canada
| | - Anne-Catherine Bernard
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen's University and Kingston General Hospital, Kingston, ON, Canada
| | - Danilo C Berton
- Division of Respirology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Denis E O'Donnell
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen's University and Kingston General Hospital, Kingston, ON, Canada
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Abrosimov VN, Ageeva KA, Filippov EV. [Evaluation of respiratory parameters in patients with chronic obstructive lung disease during physical exercises]. TERAPEVT ARKH 2021; 93:265-272. [PMID: 36286694 DOI: 10.26442/00403660.2021.03.200652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 11/22/2022]
Abstract
AIM To study the relationship between the indicators of dynamic capnography and pulse oximetry with the indicators of the 6-minute walk test (6MWT) in patients with chronic obstructive pulmonary disease (COPD). MATERIALS AND METHODS 67 patients of both sexes were examined: 45 patients with COPD (age 60.02.74 years) and 25 patients of the control group (age 47.603.46 years). The study of the functional capabilities of the patients respiratory system was carried out before, during and after the 6MWT on the equipment LifeSense LS1-9R capnograph-pulse oximeter (MedAir AB). RESULTS AND DISCUSSION In the comparison group, the parameters of dyspnea at rest were higher than the control group (p0.05), the spirometry indices were significantly lower (p0.05). Shortness of breath as a reason for stopping/slowing down the pace during the 6MWT was noted by patients of both groups (p0.05). When analyzing the PETCO2 trend graphs, periodic breathing (PВ) was revealed. In the group of patients with COPD, signs of PВ in the analysis of the PETCO2 trend were found in 80.95% (p0.05). Regression analysis of Cox proportional risks of mortality in patients with COPD revealed the prognostic value of the following parameters of a comprehensive assessment of the patient: body mass index (BMI), BODE index, dyspnea index on the mMRS scale, Borg, forced expiratory volume in 1 second (FEV1), index Tiffno, signs of PВ, distance 6MWT, signs of PВ and desaturation during 6MWT. At the same time, the total contribution of these indicators to the risk of a lethal event was assessed (p=0.003). CONCLUSION When analyzing the correlation dependence, it was revealed that the presence of PВ was a prognostically unfavorable sign in patients with COPD. Predictors of an unfavorable course of COPD were BMI (23.0 kg/m2), BODE index, dyspnea indices on the mMRS, Borg, FEV1 scales, Tiffnos index, signs of PH, distance 6MST, signs of PD and desaturation during 6MST (reliability of the model coefficient p=0.003) in terms of forecast.
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23
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Agostoni P, Emdin M, De Martino F, Apostolo A, Masè M, Contini M, Carriere C, Vignati C, Sinagra G. Roles of periodic breathing and isocapnic buffering period during exercise in heart failure. Eur J Prev Cardiol 2021; 27:19-26. [PMID: 33238742 PMCID: PMC7691624 DOI: 10.1177/2047487320952029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
In heart failure, exercise - induced periodic breathing and end tidal carbon dioxide pressure value during the isocapnic buffering period are two features identified at cardiopulmonary exercise testing strictly related to sympathetic activation. In the present review we analysed the physiology behind periodic breathing and the isocapnic buffering period and present the relevant prognostic value of both periodic breathing and the presence/absence of the identifiable isocapnic buffering period.
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Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Italy.,Department of Clinical Sciences and Community Health, University of Milano, Italy
| | - Michele Emdin
- Life Science Institute, Scuola Superiore Sant'Anna, Italy.,Fondazione Gabriele Monasterio, CNR-Regione Toscana, Italy
| | | | | | - Marco Masè
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Italy
| | | | - Cosimo Carriere
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Italy.,Department of Clinical Sciences and Community Health, University of Milano, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Italy
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24
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Abstract
In cardiopulmonary medicine, residual exertional dyspnea (RED) can be defined by the persistence of limiting breathlessness in a patient who is already under the best available therapy for the underlying heart and/or lung disease. RED is a challenge to the pulmonologist because the patient (and the referring physician) assumes that the "lung doctor" should invariably provide a successful plan to fight the symptom. After presenting a simplified framework to understand the neurobiological underpinnings of dyspnea in cardiorespiratory disease, I discuss the seeds of RED associated with 1) increased metabolic cost of work, 2) increased inspiratory constraints, 3) diaphragm dysfunction, 4) impaired right ventricle preload, 5) increased central and/or peripheral chemosensitivity, 6) increased physiological dead space, 7) increased pulmonary venous and/or high left ventricle filling pressures, 8) impaired chronotropic response to exertion, and 9) increased activation of the cortical-limbic circuits. I finalize by outlining the following two common coexistence of diseases in which these multiple mechanisms interact to produce severe RED: chronic obstructive pulmonary disease-heart failure with reduced ejection fraction and chronic pulmonary fibrosis-emphysema. RED exposes the important limitations of the current reductionist approach focused only on the (over)treatment of the poorly reversible cardiopulmonary disease(s). Conversely, recognizing the existence of RED sets the stage for a more holistic approach toward one of the most devastating symptoms known to man.
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25
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Corte RC, De Sá J, Carlos R, Felismino AS, Cruz NO, Onofre T, Pereira E, Bruno S. Ventilation Dispersion Index as an Objective Evaluation Tool of Exercise Oscillatory Ventilation in Patients With Heart Failure. J Card Fail 2020; 27:419-426. [PMID: 33038533 DOI: 10.1016/j.cardfail.2020.09.481] [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: 02/10/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is related to worse prognosis in patients with heart failure (HF). However, its determination is subjective and there is no standard measure to identify it. The aim of the study was to evaluate and characterize the EOV of patients with HF using the ventilation dispersion index (VDI). METHODS AND RESULTS Patients underwent cardiopulmonary exercise testing (CPX), EOV was assessed by 2 reviewers and the VDI was calculated. The receiver operator curve analysis was used to assess the ability of the VDI to predict EOV. Pearson's correlation test was performed to determine the relationship between VDI and CPX variables. Forty-three patients with HF underwent CPX and were divided into 2 groups: with a VDI of less than 0.601 and a VDI of 0.601 or greater. An area under the curve of 0.759 was observed in the receiver operator curve analysis between VDI and EOV (P = .008). The VDI showed a significant correlation with the ventilatory CPX variables. According to the cut-off point obtained on the receiver operator curve, patients with a VDI of 0.601 or greater had lower left ventricular ejection fraction and higher values of resting minute ventilation and peak minute ventilation. CONCLUSIONS The VDI proved to be a good predictor of EOV in patients with HF.
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Affiliation(s)
- Renata Cristina Corte
- Cardiovascular and metabolic rehabilitation laboratory, postgraduate physical therapy program, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Joceline De Sá
- Cardiovascular and metabolic rehabilitation laboratory, physical therapy department, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Renata Carlos
- Cardiovascular and metabolic rehabilitation laboratory, postgraduate physical therapy program, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Amanda Soares Felismino
- Cardiovascular and metabolic rehabilitation laboratory, postgraduate physical therapy program, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Nicole Oliver Cruz
- Cardiovascular and metabolic rehabilitation laboratory, postgraduate physical therapy program, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Tatiana Onofre
- Cardiovascular and metabolic rehabilitation laboratory, postgraduate physical therapy program, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Eliane Pereira
- Integrated medicine department, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
| | - Selma Bruno
- Cardiovascular and metabolic rehabilitation laboratory, physical therapy department, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.
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26
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Bem G, Pimentel M, Bublitz AK, da Silveira AD, Magalhães APA, Kochi AN, Zimerman LI, Beck-da-Silva L. Cardiopulmonary exercise testing may not predict appropriate implantable cardioverter defibrillator therapies in heart failure patients. Acta Cardiol 2020; 75:514-519. [PMID: 31169075 DOI: 10.1080/00015385.2019.1625169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: The prognostic value of cardiopulmonary exercise testing (CPET) variables for major cardiovascular events in patients with heart failure (HF) is widely established. However, the prognostic value of these variables as predictors of appropriate implantable cardioverter-defibrillator (ICD) therapies has not been sufficiently well addressed. This study aimed to evaluate CPET variables such as peak oxygen uptake (VO2 peak), relationship between change in minute ventilation (VE) and carbon dioxide output (VCO2) during incremental exercise (VE/VCO2 slope) and exercise-related periodic breathing (EPB) as appropriate ICD therapy predictors in HF patients.Methods: We retrospectively assessed 61 HF patients who underwent CPET and had ICD implanted for primary prevention. Patients were followed for 767 ± 601 days. Primary outcome was appropriate ICD-delivered therapy, either anti-tachycardia pacing (ATP) or shock.Results: The sample consisted mostly of male patients (65.6%), with severe ventricular dysfunction (mean left ventricular ejection fraction (LVEF) 27 ± 6%). The primary outcome occurred in 20 patients (32%). There were no significant differences in VO2 peak (17.7 ± 4.1 and 16.9 ± 4.5 mL/kg/min), VE/VCO2 slope (39.7 ± 8.4 and 39.6 ± 10.2) or EPB prevalence (20% and 19.5%) in patients with or without appropriate ICD therapy. According to Cox regression analysis, none of the CPET variables were significant predictors of appropriate ICD therapy.Conclusions: In this cohort study of HF patients, CPET variables did not predict appropriate ICD therapies. Further studies with large number of patients are warranted to address this issue.
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Affiliation(s)
- Gabriela Bem
- Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Cardiac Electrophysiology Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Mauricio Pimentel
- Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Cardiac Electrophysiology Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Alice K. Bublitz
- Cardiac Electrophysiology Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Anderson D. da Silveira
- Exercise Cardiology Research Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Brazil
| | - Ana Paula A. Magalhães
- Cardiac Electrophysiology Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Adriano N. Kochi
- Cardiac Electrophysiology Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Leandro I. Zimerman
- Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Cardiac Electrophysiology Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Luís Beck-da-Silva
- Cardiac Electrophysiology Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Heart Failure and Transplant Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Brazil
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27
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Abstract
PURPOSE OF REVIEW Central sleep apnea occurs in up to 50% of heart failure patients and worsens outcomes. Established therapies are limited by minimal supporting evidence, poor patient adherence, and potentially adverse cardiovascular effects. However, transvenous phrenic nerve stimulation, by contracting the diaphragm, restores normal breathing throughout sleep and has been shown to be safe and effective. This review discusses the mechanisms, screening, diagnosis, and therapeutic approaches to CSA in patients with HF. RECENT FINDINGS In a prospective, multicenter randomized Pivotal Trial (NCT01816776) of transvenous phrenic nerve stimulation with the remedē System, significantly more treated patients had a ≥ 50% reduction in apnea-hypopnea index compared with controls, with a 41 percentage point difference between group difference at 6 months (p < 0.0001). All hierarchically tested sleep, quality of life, and daytime sleepiness endpoints were significantly improved in treated patients. Freedom from serious related adverse events at 12 months was 91%. Benefits are sustained to 36 months. Transvenous phrenic nerve stimulation improves quality of life in patients with heart failure and central sleep apnea. Controlled trials evaluating the impact of this therapy on mortality/heart failure hospitalizations and "real world" experience are needed to confirm safety and effectiveness.
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28
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Heart, lungs, and muscle interplay in worsening activity-related breathlessness in advanced cardiopulmonary disease. Curr Opin Support Palliat Care 2020; 14:157-166. [PMID: 32740275 DOI: 10.1097/spc.0000000000000516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Activity-related breathlessness is a key determinant of poor quality of life in patients with advanced cardiorespiratory disease. Accordingly, palliative care has assumed a prominent role in their care. The severity of breathlessness depends on a complex combination of negative cardiopulmonary interactions and increased afferent stimulation from systemic sources. We review recent data exposing the seeds and consequences of these abnormalities in combined heart failure and chronic obstructive pulmonary disease (COPD). RECENT FINDINGS The drive to breathe increases ('excessive breathing') secondary to an enlarged dead space and hypoxemia (largely COPD-related) and heightened afferent stimuli, for example, sympathetic overexcitation, muscle ergorreceptor activation, and anaerobic metabolism (largely heart failure-related). Increased ventilatory drive might not be fully translated into the expected lung-chest wall displacement because of the mechanical derangements brought by COPD ('inappropriate breathing'). The latter abnormalities, in turn, negatively affect the central hemodynamics which are already compromised by heart failure. Physical activity then decreases, worsening muscle atrophy and dysfunction. SUMMARY Beyond the imperative of optimal pharmacological treatment of each disease, strategies to lessen ventilation (e.g., walking aids, oxygen, opiates and anxiolytics, and cardiopulmonary rehabilitation) and improve mechanics (heliox, noninvasive ventilation, and inspiratory muscle training) might mitigate the burden of this devastating symptom in advanced heart failure-COPD.
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29
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Giannoni A, Gentile F, Sciarrone P, Borrelli C, Pasero G, Mirizzi G, Vergaro G, Poletti R, Piepoli MF, Emdin M, Passino C. Upright Cheyne-Stokes Respiration in Patients With Heart Failure. J Am Coll Cardiol 2020; 75:2934-2946. [DOI: 10.1016/j.jacc.2020.04.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 12/28/2022]
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30
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Mitigation of Exercise Oscillatory Ventilation Score by Cardiac Resynchronization Therapy. J Card Fail 2020; 26:832-840. [PMID: 32205188 DOI: 10.1016/j.cardfail.2020.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 03/04/2020] [Accepted: 03/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is a consequence of ventilatory control system instability and is commonly observed in patients with advanced heart failure (HF); it is associated with adverse prognosis. The goal of this study was to evaluate the effects of cardiac resynchronization therapy (CRT) on oscillatory ventilation as quantified by a proposed EOV score. METHODS AND RESULTS Consecutive patients with HF (N = 35) who underwent clinically indicated CRT, cardiopulmonary exercise testing and carbon dioxide (CO2) chemosensitivity by rebreathe before and 4-6 months after CRT were included in this post hoc analysis. With CRT, EOV scores improved in 22 patients (63%). In these patients, left ventricular ejection fraction, left atrial volume, brain natriuretic peptide concentration, and CO2 chemosensitivity significantly improved after CRT (P < 0.05). Furthermore, minute ventilation per unit CO2 production significantly decreased, and end-tidal CO2 increased at rest and at peak exercise post-CRT. Multiple regression analysis showed only the change of CO2 chemosensitivity to be significantly associated with the improvement of the EOV score (b = 0.64; F = 11.3; P = 0.004). In the group without EOV score improvement (n = 13), though left ventricular ejection fraction significantly increased with CRT (P = 0.015), no significant changes in ventilation or gas exchange were observed. CONCLUSION The EOV score was mitigated by CRT and was associated with decreased CO2 chemosensitivity.
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31
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Agostoni P, Salvioni E. Exertional Periodic Breathing in Heart Failure: Mechanisms and Clinical Implications. Clin Chest Med 2020; 40:449-457. [PMID: 31078221 DOI: 10.1016/j.ccm.2019.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Periodic breathing (PB) during exercise is a slow, prominent, consistent fluctuation in ventilation and derived parameters that may be persistent for the entire exercise or present only in the early phases of exercise. It is associated with a negative prognosis, particularly if concomitant with PB during sleep. Little is known about exercise-induced PB physiology, but hyperventilation is likely due to an increased sympathetic activity combined with an enhanced stimulation of intrapulmonary, chemoreceptors and metaboreceptors, low cardiac output leading to increased circulatory delay, and cerebrovascular reactivity to CO2, all with have a definite role.
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Affiliation(s)
- Piergiuseppe Agostoni
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via Parea 4, Milano 20138, Italy; Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milano 20138, Italy.
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32
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Abstract
The heart and lungs are intimately linked. Hence, impaired function of one organ may lead to changes in the other. Accordingly, heart failure is associated with airway obstruction, loss of lung volume, impaired gas exchange, and abnormal ventilatory control. Cardiopulmonary exercise testing is an excellent tool for evaluation of gas exchange and ventilatory control. Indeed, many parameters routinely measured during cardiopulmonary exercise testing, including the level of minute ventilation per unit of carbon dioxide production and the presence of exercise oscillatory ventilation, have been found to be strongly associated with prognosis in patients with heart failure.
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Affiliation(s)
- Ivan Cundrle
- Department of Anesthesiology and Intensive Care, St. Anne's University Hospital, Pekarska 53, Brno 65691, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Lyle J Olson
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Bruce D Johnson
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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33
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Kinoshita H, Sairaku A, Morishima N, Dohi Y, Sada Y, Higashi A, Yamabe S, Kihara Y. Prognostic significance of oscillatory ventilation at rest in patients with advanced heart failure undergoing cardiopulmonary exercise testing. Int J Cardiol 2020; 301:142-146. [DOI: 10.1016/j.ijcard.2019.11.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 10/24/2019] [Accepted: 11/11/2019] [Indexed: 01/04/2023]
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34
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Rovai S, Corrà U, Piepoli M, Vignati C, Salvioni E, Bonomi A, Mattavelli I, Arcari L, Scardovi AB, Perrone Filardi P, Lagioia R, Paolillo S, Magrì D, Limongelli G, Metra M, Senni M, Scrutinio D, Raimondo R, Emdin M, Lombardi C, Cattadori G, Parati G, Re F, Cicoira M, Villani GQ, Minà C, Correale M, Frigerio M, Perna E, Mapelli M, Magini A, Clemenza F, Bussotti M, Battaia E, Guazzi M, Bandera F, Badagliacca R, Di Lenarda A, Pacileo G, Maggioni A, Passino C, Sciomer S, Sinagra G, Agostoni P. Exercise oscillatory ventilation and prognosis in heart failure patients with reduced and mid-range ejection fraction. Eur J Heart Fail 2019; 21:1586-1595. [PMID: 31782225 DOI: 10.1002/ejhf.1595] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS Exercise oscillatory ventilation (EOV) is a pivotal cardiopulmonary exercise test parameter for the prognostic evaluation of patients with chronic heart failure (HF). It has been described in patients with HF with reduced ejection fraction (<40%, HFrEF) and with HF with preserved ejection fraction (>50%, HFpEF), but no data are available for patients with HF with mid-range ejection fraction (40-49%, HFmrEF). The aim of the study was to evaluate the prognostic role of EOV in HFmrEF patients. METHODS AND RESULTS We analysed 1239 patients with HFmrEF and 4482 patients with HFrEF, enrolled in the MECKI score database, with a 2-year follow-up. The study endpoint was the composite of cardiovascular death, urgent heart transplant, and ventricular assist device implantation. We identified EOV in 968 cases (16% and 17% of cases in HFmrEF and HFrEF, respectively). HFrEF EOV+ patients were significantly older, and their parameters suggested a more severe HF than HFrEF EOV- patients. A similar behaviour was found in HFmrEF EOV+ vs. EOV- patients. Kaplan-Meier analysis, irrespective of ejection fraction, showed that EOV is associated with a worse survival, and that patients with HFrEF and HFmrEF EOV+ had a significantly worse outcome than the EOV- of the same ejection fraction groups. EOV-associated survival differences in HFmrEF patients started after 18 months of follow-up. CONCLUSION Exercise oscillatory ventilation has a similar prevalence and ominous prognostic value in both HFmrEF and HFrEF patients, indicating a group of patients in need of a more intensive follow-up and a more aggressive therapy. In HFmrEF, the survival curves between EOV+ and EOV- patients diverged only after 18 months.
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Affiliation(s)
- Sara Rovai
- U.O Scompenso, Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Sport and Exercise Medicine Division, Department of Medicine, Università degli Studi di Padova, Padova, Italy
| | - Ugo Corrà
- Cardiology Department, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno Institute, Veruno, Italy
| | | | - Carlo Vignati
- U.O Scompenso, Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milan, Italy
| | | | - Alice Bonomi
- U.O Scompenso, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | - Luca Arcari
- Cardiology Division, Santo Spirito Hospital, Rome, Italy
| | | | | | - Rocco Lagioia
- Division of Cardiology, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, "Sapienza" Università degli Studi di Roma, Rome, Italy
| | - Giuseppe Limongelli
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Naples, Italy
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Michele Senni
- Department of Cardiology, Heart Failure and Heart Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | | | - Rosa Raimondo
- Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Tradate, Italy
| | - Michele Emdin
- UOC Cardiologia e Medicina cardiovascolare, Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Carlo Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gaia Cattadori
- Unità Operativa Cardiologia Riabilitativa, Multimedica IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy
| | - Federica Re
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | | | | | - Chiara Minà
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT, Palermo, Italy
| | | | - Maria Frigerio
- Dipartimento Cardiologico 'A. De Gasperis', Ospedale Cà Granda-A.O. Niguarda, Milan, Italy
| | - Enrico Perna
- Dipartimento Cardiologico 'A. De Gasperis', Ospedale Cà Granda-A.O. Niguarda, Milan, Italy
| | - Massimo Mapelli
- U.O Scompenso, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | - Francesco Clemenza
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT, Palermo, Italy
| | - Maurizio Bussotti
- Cardiac Rehabilitation Unit, Fondazione Salvatore Maugeri, IRCCS, Scientific Institute of Milan, Milan, Italy
| | - Elisa Battaia
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | - Marco Guazzi
- Cardiology University Department, Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, San Donato Milano, Italy
| | - Francesco Bandera
- Cardiology University Department, Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, San Donato Milano, Italy
| | - Roberto Badagliacca
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, 'Sapienza', Rome University, Rome, Italy
| | - Andrea Di Lenarda
- Department of Cardiology, Cardiovascular Center, Health Authority no. 1 and University of, Trieste, Italy
| | - Giuseppe Pacileo
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Naples, Italy
| | | | - Claudio Passino
- UOC Cardiologia e Medicina cardiovascolare, Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, 'Sapienza', Rome University, Rome, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Piergiuseppe Agostoni
- U.O Scompenso, Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milan, Italy
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35
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Ferrari F, Menegazzo WR. Global Longitudinal Strain or Measurement of Ejection Fraction: Which Method is Better in Stratifying Patients with Heart Failure? Arq Bras Cardiol 2019; 113:195-196. [PMID: 31483015 PMCID: PMC6777883 DOI: 10.5935/abc.20190151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Filipe Ferrari
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil.,Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil
| | - Willian Roberto Menegazzo
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil.,Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil
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36
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Agostoni P, Dumitrescu D. How to perform and report a cardiopulmonary exercise test in patients with chronic heart failure. Int J Cardiol 2019; 288:107-113. [DOI: 10.1016/j.ijcard.2019.04.053] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/04/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023]
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37
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Begrambekova YL, Karanadze NA, Orlova YA. Alterations of the respiratory system in heart failure. ACTA ACUST UNITED AC 2019; 59:15-24. [PMID: 30853009 DOI: 10.18087/cardio.2626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 11/18/2022]
Abstract
The review discusses mechanisms for the development of the pathology of the respiratory system in patients with CHF, such as various types of periodic respiration, pulmonary hypertension due to the pathology of the left chambers of the heart, and remodeling of the respiratory musculature. The role of chemo- and baroreceptors of the carotid zone, as well as the hyperactivation of the respiratory muscle metaboreflex in the development of the pathology of the respiratory system, and the mediated exacerbation of CHF are discussed.
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Affiliation(s)
- Yu L Begrambekova
- Lomonosov Moscow State University Medical Research and Educational Center..
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38
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Reis HV, Sperandio PA, Correa CL, Guizilini S, Neder JA, Borghi-Silva A, Reis MS. Association of Oscillatory Ventilation during Cardiopulmonary Test to Clinical and Functional Variables of Chronic Heart Failure Patients. Braz J Cardiovasc Surg 2019; 33:176-182. [PMID: 29898148 PMCID: PMC5985845 DOI: 10.21470/1678-9741-2017-0158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/27/2017] [Indexed: 01/05/2023] Open
Abstract
Objective The aim of this study is to characterize the presence of exercise oscillatory
ventilation (EOV) and to relate it with other cardiopulmonary exercise test
(CET) responses and clinical variables. Methods Forty-six male patients (age: 53.1±13.6 years old; left ventricular
ejection fraction [LVEF]: 30±8%) with heart failure were recruited to
perform a maximal CET and to correlate the CET responses with clinical
variables. The EOV was obtained according to Leite et al. criteria and
VE/VCO2 > 34 and peak VO2 < 14 ml/kg/min
were used to assess patients' severity. Results The EOV was observed in 16 of 24 patients who performed the CET, as well as
VE/VCO2 > 34 and peak VO2 < 14 ml/kg/min in
14 and 10 patients, respectively. There was no difference in clinical and
CET variables of the patients who presented EOV in CET when compared to
non-EOV patients. Also, there was no difference in CET and clinical
variables when comparing patients who presented EOV and had a
VE/VCO2 slope > 34 to patients who just had one of these
responses either. Conclusion The present study showed that there was an incidence of patients with EOV and
lower peak VO2 and higher VE/VCO2 slope values, but
they showed no difference on other prognostic variables. As well, there was
no influence of the presence of EOV on other parameters of CET in this
population, suggesting that this variable may be an independent marker of
worst prognosis in HF patients.
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Affiliation(s)
- Hugo Valverde Reis
- Research Group in Cardiorespiratory Rehabilitation (GECARE) and Department of Physical Therapy, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Priscila Abreu Sperandio
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Clynton Lourenço Correa
- Research Group in Cardiorespiratory Rehabilitation (GECARE) and Department of Physical Therapy, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Solange Guizilini
- Respiratory Division, Department of Physiotherapy, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - José Alberto Neder
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Respiratory Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Audrey Borghi-Silva
- Laboratory of Cardiopulmonary Physical Therapy (LACAP), Department of Physical Therapy, Universidade Federal de São Carlos (UFSCAR), São Carlos, SP, Brazil
| | - Michel Silva Reis
- Research Group in Cardiorespiratory Rehabilitation (GECARE) and Department of Physical Therapy, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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Brawner CA, Ehrman JK, Myers J, Chase P, Vainshelboim B, Farha S, Saval MA, McGuire R, Pozehl B, Keteyian SJ. Exercise Oscillatory Ventilation: Interreviewer Agreement and a Novel Determination. Med Sci Sports Exerc 2018; 50:369-374. [PMID: 28902683 DOI: 10.1249/mss.0000000000001423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Determination of exercise oscillatory ventilation (EOV) is subjective, and the interreviewer agreement has not been reported. The purposes of this study were, among patients with heart failure (HF), as follows: 1) to determine the interreviewer agreement for EOV and 2) to describe a novel, objective, and quantifiable measure of EOV. METHODS This was a secondary analysis of the HEART Camp: Promoting Adherence to Exercise in Patients with Heart Failure study. EOV was determined through a blinded review by six individuals on the basis of their interpretation of the EOV literature. Interreviewer agreement was assessed using Fleiss kappa (κ). Final determination of EOV was based on agreement by four of the six reviewers. A new measure (ventilation dispersion index; VDI) was calculated for each test, and its ability to predict EOV was assessed with the receiver operator characteristics curve. RESULTS Among 243 patients with HF (age, 60 ± 12 yr; 45% women), the interreviewer agreement for EOV was fair (κ = 0.303) with 10-s discrete data averages and significantly better, but only moderate (κ = 0.429) with 30-s rolling data averages. Prevalence rates of positive and indeterminate EOVs were 18% and 30% with the 10-s discrete averages and 14% and 13% with the 30-s rolling averages, respectively. VDI was strongly associated with EOV, with areas under the receiver operator characteristics curve of 0.852 to 0.890. CONCLUSIONS Interreviewer agreement for EOV in patients with HF is fair to moderate, which can negatively affect risk stratification. VDI has strong predictive validity with EOV; as such, it might be a useful measure of prognosis in patients with HF.
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Affiliation(s)
- Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Jonathan Myers
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Paul Chase
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | | | - Shadi Farha
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Matthew A Saval
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Rita McGuire
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Bunny Pozehl
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
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ECG derived Cheyne-Stokes respiration and periodic breathing are associated with cardiorespiratory arrest in intensive care unit patients. Heart Lung 2018; 48:114-120. [PMID: 30340809 DOI: 10.1016/j.hrtlng.2018.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cheyne-Stokes respiration and periodic breathing (CSRPB) have not been studied sufficiently in the intensive care unit setting (ICU). OBJECTIVES To determine whether CSRPB is associated with adverse outcomes in ICU patients. METHODS The ICU group was divided into quartiles by CSRPB (86 patients in quartile 1 had the least CSRPB and 85 patients in quartile 4 had the most CSRPB). Adverse outcomes (emergent intubation, cardiorespiratory arrest, inpatient mortality and the composite of all) were compared between patients with most CSRPB (quartile 4) and those with least CSRPB (quartile 1). RESULTS ICU patients in quartile 4 had a higher proportion of cardiorespiratory arrests (5% versus 0%, (p=.042), and more adverse events over all (19% versus 8%, p=.041) as compared to patients in quartile 1. CONCLUSIONS CSRPB can be measured in the ICU and it's severity is associated with adverse outcomes in critically ill patients.
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Corrà U. Exertional oscillatory ventilation in patients supported with continuous-flow left ventricular assist device: Not so exceptional as supposed. Eur J Prev Cardiol 2018; 25:1836-1837. [PMID: 30256670 DOI: 10.1177/2047487318803988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ugo Corrà
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, Italy
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42
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Wagner J, Agostoni P, Arena R, Belardinelli R, Dumitrescu D, Hager A, Myers J, Rauramaa R, Riley M, Takken T, Schmidt-Trucksäss A. The Role of Gas Exchange Variables in Cardiopulmonary Exercise Testing for Risk Stratification and Management of Heart Failure with Reduced Ejection Fraction. Am Heart J 2018; 202:116-126. [PMID: 29933148 DOI: 10.1016/j.ahj.2018.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/18/2018] [Indexed: 01/14/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is common in the developed world and results in significant morbidity and mortality. Accurate risk assessment methods and prognostic variables are therefore needed to guide clinical decision making for medical therapy and surgical interventions with the ultimate goal of decreasing risk and improving health outcomes. The purpose of this review is to examine the role of cardiopulmonary exercise testing (CPET) and its most commonly used ventilatory gas exchange variables for the purpose of risk stratification and management of HFrEF. We evaluated five widely studied gas exchange variables from CPET in HFrEF patients based on nine previously used systematic criteria for biomarkers. This paper provides clinicians with a comprehensive and critical overview, class recommendations and evidence levels. Although some CPET variables met more criteria than others, evidence supporting the clinical assessment of variables beyond peak V̇O2 is well-established. A multi-variable approach also including the V̇E-V̇CO2 slope and EOV is therefore recommended.
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Affiliation(s)
- Jonathan Wagner
- Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy & Department of Clinical sciences and Community health, Cardiovascular Section, University of Milano, Milano, Italy
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL
| | - Romualdo Belardinelli
- Department of Cardiovascular Sciences, Cardiac Rehabilitation Lancisi, Ancona, Italy
| | - Daniel Dumitrescu
- Herzzentrum der Universitaet zu Koeln, Klinik III fuer Innere Medizin, Cologne, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technical University of Munich, Germany
| | - Jonathan Myers
- Cardiology Division, VA Palo Alto Health Care System and Stanford University, Palo Alto, CA
| | - Rainer Rauramaa
- Foundation for Research in Health, Exercise and Nutrition, Kuopio Research Institute of Exercise Medicine, Kuopio, Finland
| | - Marshall Riley
- Department of Medicine, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Tim Takken
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
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Analysis of Exercise-Induced Periodic Breathing Using an Autoregressive Model and the Hilbert-Huang Transform. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2018; 2018:4860204. [PMID: 30046353 PMCID: PMC6038683 DOI: 10.1155/2018/4860204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/21/2018] [Indexed: 11/24/2022]
Abstract
Evaluation of exercise-induced periodic breathing (PB) in cardiopulmonary exercise testing (CPET) is one of important diagnostic evidences to judge the prognosis of chronic heart failure cases. In this study, we propose a method for the quantitative analysis of measured ventilation signals from an exercise test. We used an autoregressive (AR) model to filter the breath-by-breath measurements of ventilation from exercise tests. Then, the signals before reaching the most ventilation were decomposed into intrinsic mode functions (IMF) by using the Hilbert-Huang transform (HHT). An IMF represents a simple oscillatory pattern which catches a part of original ventilation signal in different frequency band. For each component of IMF, we computed the number of peaks as the feature of its oscillatory pattern denoted by Δi. In our experiment, 61 chronic heart failure patients with or without PB pattern were studied. The computed peaks of the third and fourth IMF components, Δ3 and Δ4, were statistically significant for the two groups (both p values < 0.02). In summary, our study shows a close link between the HHT analysis and level of intrinsic energy for pulmonary ventilation. The third and fourth IMF components are highly potential to indicate the prognosis of chronic heart failure.
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Abstract
Periodic breathing during incremental cardiopulmonary exercise testing is a regularly recurring waxing and waning of tidal volume due to oscillations in central respiratory drive. Periodic breathing is a sign of respiratory control system instability, which may occur at rest or during exercise. The possible mechanisms responsible for exertional periodic breathing might be related to any instability of the ventilatory regulation caused by: (1) increased circulatory delay (i.e., circulation time from the lung to the brain and chemoreceptors due to reduced cardiac index leading to delay in information transfer), (2) increase in controller gain (i.e., increased central and peripheral chemoreceptor sensitivity to arterial partial pressure of oxygen and of carbon dioxide), or (3) reduction in system damping (i.e., baroreflex impairment). Periodic breathing during exercise is observed in several cardiovascular disease populations, but it is a particularly frequent phenomenon in heart failure due to systolic dysfunction. The detection of exertional periodic breathing is linked to outcome and heralds worse prognosis in heart failure, independently of the criteria adopted for its definition. In small heart failure cohorts, exertional periodic breathing has been abolished with several dedicated interventions, but results have not yet been confirmed. Accordingly, further studies are needed to define the role of visceral feedbacks in determining periodic breathing during exercise as well as to look for specific tools for preventing/treating its occurrence in heart failure.
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Prueba de esfuerzo cardiopulmonar en pacientes con insuficiencia cardiaca y fracción de eyección conservada: colmando las lagunas sobre el pronóstico. Rev Esp Cardiol (Engl Ed) 2018. [DOI: 10.1016/j.recesp.2017.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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46
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Central Sleep Apnea with Cheyne-Stokes Breathing in Heart Failure – From Research to Clinical Practice and Beyond. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1067:327-351. [DOI: 10.1007/5584_2018_146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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47
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Vainshelboim B, Amin A, Christle JW, Hebbal S, Ashley EA, Myers J. A method for determining exercise oscillatory ventilation in heart failure: Prognostic value and practical implications. Int J Cardiol 2017; 249:287-291. [DOI: 10.1016/j.ijcard.2017.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/04/2017] [Accepted: 09/11/2017] [Indexed: 11/27/2022]
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48
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Castro RRTD, Lima SP, Sales ARK, Nóbrega ACLD. Minute-Ventilation Variability during Cardiopulmonary Exercise Test is Higher in Sedentary Men Than in Athletes. Arq Bras Cardiol 2017; 109:185-190. [PMID: 28977060 PMCID: PMC5586224 DOI: 10.5935/abc.20170104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 03/29/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The occurrence of minute-ventilation oscillations during exercise, named periodic breathing, exhibits important prognostic information in heart failure. Considering that exercise training could influence the fluctuation of ventilatory components during exercise, we hypothesized that ventilatory variability during exercise would be greater in sedentary men than athletes. OBJECTIVE To compare time-domain variability of ventilatory components of sedentary healthy men and athletes during a progressive maximal exercise test, evaluating their relationship to other variables usually obtained during a cardiopulmonary exercise test. METHODS Analysis of time-domain variability (SD/n and RMSSD/n) of minute-ventilation (Ve), respiratory rate (RR) and tidal volume (Vt) during a maximal cardiopulmonary exercise test of 9 athletes and 9 sedentary men was performed. Data was compared by two-tailed Student T test and Pearson´s correlations test. RESULTS Sedentary men exhibited greater Vt (SD/n: 1.6 ± 0.3 vs. 0.9 ± 0.3 mL/breaths; p < 0.001) and Ve (SD/n: 97.5 ± 23.1 vs. 71.6 ± 4.8 mL/min x breaths; p = 0.038) variabilities than athletes. VE/VCO2 correlated to Vt variability (RMSSD/n) in both groups. CONCLUSIONS Time-domain variability of Vt and Ve during exercise is greater in sedentary than athletes, with a positive relationship between VE/VCO2 pointing to a possible influence of ventilation-perfusion ratio on ventilatory variability during exercise in healthy volunteers.
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Affiliation(s)
- Renata Rodrigues Teixeira de Castro
- Laboratório de Ciências do Exercício (LACE) - Universidade Federal Fluminense (UFF), Niterói, RJ.,Hospital Naval Marcílio Dias - Marinha do Brazil, Rio de Janeiro, RJ - Brazil
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49
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Ozemek C, Arena R. Cardiopulmonary Exercise Testing in Patients With Heart Failure and a Preserved Ejection Fraction: Filling the Prognostic Knowledge Gap. ACTA ACUST UNITED AC 2017; 71:237-239. [PMID: 28919241 DOI: 10.1016/j.rec.2017.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 08/01/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Cemal Ozemek
- Department of Physical Therapy and the Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois, United States.
| | - Ross Arena
- Department of Physical Therapy and the Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois, United States
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50
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Emdin M, Mirizzi G, Giannoni A, Poletti R, Iudice G, Bramanti F, Passino C. Prognostic Significance of Central Apneas Throughout a 24-Hour Period in Patients With Heart Failure. J Am Coll Cardiol 2017; 70:1351-1364. [PMID: 28882233 DOI: 10.1016/j.jacc.2017.07.740] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/07/2017] [Accepted: 07/09/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Large trials using noninvasive mechanical ventilation to treat central apnea (CA) occurring at night ("sleep apnea") in patients with systolic heart failure (HF) have failed to improve prognosis. The prevalence and prognostic value of CA during daytime and over an entire 24-h period are not well described. OBJECTIVES This study evaluated the occurrence and prognostic significance of nighttime, daytime, and 24-h CA episodes in a large cohort of patients with systolic HF. METHODS Consecutive patients receiving guideline-recommended treatment for HF (n = 525; left ventricular ejection fraction [LVEF] of 33 ± 9%; 66 ± 12 years of age; 77% males) underwent prospective evaluation, including 24-h respiratory recording, and were followed-up using cardiac mortality as an endpoint. RESULTS The 24-h prevalence of predominant CAs (apnea/hypopnea index [AHI] ≥5 events/h, with CA of >50%) was 64.8% (nighttime: 69.1%; daytime: 57.0%), whereas the prevalence of predominant obstructive apneas (OA) was 12.8% (AHI ≥5 events/h with OAs >50%; nighttime: 14.7%; daytime: 5.9%). Episodes of CA were associated with neurohormonal activation, ventricular arrhythmic burden, and systolic/diastolic dysfunction (all p < 0.05). During a median 34-month follow-up (interquartile range [IQR]: 17 to 36 months), 50 cardiac deaths occurred. Nighttime, daytime, and 24-h moderate-to-severe CAs were associated with increased cardiac mortality (AHI of </≥15 events/h; log-rank: 6.6, 8.7, and 5.3, respectively; all p < 0.05; central apnea index [CAI] of </≥10 events/h; log-rank 8.9, 11.2, and 10.9, respectively; all p < 0.001). Age, B-type natriuretic peptide level, renal dysfunction, 24-h AHI, CAI, and time with oxygen saturation of <90% were independent predictors of outcome. CONCLUSIONS In systolic HF patients, CAs occurred throughout a 24-h period and were associated with a neurohormonal activation, ventricular arrhythmic burden, and worse prognosis.
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Affiliation(s)
- Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | - Gianluca Mirizzi
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | | | | | | | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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