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Tran T, Muralidhar A, Hunter K, Buchanan C, Coe G, Hieda M, Tompkins C, Zipse M, Spotts MJ, Laing SG, Fosmark K, Hoffman J, Ambardekar AV, Wolfel EE, Lawley J, Levine B, Kohrt WM, Pal J, Cornwell WK. Right ventricular function and cardiopulmonary performance among patients with heart failure supported by durable mechanical circulatory support devices. J Heart Lung Transplant 2021; 40:128-137. [PMID: 33281029 DOI: 10.1016/j.healun.2020.11.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/15/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Patients with continuous-flow left ventricular assist devices (CF-LVADs) experience limitations in functional capacity and frequently, right ventricular (RV) dysfunction. We sought to characterize RV function in the context of global cardiopulmonary performance during exercise in this population. METHODS A total of 26 patients with CF-LVAD (aged 58 ± 11 years, 23 males) completed a hemodynamic assessment with either conductance catheters (Group 1, n = 13) inserted into the right ventricle to generate RV pressure‒volume loops or traditional Swan‒Ganz catheters (Group 2, n = 13) during invasive cardiopulmonary exercise testing. Hemodynamics were collected at rest, 2 sub-maximal levels of exercise, and peak effort. Breath-by-breath gas exchange parameters were collected by indirect calorimetry. Group 1 participants also completed an invasive ramp test during supine rest to determine the impact of varying levels of CF-LVAD support on RV function. RESULTS In Group 1, pump speed modulations minimally influenced RV function. During upright exercise, there were modest increases in RV contractility during sub-maximal exercise, but there were no appreciable increases at peak effort. Ventricular‒arterial coupling was preserved throughout the exercise. In Group 2, there were large increases in pulmonary arterial, left-sided filling, and right-sided filling pressures during sub-maximal and peak exercises. Among all participants, the cardiac output‒oxygen uptake relationship was preserved at 5.8:1. Ventilatory efficiency was severely abnormal at 42.3 ± 11.6. CONCLUSIONS Patients with CF-LVAD suffer from limited RV contractile reserve; marked elevations in pulmonary, left-sided filling, and right-sided filling pressures during exercise; and severe ventilatory inefficiency. These findings explain mechanisms for persistent reductions in functional capacity in this patient population.
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Affiliation(s)
- Tomio Tran
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Akshay Muralidhar
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kendall Hunter
- Department of Bioengineering, Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Cullen Buchanan
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Greg Coe
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Michinari Hieda
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Campus, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas Texas
| | - Christine Tompkins
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia
| | - Matthew Zipse
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Melanie J Spotts
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Stephanie G Laing
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kristina Fosmark
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jordan Hoffman
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee
| | - Amrut V Ambardekar
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Eugene E Wolfel
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Justin Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
| | - Benjamin Levine
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Campus, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas Texas
| | - Wendy M Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jay Pal
- Department of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - William K Cornwell
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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Hsu S, Houston BA, Tampakakis E, Bacher AC, Rhodes PS, Mathai SC, Damico RL, Kolb TM, Hummers LK, Shah AA, McMahan Z, Corona-Villalobos CP, Zimmerman SL, Wigley FM, Hassoun PM, Kass DA, Tedford RJ. Right Ventricular Functional Reserve in Pulmonary Arterial Hypertension. Circulation 2016; 133:2413-22. [PMID: 27169739 PMCID: PMC4907868 DOI: 10.1161/circulationaha.116.022082] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/28/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Right ventricular (RV) functional reserve affects functional capacity and prognosis in patients with pulmonary arterial hypertension (PAH). PAH associated with systemic sclerosis (SSc-PAH) has a substantially worse prognosis than idiopathic PAH (IPAH), even though many measures of resting RV function and pulmonary vascular load are similar. We therefore tested the hypothesis that RV functional reserve is depressed in SSc-PAH patients. METHODS AND RESULTS RV pressure-volume relations were prospectively measured in IPAH (n=9) and SSc-PAH (n=15) patients at rest and during incremental atrial pacing or supine bicycle ergometry. Systolic and lusitropic function increased at faster heart rates in IPAH patients, but were markedly blunted in SSc-PAH. The recirculation fraction, which indexes intracellular calcium recycling, was also depressed in SSc-PAH (0.32±0.05 versus 0.50±0.05; P=0.039). At matched exercise (25 W), SSc-PAH patients did not augment contractility (end-systolic elastance) whereas IPAH did (P<0.001). RV afterload assessed by effective arterial elastance rose similarly in both groups; thus, ventricular-vascular coupling declined in SSc-PAH. Both end-systolic and end-diastolic RV volumes increased in SSc-PAH patients to offset contractile deficits, whereas chamber dilation was absent in IPAH (+37±10% versus +1±8%, P=0.004, and +19±4% versus -1±6%, P<0.001, respectively). Exercise-associated RV dilation also strongly correlated with resting ventricular-vascular coupling in a larger cohort. CONCLUSIONS RV contractile reserve is depressed in SSc-PAH versus IPAH subjects, associated with reduced calcium recycling. During exercise, this results in ventricular-pulmonary vascular uncoupling and acute RV dilation. RV dilation during exercise can predict adverse ventricular-vascular coupling in PAH patients.
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Affiliation(s)
- Steven Hsu
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brian A Houston
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Emmanouil Tampakakis
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Anita C Bacher
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Parker S Rhodes
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Stephen C Mathai
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Rachel L Damico
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Todd M Kolb
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Laura K Hummers
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Ami A Shah
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Zsuzsanna McMahan
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Celia P Corona-Villalobos
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Stefan L Zimmerman
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Fredrick M Wigley
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - Paul M Hassoun
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD
| | - David A Kass
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Ryan J Tedford
- From Divisions of Cardiology (S.H., B.A.H., E.T., A.C.B., P.S.R., D.A.K., R.J.T.), Pulmonary and Critical Care (S.C.M., R.L.D., T.M.K., P.M.H.), and Rheumatology (L.K.H., A.A.S., Z.M., F.M.W.), Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; and Departments of Radiology (C.P.C.-V., S.L.Z.) and Biomedical Engineering (D.A.K.), Johns Hopkins Medical Institutions, Baltimore, MD.
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