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Singh I, Waxman AB. The casting of invasive cardiopulmonary exercise testing: towards a common goal. Eur Respir J 2024; 64:2400783. [PMID: 38991723 DOI: 10.1183/13993003.00783-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine and Yale New Haven Hospital, New Haven, CT, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
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2
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Cubero Salazar IM, Lancaster AC, Jani VP, Montovano MJ, Kauffman M, Weller A, Ambale-Venkatesh B, Zimmerman SL, Simpson CE, Kolb TM, Damico RL, Mathai SC, Mukherjee M, Tedford RJ, Hassoun PM, Hsu S. Poor cardiac output reserve in pulmonary arterial hypertension is associated with right ventricular stiffness and impaired interventricular dependence. Eur Respir J 2024; 64:2400420. [PMID: 38843915 DOI: 10.1183/13993003.00420-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/19/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterised by poor exercise tolerance. The contribution of right ventricular (RV) diastolic function to the augmentation of cardiac output during exercise is not known. This study leverages pressure-volume (P-V) loop analysis to characterise the impact of RV diastology on poor flow augmentation during exercise in PAH. METHODS RV P-V loops were measured in 41 PAH patients at rest and during supine bike exercise. Patients were stratified by median change in cardiac index (CI) during exercise into two groups: high and low CI reserve. Indices of diastolic function (end-diastolic elastance (E ed)) and ventricular interdependence (left ventricular transmural pressure (LVTMP)) were compared at matched exercise stages. RESULTS Compared to patients with high CI reserve, those with low reserve exhibited lower exercise stroke volume (36 versus 49 mL·m-2; p=0.0001), with higher associated exercise afterload (effective arterial elastance (E a) 1.76 versus 0.90 mmHg·mL-1; p<0.0001), RV stiffness (E ed 0.68 versus 0.26 mmHg·mL-1; p=0.003) and right-sided pressures (right atrial pressure 14 versus 8 mmHg; p=0.002). Higher right-sided pressures led to significantly lower LV filling among the low CI reserve subjects (LVTMP -4.6 versus 3.2 mmHg; p=0.0001). Interestingly, low exercise flow reserve correlated significantly with high afterload and RV stiffness, but not with RV contractility nor RV-PA coupling. CONCLUSIONS Patients with poor exercise CI reserve exhibit poor exercise RV afterload, stiffness and right-sided filling pressures that depress LV filling and stroke work. High afterload and RV stiffness were the best correlates to low flow reserve in PAH. Exercise unmasked significant pathophysiological PAH differences unapparent at rest.
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Affiliation(s)
| | - Andrew C Lancaster
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vivek P Jani
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Margaret J Montovano
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew Kauffman
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandra Weller
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bharath Ambale-Venkatesh
- Division of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stefan L Zimmerman
- Division of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine E Simpson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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3
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Poojary G, Morris N, Joshi MB, Babu AS. Role of Exercise in Pulmonary Hypertension: Evidence from Bench to Bedside. Pulse (Basel) 2024; 12:66-75. [PMID: 39022559 PMCID: PMC11249447 DOI: 10.1159/000539537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/13/2024] [Indexed: 07/20/2024] Open
Abstract
Background Pulmonary hypertension (PH) is a debilitating condition characterized by elevated pulmonary arterial pressure and progressive vascular remodelling, leading to exercise intolerance. The progression of PAH is regulated at a cellular and molecular level which influences various physiological processes. Exercise plays an important role in improving function in PH. Although the signalling pathways that regulate cardio-protection through exercise have not been fully understood, the positive impact of exercise on the various physiological systems is well established. Summary Exercise has emerged as a potential adjunctive therapy for PH, with growing evidence supporting its beneficial effects on various aspects of the disease pathophysiology. This review highlights the contributions of cellular and molecular pathways and physiological processes to exercise intolerance. Preclinical studies have provided insight into the mechanisms underlying exercise-induced improvements in PH which are modulated through improvements in endothelial function, inflammation, oxidative stress, and mitochondrial function. Along with preclinical studies, various clinical studies have demonstrated that exercise training can lead to significant improvements in exercise capacity, haemodynamics, quality of life, and functional status. Moreover, exercise interventions have been shown to improve skeletal muscle function and enhance pulmonary vascular remodelling, contributing to overall disease management. Further research efforts aimed at better understanding the role of exercise in PH pathophysiology, and refining exercise interventions are warranted to realize its full potential in the management of this complex disease. Key Messages Despite the promising benefits of exercise in PH, several challenges remain, including the optimal intensity, duration, and type of exercise training, as well as patient selection criteria and long-term adherence. Additionally, the mechanisms underlying the observed improvements require further elucidation to optimize exercise protocols and personalize treatment strategies. Nonetheless, exercise represents a promising therapeutic approach that can complement existing pharmacological therapies and improve outcomes in PH patients.
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Affiliation(s)
- Ganesha Poojary
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, India
- Department of Ageing Research, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Norman Morris
- School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, QLD, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Manjunath B. Joshi
- Department of Ageing Research, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Abraham Samuel Babu
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, India
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
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Khosla A, Zhao Y, Mojibian H, Pollak J, Singh I. High-Risk Pulmonary Embolism: Management for the Intensivist. J Intensive Care Med 2023; 38:1087-1098. [PMID: 37455352 DOI: 10.1177/08850666231188290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
High-risk pulmonary embolism (PE) also known as massive PE carries a high rate of morbidity and mortality. The incidence of high-risk PE continues to increase, yet the outcomes of high-risk PE continue to remain poor. Patients with high-risk PE are often critically ill, with complex underlying physiology, and treatment for the high-risk PE patient almost always requires care and management from an intensivist. Treatment options for high-risk PE continue to evolve rapidly with multiple options for definitive reperfusion therapy and supportive care. A thorough understanding of the physiology, risk stratification, treatment, and support options for the high-risk PE patient is necessary for all intensivists in order to improve outcomes. This article aims to provide a review from an intensivist's perspective highlighting the physiological consequences, risk stratification, and treatment options for these patients as well as providing a proposed algorithm to the risk stratification and acute management of high-risk PE.
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Affiliation(s)
- Akhil Khosla
- Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Yiyu Zhao
- Department of Anesthesia, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Hamid Mojibian
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Jeffrey Pollak
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Inderjit Singh
- Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
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5
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Tarras E, Khosla A, Heerdt PM, Singh I. Right Heart Failure in the Intensive Care Unit: Etiology, Pathogenesis, Diagnosis, and Treatment. J Intensive Care Med 2023:8850666231216889. [PMID: 38031338 DOI: 10.1177/08850666231216889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Right heart (RH) failure carries a high rate of morbidity and mortality. Patients who present with RH failure often exhibit complex aberrant cardio-pulmonary physiology with varying presentations. The treatment of RH failure almost always requires care and management from an intensivist. Treatment options for RH failure patients continue to evolve rapidly with multiple options available, including different pharmacotherapies and mechanical circulatory support devices that target various components of the RH circulatory system. An understanding of the normal RH circulatory physiology, treatment, and support options for the RH failure patients is necessary for all intensivists to improve outcomes. The purpose of this review is to provide clinical guidance on the diagnosis and management of RH failure within the intensive care unit setting, and to highlight the different pathophysiological manifestations of RH failure, its hemodynamics, and treatment options available at the disposal of the intensivist.
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Affiliation(s)
- Elizabeth Tarras
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Akhil Khosla
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Paul M Heerdt
- Department of Anesthesiology, Division of Applied Hemodynamics, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
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Forbes LM, Bull TM, Lahm T, Make BJ, Cornwell WK. Exercise Testing in the Risk Assessment of Pulmonary Hypertension. Chest 2023; 164:736-746. [PMID: 37061028 PMCID: PMC10504600 DOI: 10.1016/j.chest.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 04/17/2023] Open
Abstract
TOPIC IMPORTANCE Right ventricular dysfunction in pulmonary hypertension (PH) contributes to reduced exercise capacity, morbidity, and mortality. Exercise can unmask right ventricular dysfunction not apparent at rest, with negative implications for prognosis. REVIEW FINDINGS Among patients with pulmonary vascular disease, right ventricular afterload may increase during exercise out of proportion to increases observed among healthy individuals. Right ventricular contractility must increase to match the demands of increased afterload to maintain ventricular-arterial coupling (the relationship between contractility and afterload) and ultimately cardiac output. Impaired right ventricular contractile reserve leads to ventricular-arterial uncoupling, preventing cardiac output from increasing during exercise and limiting exercise capacity. Abnormal pulmonary vascular response to exercise can signify early pulmonary vascular disease and is associated with increased mortality. Impaired right ventricular contractile reserve similarly predicts poor outcomes, including reduced exercise capacity and death. Exercise provocation can be used to assess pulmonary vascular response to exercise and right ventricular contractile reserve. Noninvasive techniques (including cardiopulmonary exercise testing, transthoracic echocardiography, and cardiac MRI) as well as invasive techniques (including right heart catheterization and pressure-volume analysis) may be applied selectively to the screening, diagnosis, and risk stratification of patients with suspected or established PH. Further research is required to determine the role of exercise stress testing in the management of pulmonary vascular disease. SUMMARY This review describes the current understanding of clinical applications of exercise testing in the risk assessment of patients with suspected or established PH.
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Affiliation(s)
- Lindsay M Forbes
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Todd M Bull
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - Barry J Make
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - William K Cornwell
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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Müller J, Mayer L, Schneider SR, Titz A, Schwarz EI, Saxer S, Furian M, Grünig E, Ulrich S, Lichtblau M. Pulmonary arterial wedge pressure increase during exercise in patients diagnosed with pulmonary arterial or chronic thromboembolic pulmonary hypertension. ERJ Open Res 2023; 9:00379-2023. [PMID: 37753275 PMCID: PMC10518874 DOI: 10.1183/23120541.00379-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/02/2023] [Indexed: 09/28/2023] Open
Abstract
Background The course of pulmonary arterial wedge pressure (PAWP) during exercise in patients with pulmonary arterial or chronic thromboembolic pulmonary hypertension (PAH/CTEPH), further abbreviated as pulmonary vascular disease (PVD), is still unknown. The aim of the study was to describe PAWP during exercise in patients with PVD. Methods In this cross-sectional study, right heart catheter (RHC) data including PAWP, recorded during semi-supine, stepwise cycle exercise in patients with PVD, were analysed retrospectively. We investigated PAWP changes during exercise until end-exercise. Results In 121 patients (59 female, 66 CTEPH, 55 PAH, 62±17 years) resting PAWP was 10.2±4.1 mmHg. Corresponding peak changes in PAWP during exercise were +2.9 mmHg (95% CI 2.1-3.7 mmHg, p<0.001). Patients ≥50 years had a significantly higher increase in PAWP during exercise compared with those <50 years (p<0.001). The PAWP/cardiac output (CO) slopes were 3.9 WU for all patients, and 1.6 WU for patients <50 years and 4.5 WU for those ≥50 years. Conclusion In patients with PVD, PAWP increased slightly but significantly with the onset of exercise compared to resting values. The increase in PAWP during exercise was age-dependent, with patients ≥50 years showing a rapid PAWP increase even with minimal exercise. PAWP/CO slopes >2 WU are common in patients with PVD aged ≥50 years without exceeding the PAWP of 25 mmHg during exercise.
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Affiliation(s)
- Julian Müller
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Laura Mayer
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Simon R. Schneider
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Anna Titz
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Esther I. Schwarz
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Stephanie Saxer
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Michael Furian
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | | | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- These authors contributed equally
| | - Mona Lichtblau
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- These authors contributed equally
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8
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Pezzuto B, Agostoni P. The Current Role of Cardiopulmonary Exercise Test in the Diagnosis and Management of Pulmonary Hypertension. J Clin Med 2023; 12:5465. [PMID: 37685532 PMCID: PMC10487723 DOI: 10.3390/jcm12175465] [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: 06/26/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis if left untreated. Despite remarkable achievements in understanding disease pathophysiology, specific treatments, and therapeutic strategies, we are still far from a definitive cure for the disease, and numerous evidences have underlined the importance of early diagnosis and treatment to improve the prognosis. Cardiopulmonary exercise testing (CPET) is the gold standard for assessing functional capacity and evaluating the pathophysiological mechanisms underlying exercise limitation. As effort dyspnea is the earliest and one of the main clinical manifestations of PAH, CPET has been shown to provide valid support in early detection, differential diagnosis, and prognostic stratification of PAH patients, being a useful tool in both the first approach to patients and follow-up. The purpose of this review is to present the current applications of CPET in pulmonary hypertension and to propose possible future utilization to be further investigated.
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Affiliation(s)
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy;
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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9
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Cardiopulmonary Exercise Testing in Pulmonary Arterial Hypertension. Heart Fail Clin 2023; 19:35-43. [DOI: 10.1016/j.hfc.2022.08.015] [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: 11/24/2022]
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10
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Arena R, Ozemek C, Canada JM, Lavie CJ, Borghi-Silva A, Bond S, Popovic D, Argiento P, Guazzi M. Right Ventricular Contractile Reserve: A Key Metric to Identifying when Cardiorespiratory Fitness will Improve with Pulmonary Vasodilators. Curr Probl Cardiol 2022; 48:101423. [PMID: 36167224 DOI: 10.1016/j.cpcardiol.2022.101423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022]
Abstract
Cardiorespiratory fitness (CRF) has been proposed as a vital sign for the past several years, supported by a wealth of evidence demonstrating its significance as a predictor of health trajectory, exercise/functional capacity, and quality of life. According to the Fick equation, oxygen consumption (VO2) is the product of cardiac output (CO) and arterial-venous oxygen difference, with the former being a primary driver of one's aerobic capacity. In terms of the dependence of aerobic capacity on a robust augmentation of CO from rest to maximal exercise, left ventricular (LV) CO has been the historic focal point. Patients with pulmonary arterial hypertension (PAH) or secondary pulmonary hypertension (PH) present with a significantly compromised CRF; as pathophysiology worsens, so too does CRF. Interventions to improve pulmonary hemodynamics continue to emerge and are now a standard of clinical care in several patient populations with increased pulmonary pressures; new pharmacologic options continue to be explored. Improvement in CRF/aerobic capacity has been and continues to be a primary or leading secondary endpoint in clinical trials examining the effectiveness of pulmonary vasodilators. A central premise for including CRF/aerobic capacity as an endpoint is that pulmonary vasodilation will lead to a significant downstream increase in LV CO and therefore peak VO2. However, the importance of right ventricular (RV) CO to the peak VO2 response continues to be overlooked. The current review provides an overview of relevant principles of exercise physiology, approaches to assessing RV contractile reserve and proposals for clinical trial design and subject phenotyping.
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Affiliation(s)
- Ross Arena
- Department of Physical Therapy, College of Applied Science, University of Illinois Chicago, Chicago, IL ; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL.
| | - Cemal Ozemek
- Department of Physical Therapy, College of Applied Science, University of Illinois Chicago, Chicago, IL ; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL
| | - Justin M Canada
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Carl J Lavie
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-University of Queensland School of Medicine, New Orleans, LA
| | - Audrey Borghi-Silva
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Cardiopulmonary Physiotherapy Laboratory, Federal University of Sao Carlos, São Carlos, SP, Brazil
| | - Samantha Bond
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Biomedical and Health Information Sciences, College of Applied Science, University of Illinois Chicago, Chicago, IL
| | - Dejana Popovic
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia; Mayo Clinic, Rochester, Minnesota
| | - Paola Argiento
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Marco Guazzi
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Biological Sciences, San Paolo Hospital, Cardiology Division, University of Milano School of Medicine, Milano, Italy
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Lee MH, Menezes TCF, Reisz JA, Ferreira EVM, Graham BB, Oliveira RKF. Exercise metabolomics in pulmonary arterial hypertension: Where pulmonary vascular metabolism meets exercise physiology. Front Physiol 2022; 13:963881. [PMID: 36171971 PMCID: PMC9510894 DOI: 10.3389/fphys.2022.963881] [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: 06/08/2022] [Accepted: 08/23/2022] [Indexed: 01/29/2023] Open
Abstract
Pulmonary arterial hypertension is an incurable disease marked by dysregulated metabolism, both at the cellular level in the pulmonary vasculature, and at the whole-body level characterized by impaired exercise oxygen consumption. Though both altered pulmonary vascular metabolism and abnormal exercise physiology are key markers of disease severity and pulmonary arterial remodeling, their precise interactions are relatively unknown. Herein we review normal pulmonary vascular physiology and the current understanding of pulmonary vascular cell metabolism and cardiopulmonary response to exercise in Pulmonary arterial hypertension. We additionally introduce a newly developed international collaborative effort aimed at quantifying exercise-induced changes in pulmonary vascular metabolism, which will inform about underlying pathophysiology and clinical management. We support our investigative approach by presenting preliminary data and discuss potential future applications of our research platform.
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Affiliation(s)
- Michael H. Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Thaís C. F. Menezes
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Julie A. Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Eloara V. M. Ferreira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Brian B. Graham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Rudolf K. F. Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil,*Correspondence: Rudolf K. F. Oliveira,
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12
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Heerdt PM, Singh I, Elassal A, Kheyfets V, Richter MJ, Tello K. Pressure-based estimation of right ventricular ejection fraction. ESC Heart Fail 2022; 9:1436-1443. [PMID: 35150211 PMCID: PMC8934966 DOI: 10.1002/ehf2.13839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/04/2022] [Accepted: 01/31/2022] [Indexed: 11/05/2022] Open
Abstract
AIMS A method for estimating right ventricular ejection fraction (RVEF) from RV pressure waveforms was recently validated in an experimental model. Currently, cardiac magnetic resonance imaging (MRI) is the clinical reference standard for measurement of RVEF in pulmonary arterial hypertension (PAH). The present study was designed to test the hypothesis that the pressure-based method can detect clinically significant reductions in RVEF as determined by cardiac MRI in patients with PAH. METHODS AND RESULTS RVEF estimates derived from analysis of RV pressure waveforms recorded during right heart catheterization (RHC) in 25 patients were compared with cardiac MRI measurements of RVEF obtained within 24 h. Three investigators blinded to cardiac MRI results independently performed pressure-based RVEF estimation with the mean of their results used for comparison. Linear regression was used to assess correlation, and a receiver operator characteristic (ROC) curve was derived to define ability of the pressure-based method to detect a maladaptive RV response, defined as RVEF <35% on cardiac MRI. In 23 patients, an automated adaptation of the pressure-based RVEF method was also applied as proof of concept for beat-to-beat RVEF monitoring. The study cohort was comprised of 16 female and 9 male PAH patients with an average age of 53 ± 13 years. RVEF measured by cardiac MRI ranged from 16% to 57% (mean 37.7 ± 11.6%), and estimated RVEF from 15% to 54% (mean 36.2 ± 11.2%; P = 0.6). Measured and estimated RVEF were significantly correlated (r2 = 0.78; P < 0.0001). ROC curve analysis demonstrated an area under the curve of 0.94 ± 0.04 with a sensitivity of 81% and specificity of 85% for predicting a maladaptive RV response. As a secondary outcome, with the recognized limitation of non-coincident measures, Bland-Altman analysis was performed and indicated minimal bias for estimated RVEF (-1.5%) with limits of agreement of ± 10.9%. Adaptation of the pressure-based estimation method to provide beat-to-beat RVEF also demonstrated significant correlation between the median beat-to-beat value over 10 s with cardiac MRI (r2 = 0.66; P < 0.001), and an area under the ROC curve of 0.94 ± 0.04 (CI = 0.86 to 1.00) with sensitivity and specificity of 78% and 86%, respectively, for predicting a maladaptive RV response. CONCLUSIONS Pressure-based estimation of RVEF correlates with cardiac MRI and detects clinically significant reductions in RVEF. Study results support potential utility of pressure-based RVEF estimation for assessing the response to diagnostic or therapeutic interventions during RHC.
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Affiliation(s)
- Paul M. Heerdt
- Department. of Anesthesiology, Division of Applied HemodynamicsYale School of MedicineNew HavenCTUSA
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineYale School of MedicineP.O. Box 208057, 300 Cedar Street TAC ‐ 441 SouthNew HavenCT06520‐8057USA
| | - Ahmed Elassal
- Department. of Anesthesiology, Division of Applied HemodynamicsYale School of MedicineNew HavenCTUSA
| | - Vitaly Kheyfets
- Department of Bioengineering, School of MedicineUniversity of Colorado Denver, Anschutz Medical CenterDenverCOUSA
| | - Manuel J. Richter
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC)GiessenGermany
| | - Khodr Tello
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC)GiessenGermany
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Shah SJ, Borlaug BA, Chung ES, Cutlip DE, Debonnaire P, Fail PS, Gao Q, Hasenfuß G, Kahwash R, Kaye DM, Litwin SE, Lurz P, Massaro JM, Mohan RC, Ricciardi MJ, Solomon SD, Sverdlov AL, Swarup V, van Veldhuisen DJ, Winkler S, Leon MB. Atrial shunt device for heart failure with preserved and mildly reduced ejection fraction (REDUCE LAP-HF II): a randomised, multicentre, blinded, sham-controlled trial. Lancet 2022; 399:1130-1140. [PMID: 35120593 DOI: 10.1016/s0140-6736(22)00016-2] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 12/28/2021] [Accepted: 01/05/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Placement of an interatrial shunt device reduces pulmonary capillary wedge pressure during exercise in patients with heart failure and preserved or mildly reduced ejection fraction. We aimed to investigate whether an interatrial shunt can reduce heart failure events or improve health status in these patients. METHODS In this randomised, international, blinded, sham-controlled trial performed at 89 health-care centres, we included patients (aged ≥40 years) with symptomatic heart failure, an ejection fraction of at least 40%, and pulmonary capillary wedge pressure during exercise of at least 25 mm Hg while exceeding right atrial pressure by at least 5 mm Hg. Patients were randomly assigned (1:1) to receive either a shunt device or sham procedure. Patients and outcome assessors were masked to randomisation. The primary endpoint was a hierarchical composite of cardiovascular death or non-fatal ischemic stroke at 12 months, rate of total heart failure events up to 24 months, and change in Kansas City Cardiomyopathy Questionnaire overall summary score at 12 months. Pre-specified subgroup analyses were conducted for the heart failure event endpoint. Analysis of the primary endpoint, all other efficacy endpoints, and safety endpoints was conducted in the modified intention-to-treat population, defined as all patients randomly allocated to receive treatment, excluding those found to be ineligible after randomisation and therefore not treated. This study is registered with ClinicalTrials.gov, NCT03088033. FINDINGS Between May 25, 2017, and July 24, 2020, 1072 participants were enrolled, of whom 626 were randomly assigned to either the atrial shunt device (n=314) or sham procedure (n=312). There were no differences between groups in the primary composite endpoint (win ratio 1·0 [95% CI 0·8-1·2]; p=0·85) or in the individual components of the primary endpoint. The prespecified subgroups demonstrating a differential effect of atrial shunt device treatment on heart failure events were pulmonary artery systolic pressure at 20W of exercise (pinteraction=0·002 [>70 mm Hg associated with worse outcomes]), right atrial volume index (pinteraction=0·012 [≥29·7 mL/m2, worse outcomes]), and sex (pinteraction=0·02 [men, worse outcomes]). There were no differences in the composite safety endpoint between the two groups (n=116 [38%] for shunt device vs n=97 [31%] for sham procedure; p=0·11). INTERPRETATION Placement of an atrial shunt device did not reduce the total rate of heart failure events or improve health status in the overall population of patients with heart failure and ejection fraction of greater than or equal to 40%. FUNDING Corvia Medical.
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Affiliation(s)
- Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | | | - Eugene S Chung
- The Lindner Research Center at The Christ Hospital, Cincinnati, OH, USA
| | | | | | - Peter S Fail
- Cardiovascular Institute of the South, Houma, LA, USA
| | - Qi Gao
- Baim Clinical Research Institute, Boston, MA, USA
| | - Gerd Hasenfuß
- Heart Center, University Medical Center, Göttingen, Germany
| | | | | | - Sheldon E Litwin
- Medical University of South Carolina and Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Philipp Lurz
- Heart Center Leipzig at University Leipzig, Leipzig, Germany
| | | | | | | | | | - Aaron L Sverdlov
- John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia
| | | | - Dirk J van Veldhuisen
- University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - Martin B Leon
- Cardiovascular Research Foundation, New York City, NY, USA
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14
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Boudart C, Su F, Pitisci L, Dhoine A, Duranteau O, Jespers P, Herpain A, Vanderpool R, Brimioulle S, Creteur J, Naeije R, Van Obbergh L, Dewachter L. Early Hyperdynamic Sepsis Alters Coronary Blood Flow Regulation in Porcine Fecal Peritonitis. Front Physiol 2021; 12:754570. [PMID: 34925058 PMCID: PMC8678271 DOI: 10.3389/fphys.2021.754570] [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: 08/06/2021] [Accepted: 10/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Sepsis is a common condition known to impair blood flow regulation and microcirculation, which can ultimately lead to organ dysfunction but such contribution of the coronary circulation remains to be clarified. We investigated coronary blood flow regulatory mechanisms, including autoregulation, metabolic regulation, and endothelial vasodilatory response, in an experimental porcine model of early hyperdynamic sepsis. Methods: Fourteen pigs were randomized to sham (n = 7) or fecal peritonitis-induced sepsis (n = 7) procedures. At baseline, 6 and 12 h after peritonitis induction, the animals underwent general and coronary hemodynamic evaluation, including determination of autoregulatory breakpoint pressure and adenosine-induced maximal coronary vasodilation for coronary flow reserve and hyperemic microvascular resistance calculation. Endothelial-derived vasodilatory response was assessed both in vivo and ex vivo using bradykinin. Coronary arteries were sampled for pathobiological evaluation. Results: Sepsis resulted in a right shift of the autoregulatory breakpoint pressure, decreased coronary blood flow reserve and increased hyperemic microvascular resistance from the 6th h after peritonitis induction. In vivo and ex vivo endothelial vasomotor function was preserved. Sepsis increased coronary arteries expressions of nitric oxide synthases, prostaglandin I2 receptor, and prostaglandin F2α receptor. Conclusion: Autoregulation and metabolic blood flow regulation were both impaired in the coronary circulation during experimental hyperdynamic sepsis, although endothelial vasodilatory response was preserved.
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Affiliation(s)
- Céline Boudart
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Physiology and Pharmacology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Fuhong Su
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Pitisci
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arnaud Dhoine
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Physiology and Pharmacology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier Duranteau
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pascale Jespers
- Laboratory of Physiology and Pharmacology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Antoine Herpain
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Rebecca Vanderpool
- Division of Translational and Regenerative Medicine, Department of Medicine, The University of Arizona College of Medicine, Tucson, AZ, United States
| | - Serge Brimioulle
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Naeije
- Laboratory of Physiology and Pharmacology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Luc Van Obbergh
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Laurence Dewachter
- Laboratory of Physiology and Pharmacology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
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15
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Mandoli GE, Pastore MC, Benfari G, Setti M, Nistor D, D'Ascenzi F, Focardi M, Baccani B, Patti G, Valente S, Mondillo S, Cameli M. New echocardiographic indices of shift to biventricular failure to optimize risk stratification of chronic heart failure. ESC Heart Fail 2021; 9:476-485. [PMID: 34874122 PMCID: PMC8788050 DOI: 10.1002/ehf2.13722] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/01/2021] [Accepted: 11/06/2021] [Indexed: 01/15/2023] Open
Abstract
Aims The present study investigated the prognostic impact of either isolated left atrial (LA) impairment, or its association with right ventricular (RV) failure, in heart failure (HF) with reduced ejection fraction (HFrEF), using basic and speckle tracking echocardiography (STE). Methods and results One hundred and six outpatients with HFrEF were enrolled in this prospective observational study. Patients with primary lung diseases, non‐sinus rhythm, previous cardiac surgery, and poor acoustic window were excluded. After clinical examination and basic echocardiography, STE was used to measure peak atrial longitudinal strain (PALS) and a new marker of RV performance and pulmonary circulation relation: free‐wall RV longitudinal strain (fwRVLS)/systolic pulmonary artery pressure (sPAP). Patients were followed for all‐cause/cardiovascular death and HF hospitalization. Of 84 eligible patients (60.1 ± 11.5 years; 82% male patients), 48 reached the combined endpoint (cardiovascular death and/or HF hospitalization). Population was divided into three groups: Group 1 (PALS ≥ 15 and fwRVLS/sPAP ≤ −0.5), Group 2 (PALS ≤ 15 and fwRVLS/sPAP ≤ −0.5), and Group 3 (PALS ≤ 15 and fwRVLS/sPAP > −0.5). Mean follow up was 3.5 ± 0.3 years. The higher severity groups were associated with higher LA volume index (P < 0.0001), New York Heart Association class (P = 0.02), mitral regurgitation (P = 0.0004) and tricuspid regurgitation grades (P < 0.0001), lower left ventricular (LV) ejection fraction (P = 0.0003), LV global longitudinal strain (P < 0.0001), PALS (P < 0.0001), tricuspid annular plane systolic excursion (P < 0.007), sPAP (P < 0.0001), and RV strain (P < 0.0001). Reduced PALS and fwRVLS/sPAP were independent predictors of the combined endpoint with adjusted Cox models (hazard ratio = 9.54; 95% confidence interval = 2.95–30.92; P = 0.0002 for Group 3 vs. Group 1). Kaplan–Meier curves showed early and persistent divergence between the three groups for the prediction of the combined endpoint and of all‐cause death (P < 0.0001). Conclusions The combination of LA and right heart damage entails worse prognosis in patients with HFrEF. The evaluation of PALS and fwRVLS/sPAP could aid risk stratification of HFrEF patients to provide them early treatment.
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Affiliation(s)
- Giulia Elena Mandoli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, 53100, Italy
| | - Maria Concetta Pastore
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, 53100, Italy.,Department of Thoracic and Cardiovascular Diseases, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Martina Setti
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Dan Nistor
- Department M3, University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Târgu Mureș, Romania
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, 53100, Italy
| | - Marta Focardi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, 53100, Italy
| | - Bernardo Baccani
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, 53100, Italy
| | - Giuseppe Patti
- Department of Thoracic and Cardiovascular Diseases, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Serafina Valente
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, 53100, Italy
| | - Sergio Mondillo
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, 53100, Italy
| | - Matteo Cameli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Viale Bracci 1, Siena, 53100, Italy
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16
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Ewert R, Stubbe B, Heine A, Desole S, Habedank D, Knaack C, Hortien F, Opitz CF. [Invasive Cardiopulmonary Exercise Testing: A Review]. Pneumologie 2021; 76:98-111. [PMID: 34844269 DOI: 10.1055/a-1651-7450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Right heart catheterization (RHC) is the internationally standardized reference method for measuring pulmonary hemodynamics under resting conditions. In recent years, increasing efforts have been made to establish the reliable assessment of exercise hemodynamics as well, in order to obtain additional diagnostic and prognostic data. Furthermore, cardiopulmonary exercise testing (CPET), as the most comprehensive non-invasive exercise test, is increasingly performed in combination with RHC providing detailed pathophysiological insights into the exercise response, so-called invasive cardiopulmonary exercise testing (iCPET).In this review, the accumulated experience with iCPET is presented and methodological details are discussed. This complex examination is especially helpful in differentiating the underlying causes of unexplained dyspnea. In particular, early forms of cardiac or pulmonary vascular dysfunction can be detected by integrated analysis of hemodynamic as well as ventilatory and gas exchange data. It is expected that with increasing validation of iCPET parameters, a more reliable differentiation of normal from pathological stress reactions will be possible.
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Affiliation(s)
- Ralf Ewert
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Beate Stubbe
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Alexander Heine
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Susanna Desole
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Dirk Habedank
- DRK Kliniken Berlin Köpenick, Medizinische Klinik Kardiologie, Berlin
| | - Christine Knaack
- Universitätsmedizin Greifswald, Klinik für Innere Medizin C, Greifswald
| | - Franziska Hortien
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Christian F Opitz
- DRK Kliniken Berlin Westend, Klinik für Innere Medizin, Schwerpunkt Kardiologie, Berlin
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17
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Naeije R, Richter MJ, Rubin LJ. The physiologic basis of pulmonary arterial hypertension. Eur Respir J 2021; 59:13993003.02334-2021. [PMID: 34737219 PMCID: PMC9203839 DOI: 10.1183/13993003.02334-2021] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare dyspnea-fatigue syndrome caused by a progressive increase in pulmonary vascular resistance (PVR) and eventual right ventricular (RV) failure. In spite of extensive pulmonary vascular remodeling, lung function in PAH is generally well preserved, with hyperventilation and increased physiologic dead space, but minimal changes in lung mechanics and only mild to moderate hypoxemia and hypocapnia. Hypoxemia is mainly caused by a low mixed venous PO2 from a decreased cardiac output. Hypocapnia is mainly caused by an increased chemosensitivity. Exercise limitation in PAH is cardiovascular rather than ventilatory or muscular. The extent of pulmonary vascular disease in PAH is defined by multipoint pulmonary vascular pressure-flow relationships with a correction for hematocrit. Pulsatile pulmonary vascular pressure-flow relationships in PAH allow for the assessment of RV hydraulic load. This analysis is possible either in the frequency-domain or in the time-domain. The RV in PAH adapts to increased afterload by an increased contractility to preserve its coupling to the pulmonary circulation. When this homeometric mechanism is exhausted, the RV dilates to preserve flow output by an additional heterometric mechanism. Right heart failure is then diagnosed by imaging of increased right heart dimensions and clinical systemic congestion signs and symptoms. The coupling of the RV to the pulmonary circulation is assessed by the ratio of end-systolic to arterial elastances, but these measurements are difficult. Simplified estimates of RV-PA coupling can be obtained by magnetic resonance or echocardiographic imaging of ejection fraction.
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Affiliation(s)
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Lewis J Rubin
- University of California, San Diego, La Jolla, CA, USA
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18
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Persistent Exertional Intolerance after COVID-19: Insights from Invasive Cardiopulmonary Exercise Testing. Chest 2021; 161:54-63. [PMID: 34389297 PMCID: PMC8354807 DOI: 10.1016/j.chest.2021.08.010] [Citation(s) in RCA: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Some Coronavirus disease 2019 (COVID-19) patients who have recovered from their acute infection after experiencing only mild symptoms continue to exhibit persistent exertional limitation that is often unexplained by conventional investigative studies. RESEARCH QUESTION What is the patho-physiological mechanism of exercise intolerance that underlies the post-COVID-19 long haul syndrome following COVID-19 in patients without cardio-pulmonary disease? STUDY DESIGN AND METHODS This study examined the systemic and pulmonary hemodynamics, ventilation, and gas exchange in 10 post-COVID-19 patients without cardio-pulmonary disease during invasive cardiopulmonary exercise testing (iCPET) and compared the results to 10 age- and sex matched controls. These data were then used to define potential reasons for exertional limitation in the post-COVID-19 cohort. RESULTS Post-COVID-19 patients exhibited markedly reduced peak exercise aerobic capacity (VO2) compared to controls (70±11%predicted vs. 131±45%predicted; p<0.0001). This reduction in peak VO2 was associated with impaired systemic oxygen extraction (i.e., narrow CaVO2/CaO2) compared to controls (0.49±0.1 vs. 0.78±0.1, p<0.0001) despite a preserved peak cardiac index (7.8±3.1 vs. 8.4±2.3 L/min, p>0.05). Additionally, post-COVID-19 patients demonstrated greater ventilatory inefficiency (i.e., abnormal VE/VCO2 slope: 35±5 vs. 27±5, p=0.01) compared to controls without an increase in dead space ventilation. INTERPRETATION Post-COVID-19 patients without cardiopulmonary disease demonstrate a marked reduction in peak VO2 from a peripheral rather than a central cardiac limit along with an exaggerated hyper-ventilatory response during exercise.
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19
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Abstract
Exercise intolerance is the dominant symptom of pulmonary hypertension (PH). The gold standard for the estimation of exercise capacity is a cycle ergometer incremental cardiopulmonary exercise test (CPET). The main clinical variables generated by a CPET are peak oxygen uptake (Vo2peak), ventilatory equivalents for carbon dioxide (VE/Vco2), systolic blood pressure, oxygen (O2) pulse, and chronotropic responses. PH is associated with hyperventilation at rest and at exercise, and an increase in physiologic dead space. Maximal cardiac output depends on right ventricular function and critically determines a PH patient's exercise capacity. Dynamic arterial O2 desaturation can also depress the Vo2peak.
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20
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Cobra SDB, Rodrigues MP, de Melo FX, Ferreira NMC, Melo-Silva CA. Right ventricular contractility decreases during exercise in patients with non-advanced idiopathic pulmonary fibrosis. Medicine (Baltimore) 2021; 100:e25915. [PMID: 34232164 PMCID: PMC8270621 DOI: 10.1097/md.0000000000025915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 04/21/2021] [Indexed: 01/04/2023] Open
Abstract
Early right ventricular dysfunction in patients with non-advanced idiopathic pulmonary fibrosis (IPF) has not been fully elucidated. Thus, we aimed to assess right ventricular functions in IPF patients and controls by speckle-tracking strain echocardiography at rest and peak exercise.We screened 116 IPF patients from February to August 2019 to include 20 patients with no history of oxygen therapy, peripheral saturation levels ≥92% at rest, Gender-Age-Physiology Index score ≤5, and modified Medical Research Council score ≤3. Additionally, we enrolled 10 matched controls. Transthoracic echocardiography images were acquired at rest and during a cardiopulmonary exercise test. We analyzed 2-dimensional echocardiographic parameters and right ventricular function using the global longitudinal strain assessed by the 2-dimensional speckle-tracking technique.In the control group, we found normal values of right ventricle longitudinal strain (RVLS) at rest and at peak exercise, the latter being much more negative (-23.6 ± 2.2% and -26.8 ± 3.1%, respectively; P < .001). By contrast, RVLS values in the IPF group increased from -21.1 ± 3.8% at rest to -17.0 ± 4.5% at peak exercise (P < .001). The exercise revealed a difference between the 2 groups as the mean RVLS values moved during peak exercise in opposite directions. Patients with IPF got worse, whereas control patients presented improved right ventricular contractility.Right ventricular dysfunction was unveiled by speckle-tracking echocardiography during exercise in non-advanced IPF patients. We suggest that this reflects an inadequate right ventricular-arterial coupling decreasing the right ventricular longitudinal contraction during exercise in these patients. This parameter may be useful as an early index of suspected pulmonary hypertension.
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Affiliation(s)
- Sandra de Barros Cobra
- Department of Cardiology, Federal District Base Hospital Institute and School of Medicine, University of Brasília, Brasília 70.330-150 – DF
| | | | | | | | - César Augusto Melo-Silva
- Laboratory of Respiratory Physiology, University of Brasília
- Division of Physical Therapy, University Hospital of Brasília, Brasília 70.910-900 – DF
- Núcleo de Integração Funcional, Rehabilitation Center, Brasília 70.830-350 – DF, Brazil
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21
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Singh I, Oliveira RKF, Naeije R, Oldham WM, Faria-Urbina M, Waxman AB, Systrom DM. Systemic vascular distensibility relates to exercise capacity in connective tissue disease. Rheumatology (Oxford) 2021; 60:1429-1434. [PMID: 33001175 DOI: 10.1093/rheumatology/keaa510] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/06/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Exercise intolerance is a common clinical manifestation of CTD. Frequently, CTD patients have associated cardio-pulmonary disease, including pulmonary hypertension or heart failure that impairs aerobic exercise capacity (pVO2). The contribution of the systemic micro-vasculature to reduced exercise capacity in CTD patients without cardiopulmonary disease has not been fully described. In this study, we sought to examine the role of systemic vascular distensibility, α in reducing exercise capacity (i.e. pVO2) in CTD patients. METHODS Systemic and pulmonary vascular distensibility, α (%/mmHg) was determined from multipoint systemic pressure-flow plots during invasive cardiopulmonary exercise testing with pulmonary and radial arterial catheters in place in 42 CTD patients without cardiopulmonary disease and compared with 24 age and gender matched normal controls. RESULTS During exercise, systemic vascular distensibility, α was reduced in CTD patients compared with controls (0.20 ± 0.12%/mmHg vs 0.30 ± 0.13%/mmHg, P =0.01). The reduced systemic vascular distensibility α, was associated with impaired stroke volume augmentation. On multivariate analysis, systemic vascular distensibility, α was associated with a decreased exercise capacity (pVO2) and decreased systemic oxygen extraction. CONCLUSION Systemic vascular distensibility, α is associated with impaired systemic oxygen extraction and decreased aerobic capacity in patients with CTD without cardiopulmonary disease.
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Affiliation(s)
- Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Rudolf K F Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo - UNIFESP, São Paulo, Brazil
| | - Robert Naeije
- Department of Medicine, Erasme University Hospital, Brussels, Belgium
| | - William M Oldham
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mariana Faria-Urbina
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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22
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High Right Ventricular Afterload during Exercise in Patients with Pulmonary Arterial Hypertension. J Clin Med 2021; 10:jcm10092024. [PMID: 34065097 PMCID: PMC8126033 DOI: 10.3390/jcm10092024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/30/2021] [Indexed: 12/17/2022] Open
Abstract
The right ventricle (RV) is more sensitive to an increase in afterload than the left ventricle (LV), and RV afterload during exercise increases more easily than LV afterload. Pulmonary arterial hypertension (PAH)-specific therapy has improved pulmonary hemodynamics at rest; however, the pulmonary hemodynamic response to exercise is still abnormal in most patients with PAH. In these patients, RV afterload during exercise could be higher, resulting in a greater increase in RV wall stress. Recently, an increasing number of studies have indicated the short-term efficacy of exercise training. However, considering the potential risk of promoting myocardial maladaptive remodeling, even low-intensity repetitive exercise training could lead to long-term clinical deterioration. Further studies investigating the long-term effects on the RV and pulmonary vasculature are warranted. Although the indications for exercise training for patients with PAH have been expanding, exercise training may be associated with various risks. Training programs along with risk stratification based on the pulmonary hemodynamic response to exercise may enhance the safety of patients with PAH.
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23
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Raza F, Kozitza C, Chybowski A, Goss KN, Berei T, Runo J, Eldridge M, Chesler N. Interferon-β-Induced Pulmonary Arterial Hypertension: Approach to Diagnosis and Clinical Monitoring. JACC Case Rep 2021; 3:1038-1043. [PMID: 34317680 PMCID: PMC8311374 DOI: 10.1016/j.jaccas.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 11/23/2022]
Abstract
A 48-year-old woman who had been receiving long-term interferon-β for 8 years for multiple sclerosis developed drug-induced World Health Organization group I pulmonary arterial hypertension. Triple therapy for pulmonary arterial hypertension and suspension of interferon-β led to improvement from a high-risk to low-risk state and improvement in exercise hemodynamics, including vascular distensibility, and right ventricle–pulmonary artery coupling. (Level of Difficulty: Advanced.)
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Key Words
- 6MWD, 6-min walk distance
- BNP, B-type natriuretic peptide
- BP, blood pressure
- CMR, cardiac magnetic resonance
- CPET, cardiopulmonary exercise test
- Dlco, diffusion capacity of carbon monoxide
- ET, endothelin
- IFN, interferon
- MS, multiple sclerosis
- NYHA, New York Heart Association
- PA, pulmonary arterial
- PAH, pulmonary arterial hypertension
- RHC, right-sided heart catheterization
- RV, right ventricular
- exercise
- pulmonary hypertension
- right ventricle
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Affiliation(s)
- Farhan Raza
- Division of Cardiology, Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
- Address for correspondence: Dr. Farhan Raza, Division of Cardiology, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue, CSC-E5/582B, Madison, Wisconsin 53792, USA. @farhanraza1984
| | - Callyn Kozitza
- Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA
| | - Amy Chybowski
- Division of Pulmonary and Critical Care, Department of Medicine and Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Kara N. Goss
- Division of Pulmonary and Critical Care, Department of Medicine and Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Theodore Berei
- Department of Pharmacy, University of Wisconsin, Madison, Wisconsin, USA
| | - James Runo
- Division of Pulmonary and Critical Care, Department of Medicine and Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Marlowe Eldridge
- Department of Pediatrics. University of Wisconsin, Madison, Wisconsin, USA
| | - Naomi Chesler
- Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA
- Department of Pediatrics. University of Wisconsin, Madison, Wisconsin, USA
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24
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Richter MJ, Yogeswaran A, Husain-Syed F, Vadász I, Rako Z, Mohajerani E, Ghofrani HA, Naeije R, Seeger W, Herberg U, Rieth A, Tedford RJ, Grimminger F, Gall H, Tello K. A novel non-invasive and echocardiography-derived method for quantification of right ventricular pressure-volume loops. Eur Heart J Cardiovasc Imaging 2021; 23:498-507. [PMID: 33668064 DOI: 10.1093/ehjci/jeab038] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/12/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS We sought to assess the feasibility of constructing right ventricular (RV) pressure-volume (PV) loops solely by echocardiography. METHODS AND RESULTS We performed RV conductance and pressure wire (PW) catheterization with simultaneous echocardiography in 35 patients with pulmonary hypertension. To generate echocardiographic PV loops, a reference RV pressure curve was constructed using pooled PW data from the first 20 patients (initial cohort). Individual pressure curves were then generated by adjusting the reference curve according to RV isovolumic and ejection phase duration and estimated RV systolic pressure. The pressure curves were synchronized with echocardiographic volume curves. We validated the reference curve in the remaining 15 patients (validation cohort). Methods were compared with correlation and Bland-Altman analysis. In the initial cohort, echocardiographic and conductance-derived PV loop parameters were significantly correlated {rho = 0.8053 [end-systolic elastance (Ees)], 0.8261 [Ees/arterial elastance (Ea)], and 0.697 (stroke work); all P < 0.001}, with low bias [-0.016 mmHg/mL (Ees), 0.1225 (Ees/Ea), and -39.0 mmHg mL (stroke work)] and acceptable limits of agreement. Echocardiographic and PW-derived Ees were also tightly correlated, with low bias (-0.009 mmHg/mL) and small limits of agreement. Echocardiographic and conductance-derived Ees, Ees/Ea, and stroke work were also tightly correlated in the validation cohort (rho = 0.9014, 0.9812, and 0.9491, respectively; all P < 0.001), with low bias (0.0173 mmHg/mL, 0.0153, and 255.1 mmHg mL, respectively) and acceptable limits. CONCLUSION The novel echocardiographic method is an acceptable alternative to invasively measured PV loops to assess contractility, RV-arterial coupling, and RV myocardial work. Further validation is warranted.
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Affiliation(s)
- Manuel J Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Athiththan Yogeswaran
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Faeq Husain-Syed
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - István Vadász
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Zvonimir Rako
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Emad Mohajerani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Hossein A Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany.,Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Benekestr. 2-8, Bad Nauheim 61231, Germany.,Department of Medicine, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Robert Naeije
- Erasme University Hospital, Route de Lennik 808, Brussels 1070, Belgium
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany.,Department of Internal Medicine, German Center for Lung Research (DZL), Cardio-Pulmonary Institute (CPI), Justus-Liebig-University Giessen, Aulweg 130, Giessen 35392, Germany
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University of Bonn, Building 30, Venusberg-Campus 1, Bonn 53127, Germany
| | - Andreas Rieth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Friedrich Grimminger
- Department of Internal Medicine, German Center for Lung Research (DZL), Cardio-Pulmonary Institute (CPI), Justus-Liebig-University Giessen, Aulweg 130, Giessen 35392, Germany.,Institute for Lung Health (ILH), Justus-Liebig-University Giessen, Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Klinikstrasse 32, Giessen 35392, Germany
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25
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Messina CMS, Ferreira EVM, Singh I, Fonseca AXC, Ramos RP, Nery LE, Systrom DM, Oliveira RKF, Ota-Arakaki JS. Impact of right ventricular work and pulmonary arterial compliance on peak exercise oxygen uptake in idiopathic pulmonary arterial hypertension. Int J Cardiol 2021; 331:230-235. [PMID: 33545265 DOI: 10.1016/j.ijcard.2021.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/26/2020] [Accepted: 01/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is associated with increased right ventricular (RV) afterload, RV dysfunction and decreased peak oxygen uptake (pVO2). However, the pulmonary hemodynamic mechanisms measured by exercise right heart catheterization (RHC) that contribute to reduced pVO2 in idiopathic PAH (IPAH) are not completely characterized. Therefore, we sought to evaluate the exercise RHC determinants of pVO2 in patients with IPAH. METHODS 519 consecutive patients with suspected and/or confirmed pulmonary hypertension were prospectively screened to identify 20 patients with IPAH. All IPAH patients were prospectively evaluated with resting and exercise RHC and cardiopulmonary exercise testing. RESULTS 85% of the patients were female; the median age was 34[29-42] years old. At peak exercise, mean pulmonary arterial (PA) pressure was 76 ± 17 mmHg, PA wedge pressure was 14 ± 5 mmHg, cardiac output (CO) was 5.7 ± 1.9 L/min, pulmonary vascular resistance was 959 ± 401 dynes/s/cm5 and PA compliance was 0.9[0.6-1.2] ml/mmHg. On univariate analysis, pVO2 positively correlated to peak CO, peak cardiac index, peak stroke volume index, peak RV stroke work index (RVSWI) and peak oxygen saturation. There was a negative correlation between pVO2 and Δ (rest to peak change) PA compliance. In age-adjusted multivariate model, peak RVSWI (Coefficient = 0.15, Beta = 0.63, 95% CI [0.07-0.22], p < 0.01) and ΔPA compliance (Coefficient = -2.51, Beta = -0.43, 95% CI [-4.34-(-0.68)], p = 0.01) had the best performance predicting pVO2 (R2 = 0.66). CONCLUSIONS In conclusion, a load dependent measurement of RV function (RVSWI) and the pulsatile component of RV afterload (ΔPA compliance) significantly influence pVO2 in IPAH, further highlighting the pivotal role of hemodynamic coupling to IPAH exercise capacity.
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Affiliation(s)
- Carolina M S Messina
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Eloara V M Ferreira
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Angelo X C Fonseca
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Roberta P Ramos
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Luiz E Nery
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Rudolf K F Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil.
| | - Jaquelina S Ota-Arakaki
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
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26
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Wernhart S, Hedderich J, Weihe E. Vital capacity and valvular dysfunction could serve as non-invasive predictors to screen for exercise pulmonary hypertension in the elderly based on a new diagnostic score. J Cardiovasc Thorac Res 2021; 13:68-78. [PMID: 33815705 PMCID: PMC8007893 DOI: 10.34172/jcvtr.2021.05] [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: 09/18/2020] [Accepted: 01/05/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction: Exercise pulmonary hypertension (exPH) has been defined as total pulmonary resistance (TPR) >3 mm Hg/L/min and mean pulmonary artery pressure (mPAP) >30 mm Hg, albeit with a considerable risk of false positives in elderly patients with lower cardiac output during exercise.
Methods: We retrospectively analysed patients with unclear dyspnea receiving right heart catheterisation at rest and exercise (n=244) between January 2015 and January 2020. Lung function testing, blood gas analysis, and echocardiography were performed. We elaborated a combinatorial score to advance the current definition of exPH in an elderly population (mean age 67.0 years±11.9). A stepwise regression model was calculated to non-invasively predict exPH.
Results: Analysis of variables across the achieved peak power allowed the creation of a model for defining exPH, where three out of four criteria needed to be fulfilled: Peak power ≤100 Watt, pulmonary capillary wedge pressure ≥18 mm Hg, pulmonary vascular resistance >3 Wood Units, and mPAP ≥35 mm Hg. The new scoring model resulted in a lower number of exPH diagnoses than the current suggestion (63.1% vs. 78.3%). We present a combinatorial model with vital capacity (VCmax) and valvular dysfunction to predict exPH (sensitivity 93.2%; specificity 44.2%, area under the curve 0.73) based on our suggested criteria. The odds of the presence of exPH were 2.1 for a 1 l loss in VCmax and 3.6 for having valvular dysfunction.
Conclusion: We advance a revised definition of exPH in elderly patients in order to overcome current limitations. We establish a new non-invasive approach to predict exPH by assessing VCmax and valvular dysfunction for early risk stratification in elderly patients.
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Affiliation(s)
- Simon Wernhart
- Department of Cardiology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany.,University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Jürgen Hedderich
- Medistat-Biomedical Statistics, Medistat GmbH, Kronshagen, Germany
| | - Eberhard Weihe
- Institute of Anatomy and Cell Biology of the Philipps-University Marburg, Germany
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27
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Harder EM, Vanderpool R, Rahaghi FN. Advanced Imaging in Pulmonary Vascular Disease. Clin Chest Med 2021; 42:101-112. [PMID: 33541604 DOI: 10.1016/j.ccm.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although the diagnosis of pulmonary hypertension requires invasive testing, imaging serves an important role in the screening, classification, and monitoring of patients with pulmonary vascular disease (PVD). The development of advanced imaging techniques has led to improvements in the understanding of disease pathophysiology, noninvasive assessment of hemodynamics, and stratification of patient risk. This article discusses the current role of advanced imaging and the emerging novel techniques for visualizing the lung parenchyma, mediastinum, and heart in PVD.
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Affiliation(s)
- Eileen M Harder
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, 15 Francis Street, Boston, MA 02115, USA.
| | - Rebecca Vanderpool
- Division of Translational and Regenerative Medicine, Department of Medicine, University of Arizona, 1656 East Mabel Street, Tucson, AZ 85721, USA. https://twitter.com/rrvdpool
| | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, 15 Francis Street, Boston, MA 02115, USA
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28
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Sex-Related Differences in Dynamic Right Ventricular-Pulmonary Vascular Coupling in Heart Failure With Preserved Ejection Fraction. Chest 2021; 159:2402-2416. [PMID: 33388286 DOI: 10.1016/j.chest.2020.12.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/16/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is associated with poorer outcomes in heart failure with preserved ejection fraction (HFpEF). Although female subjects are more likely to have HFpEF, male subjects have worse prognosis and resting RV function. The contribution of dynamic RV-pulmonary arterial (RV-PA) coupling between sex and its impact on peak exercise capacity (VO2) in HFpEF is not known. RESEARCH QUESTION The goal of this study was to investigate the differential effects of sex on RV-PA coupling during maximum incremental exercise in patients with HFpEF. STUDY DESIGN AND METHODS This study examined rest and exercise invasive pulmonary hemodynamics in 22 male patients with HFpEF and 27 female patients with HFpEF. To further investigate the discrepancy in RV-PA response between sex, 26 age-matched control subjects (11 male subjects and 15 female subjects) were included. Single beat analysis of RV pressure waveforms was used to determine the end-systolic elastance (Ees) and pulmonary arterial elastance. RV-PA coupling was determined as the ratio of end-systolic elastance/PA elastance. RESULTS Both HFpEF groups experienced decreased peak VO2 (% predicted). However, male patients with HFpEF experienced a greater decrement in peak VO2 compared with female patients (58 ± 16% vs 70 ± 15%; P < .05). Male patients with HFpEF had a more pronounced increase in RV afterload, Ea (1.8 ± 0.6 mm Hg/mL/m2 vs 1.3 ± 0.4 mm Hg/mL/m2; P < .05) and failed to increase RV contractility during exercise, resulting in dynamic RV-PA uncoupling (0.9 ± 0.4 vs 1.2 ± 0.4; P < .05) and subsequent reduced stroke volume index augmentation. In contrast, female patients with HFpEF were able to augment RV contractility in the face of increasing afterload, preserving RV-PA coupling during exercise. INTERPRETATION Male patients with HFpEF were more compromised regarding dynamic RV-PA uncoupling and reduced peak VO2 compared with female patients. This finding was driven by both RV contractile impairment and afterload mismatch. In contrast, female patients with HFpEF had preserved RV-PA coupling during exercise and better peak exercise VO2 compared with male patients with HFpEF.
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29
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Wright SP, Dawkins TG, Eves ND, Shave R, Tedford RJ, Mak S. Hemodynamic function of the right ventricular-pulmonary vascular-left atrial unit: normal responses to exercise in healthy adults. Am J Physiol Heart Circ Physiol 2020; 320:H923-H941. [PMID: 33356960 DOI: 10.1152/ajpheart.00720.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
With each heartbeat, the right ventricle (RV) inputs blood into the pulmonary vascular (PV) compartment, which conducts blood through the lungs at low pressure and concurrently fills the left atrium (LA) for output to the systemic circulation. This overall hemodynamic function of the integrated RV-PV-LA unit is determined by complex interactions between the components that vary over the cardiac cycle but are often assessed in terms of mean pressure and flow. Exercise challenges these hemodynamic interactions as cardiac filling increases, stroke volume augments, and cycle length decreases, with PV pressures ultimately increasing in association with cardiac output. Recent cardiopulmonary exercise hemodynamic studies have enriched the available data from healthy adults, yielded insight into the underlying mechanisms that modify the PV pressure-flow relationship, and better delineated the normal limits of healthy responses to exercise. This review will examine hemodynamic function of the RV-PV-LA unit using the two-element Windkessel model for the pulmonary circulation. It will focus on acute PV and LA responses that accommodate increased RV output during exercise, including PV recruitment and distension and LA reservoir expansion, and the integrated mean pressure-flow response to exercise in healthy adults. Finally, it will consider how these responses may be impacted by age-related remodeling and modified by sex-related cardiopulmonary differences. Studying the determinants and recognizing the normal limits of PV pressure-flow relations during exercise will improve our understanding of cardiopulmonary mechanisms that facilitate or limit exercise.
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Affiliation(s)
- S P Wright
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - T G Dawkins
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
| | - N D Eves
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - R Shave
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - R J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - S Mak
- Division of Cardiology, Department of Medicine, Sinai Health, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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30
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Sibomana JP, Campeche A, Carvalho-Filho RJ, Correa RA, Duani H, Pacheco Guimaraes V, Hilton JF, Kassa B, Kumar R, Lee MH, Loureiro CMC, Mazimba S, Mickael C, Oliveira RKF, Ota-Arakaki JS, Rezende CF, Silva LCS, Sinkala E, Ahmed HY, Graham BB. Schistosomiasis Pulmonary Arterial Hypertension. Front Immunol 2020; 11:608883. [PMID: 33362796 PMCID: PMC7758287 DOI: 10.3389/fimmu.2020.608883] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/03/2020] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a disease of the lung blood vessels that results in right heart failure. PAH is thought to occur in about 5% to 10% of patients with hepatosplenic schistosomiasis, particularly due to S. mansoni. The lung blood vessel injury may result from a combination of embolization of eggs through portocaval shunts into the lungs causing localized Type 2 inflammatory response and vessel remodeling, triggering of autonomous pathology that becomes independent of the antigen, and high cardiac output as seen in portopulmonary hypertension. The condition is likely underdiagnosed as there is little systematic screening, and risk factors for developing PAH are not known. Screening is done by echocardiography, and formal diagnosis requires invasive right heart catheterization. Patients with Schistosoma-associated PAH show reduced functional capacity and can be treated with pulmonary vasodilators, which improves symptoms and may improve survival. There are animal models of this disease that might help in understanding disease pathogenesis and identify novel targets to screen and treatment. Pathogenic mechanisms include Type 2 immunity and activation and signaling in the TGF-β pathway. There are still major uncertainties regarding Schistosoma-associated PAH development, course and treatment.
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Affiliation(s)
- Jean Pierre Sibomana
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Tikur Anbessa Specialized Hospital, College of Health Sciences, University of Addis Ababa, Addis Ababa, Ethiopia
- Department of Medicine, Butare University Teaching Hospital, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Aloma Campeche
- Division of Gastroenterology, Department of Medicine, Santa Casa Hospital, Salvador, Bahia, Brazil
| | - Roberto J. Carvalho-Filho
- Division of Gastroenterology, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Ricardo Amorim Correa
- Internal Medicine/Pulmonary Division, Medical School, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Helena Duani
- Internal Medicine/Infectious Diseases Division, Medical School, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Virginia Pacheco Guimaraes
- Pulmonary Department, Hospital Júlia Kubistchek, Fundação Hospitalar of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Joan F. Hilton
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
| | - Biruk Kassa
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Rahul Kumar
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Michael H. Lee
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | | | - Sula Mazimba
- Division of Cardiology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Claudia Mickael
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Rudolf K. F. Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Jaquelina S. Ota-Arakaki
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Camila Farnese Rezende
- Pulmonary Medicine, Hospital das Clinicas, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Luciana C. S. Silva
- Internal Medicine Department, Medical School, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Edford Sinkala
- Hepatology Clinic, Department of Medicine, University of Zambia Teaching Hospital, Lusaka, Zambia
| | - Hanan Yusuf Ahmed
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Tikur Anbessa Specialized Hospital, College of Health Sciences, University of Addis Ababa, Addis Ababa, Ethiopia
| | - Brian B. Graham
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
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31
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Kinoshita M, Inoue K, Higashi H, Akazawa Y, Sasaki Y, Fujii A, Uetani T, Inaba S, Aono J, Nagai T, Nishimura K, Ikeda S, Yamaguchi O. Impact of right ventricular contractile reserve during low-load exercise on exercise intolerance in heart failure. ESC Heart Fail 2020; 7:3810-3820. [PMID: 32924319 PMCID: PMC7755000 DOI: 10.1002/ehf2.12968] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/21/2020] [Accepted: 08/06/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS Traditional criteria for heart transplantation by cardiopulmonary exercise testing (CPX) include peak oxygen uptake (VO2 ) < 14 mL/kg/min. Reaching a sufficient exercise load is challenging for patients with refractory heart failure (HF) because of their exercise intolerance. Recently, a substantial impact of right ventricular (RV) dysfunction was highlighted on urgent heart transplantation and mortality. This study aims to investigate the impact of RV contractile reserve, assessed by low-load exercise stress echocardiography (ESE), on exercise intolerance defined as peak VO2 < 14 mL/kg/min, in patients with HF. METHODS AND RESULTS We prospectively examined 67 consecutive patients hospitalized for HF who underwent ESE and CPX under a stabilized HF condition. Although low-load ESE was defined as 25 W load exercise, an increment in RV systolic (s') velocity was regarded as the preservation of RV contractile reserve. All patients completed low-load ESE. During low-load ESE, the variation in RV s' velocity significantly correlated with peak VO2 (r = 0.787, P < 0.001). The change in RV s' velocity during low-load ESE accurately identified patients with peak VO2 < 14 mL/kg/min (area under the curve, 0.95; sensitivity, 92%; specificity, 85%). The intraclass correlation coefficient for intra-observer and inter-observer agreement for the change in RV s' velocity was 0.96 (95% confidence interval, 0.88-0.99, P < 0.001) and 0.86 (95% confidence interval, 0.64-0.95, P < 0.001), respectively. The RV-to-pulmonary circulation (PC) coupling, which was assessed by the slope of the relationship between RV s' velocity and pulmonary artery systolic pressure at rest and low-load exercise, was worse in the low-peak VO2 group (<14 mL/kg/min) than the preserved-peak VO2 group (≥14 mL/kg/min). CONCLUSIONS The change in RV s' velocity during low-load ESE could estimate the exercise capacity in HF patients. The assessments of RV contractile reserve and RV-to-PC coupling could be clinically beneficial to distinguish high-risk HF patients.
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Affiliation(s)
- Masaki Kinoshita
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Katsuji Inoue
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Yusuke Akazawa
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Yasuhiro Sasaki
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Akira Fujii
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Teruyoshi Uetani
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Shinji Inaba
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Jun Aono
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Takayuki Nagai
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Kazuhisa Nishimura
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Shuntaro Ikeda
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension and NephrologyEhime University Graduate School of MedicineShitsukawa, ToonEhime791‐0295Japan
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Sayegh ALC, Silva BM, Ferreira EVM, Ramos RP, Fisher JP, Nery LE, Ota-Arakaki JS, Oliveira RKF. Clinical utility of ventilatory and gas exchange evaluation during low-intensity exercise for risk stratification and prognostication in pulmonary arterial hypertension. Respirology 2020; 26:264-272. [PMID: 33118293 DOI: 10.1111/resp.13959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/11/2020] [Accepted: 09/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Peak oxygen consumption (pVO2 ), determined from CPET, provides a valuable indication of PAH severity and patient prognosis. However, CPET is often contraindicated in severe PAH and frequently terminated prior to achievement of a sufficient exercise effort. We sought to determine whether in PAH low-intensity [i.e. freewheeling exercise (FW)] exercise reveals abnormal VE /VCO2 and PET CO2 responses that are associated with pVO2 and serve as indices of PAH risk stratification and mortality. METHODS Retrospective analysis of CPET from 97 PAH patients and 20 age-matched controls was undertaken. FW VE /VCO2 and PET CO2 were correlated with pVO2 % age-predicted. Prognostication analysis was conducted using pVO2 > 65% age-predicted, as known to represent a low mortality risk. Primary outcome was mortality from any cause. RESULTS FW PET CO2 was correlated with pVO2 (P < 0.0001; r = 0.52), while FW VE /VCO2 was not (P = 0.13; r = -0.16). ROC curve analyses showed that FW PET CO2 (AUC = 0.659), but not FW VE /VCO2 (AUC = 0.587), provided predictive information identifying pVO2 > 65% age-predicted (best cut-off value of 28 mm Hg). By Cox analysis, FW PET CO2 < 28 mm Hg remained a predictor of mortality after adjusting for age and PAH aetiology (HR: 2.360, 95% CI: 1.144-4.866, P = 0.020). CONCLUSION Low PET CO2 during FW is associated with reduced pVO2 in PAH and provides predictive information for PAH risk stratification and prognostication.
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Affiliation(s)
- Ana Luiza C Sayegh
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil.,Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Bruno Moreira Silva
- Department of Physiology, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Eloara V M Ferreira
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Roberta P Ramos
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - James P Fisher
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Luiz E Nery
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Jaquelina S Ota-Arakaki
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Rudolf K F Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil
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Singh I, Oliveira RKF, Heerdt P, Brown MB, Faria-Urbina M, Waxman AB, Systrom DM. Dynamic right ventricular function response to incremental exercise in pulmonary hypertension. Pulm Circ 2020; 10:2045894020950187. [PMID: 33062259 PMCID: PMC7534091 DOI: 10.1177/2045894020950187] [Citation(s) in RCA: 8] [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] [Received: 05/29/2020] [Accepted: 07/27/2020] [Indexed: 12/22/2022] Open
Abstract
Pulmonary hypertension is a progressive disease whose survival is linked to adequate right ventricle adaptation to its afterload. In the current study, we performed an in-depth characterization of right ventricle function during maximum incremental exercise in patients with pulmonary hypertension and how it relates to exercise capacity. A total of 377 pulmonary hypertension patients who completed a maximum symptom-limited invasive cardiopulmonary exercise testing were evaluated to identify 45 patients with heart failure with preserved ejection fraction, 48 with exercise pulmonary hypertension, and 47 with established pulmonary arterial hypertension. These patients were compared to 17 age- and gender-matched normal controls. Load-adjusted right ventricle function was quantified as the ratio of right ventricle stroke work index to pulmonary arterial elastance. All patients with pulmonary hypertension had reduced peak VO2 %predicted compared to controls. Right ventricle function deteriorated for all pulmonary hypertension groups by 50% of peak VO2. Worsening of right ventricle function during freewheeling exercise was associated with greater reduction in peak VO2 compared to those whose right ventricle function deteriorated at later exercise stages (i.e. min 1, 2, and 3). On multivariate analysis, reduced ratio of right ventricle stroke work index to arterial elastance was an independent predictor of peak VO2 %predicted (β-Coefficient –5.46, 95% CI: –9.47 to –1.47, p = 0.01). Right ventricle function deteriorates early during incremental exercise in pulmonary hypertension, occurring by 50% of peak oxygen uptake. The current study demonstrates that right ventricle dysfunction is an early phenomenon during incremental exercise in pulmonary hypertension, occurring by 50% of peak oxygen uptake. The threshold at which right ventricle function is compromised during incremental exercise in pulmonary hypertension influences aerobic capacity and may help guide exercise strategies to mitigate dynamic worsening of right ventricle function during exercise training.
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Affiliation(s)
- Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Rudolf K F Oliveira
- Division of Respiratory Diseases, Federal University of São Paulo - UNIFESP, São Paulo, Brazil
| | - Paul Heerdt
- Division of Anaesthesiology, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Mary B Brown
- Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Mariana Faria-Urbina
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Yan H, Ouyang Y, Wang L, Luo X, Zhan Q. Effect of respiratory rehabilitation training on elderly patients with COVID-19: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22109. [PMID: 32925755 PMCID: PMC7489687 DOI: 10.1097/md.0000000000022109] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients with the Corona Virus Disease 2019 (COVID-19) often see their respiratory, physical, and psychological functions impaired to varying degrees, especially for the elderly patients. Timely respiratory rehabilitation intervention for such patients may improve their prognoses. However, its relative effectiveness has not been proved. Therefore, this study is purposed to determine the effect of respiratory rehabilitation on elderly patients with COVID-19. METHODS This study will search the following electronic databases: Embase, MEDLINE, PubMed, Cochrane Library, China national knowledge infrastructure database, Wan Fang database, Chinese Science and Technology Periodical Database, and Chinese Biomedical Literature Database, with the retrieval period running from their inception to August 2020. All randomized controlled trials of respiratory rehabilitation training on elderly patients with COVID-19 are collected, and the data are selected and extracted independently according to the pre-designed inclusion/exclusion criteria. Cochrane bias risk assessment tool is used to evaluate the method quality and bias risk. All data analyses will be implemented by using Revman5.3 and Stata14 software. RESULTS This study will make a high-quality and comprehensive evaluation of the efficacy of respiratory rehabilitation training on elderly patients with COVID-19. CONCLUSION The conclusions of this systematic review will deliver more convincing evidence. ETHICS AND DISSEMINATION The private information collected from individuals will not be published. And this systematic review will also not involve impairing the participants' rights. Ethical approval is not required. The results may be published in a peer-reviewed journal or disseminated in relevant conferences.
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Affiliation(s)
| | - Yonghong Ouyang
- Department of General Medicine, The First Affiliated Hospital of Hunan Traditional Chinese Medical College
| | - Lang Wang
- Department of Metabolic Endocrinology, The Affiliated ZhuZhou Hospital XiangYa Medical College CSU, Zhuzhou, Hunan 412000
| | | | - Qian Zhan
- Department of Pneumology, West China Hospital, Sichuan University, Chengdu, Sichun 610041, China
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Waller L, Krüger K, Conrad K, Weiss A, Alack K. Effects of Different Types of Exercise Training on Pulmonary Arterial Hypertension: A Systematic Review. J Clin Med 2020; 9:jcm9061689. [PMID: 32498263 PMCID: PMC7356848 DOI: 10.3390/jcm9061689] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/13/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) represents a chronic progressive disease characterized by high blood pressure in the pulmonary arteries leading to right heart failure. The disease has been a focus of medical research for many years due to its worse prognosis and limited treatment options. The aim of this study was to systematically assess the effects of different types of exercise interventions on PAH. Electronic databases were searched until July 2019. MEDLINE database was used as the predominant source for this paper. Studies with regards to chronic physical activity in adult PAH patients are compared on retrieving evidence on cellular, physiological, and psychological alterations in the PAH setting. Twenty human studies and 12 rat trials were identified. Amongst all studies, a total of 628 human subjects and 614 rats were examined. Regular physical activity affects the production of nitric oxygen and attenuates right ventricular hypertrophy. A combination of aerobic, anaerobic, and respiratory muscle training induces the strongest improvement in functional capacity indicated by an increase of 6 MWD and VO2peak. In human studies, an increase of quality of life was found. Exercise training has an overall positive effect on the physiological and psychological components of PAH. Consequently, PAH patients should be encouraged to take part in regular exercise training programs.
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Affiliation(s)
- Lena Waller
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
- Correspondence: ; Tel.: +49-641-99-25212
| | - Karsten Krüger
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
| | - Kerstin Conrad
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
| | - Astrid Weiss
- Department of Internal Medicine, Institute of Pulmonary Pharmacotherapy, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), 35392 Giessen, Germany;
| | - Katharina Alack
- Department of Exercise Physiology and Sports Therapy, Institute of Sports Sciences, Justus-Liebig-University Giessen, 35394 Giessen, Germany; (K.K.); (K.C.); (K.A.)
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Huston JH, Brittain EL, Robbins IM. Pulmonary Hypertension and Right Ventricular Failure: Lung Transplant Versus Heart-Lung Transplant. Cardiol Clin 2020; 38:269-281. [PMID: 32284103 DOI: 10.1016/j.ccl.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Pulmonary arterial hypertension is a highly morbid disease with limited treatment options that improve survival and currently the only curative treatment is transplantation. There is a small body of literature comparing the efficacy of lung and heart-lung transplantation in this population. The bulk of evidence suggests that most patients with severe right ventricular failure undergoing transplant will have recovery of right ventricular function after lung transplantation. Existing data suggest that, in the absence of complex congenital heart disease or significant left ventricular dysfunction, double-lung transplant is the surgical procedure of choice.
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Affiliation(s)
- Jessica H Huston
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 5037, Nashville, TN 37232, USA.
| | - Evan L Brittain
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 300A, Nashville, TN 37203, USA
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, T1218 MCN, Nashville, TN, USA
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Wright SP, Groves L, Vishram-Nielsen JKK, Karvasarski E, Valle FH, Alba AC, Mak S. Elevated pulmonary arterial elastance and right ventricular uncoupling are associated with greater mortality in advanced heart failure. J Heart Lung Transplant 2020; 39:657-665. [PMID: 32184043 DOI: 10.1016/j.healun.2020.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/27/2020] [Accepted: 02/14/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The objectives of this study were to describe right ventricular-pulmonary arterial elastance coupling hemodynamic phenotypes and their frequency in patients with advanced heart failure and to evaluate the association of elastance-based indices with all-cause mortality, cardiac transplantation, and left ventricular assist device therapy. METHODS This study included 175 patients with heart failure undergoing right heart catheterization to evaluate candidacy for advanced therapies and 21 healthy controls. We modified a single-beat approach to elastance to account for the magnitude of pulmonary arterial pressure and estimated right ventricular end-systolic elastance (Ees), pulmonary arterial elastance (Ea), and the Ees:Ea ratio. We defined elevated pulmonary arterial load as an Ea > 0.5 mm Hg/ml, and ventriculo-arterial uncoupling as an Ees:Ea < 0.8. We evaluated associations between Ees, Ea, and Ees:Ea with all-cause mortality and composite event-free survival using multivariable Cox proportional-hazard models, adjusted for age and sex. RESULTS All 21 controls had Ea ≤ 0.5 mm Hg/ml and Ees:Ea ≥ 0.8. Of 175 patients with heart failure, 63% had Ea > 0.5 mm Hg/ml. Ees:Ea was lower in patients than in controls (p < 0.001), and 47% of the patients demonstrated Ees:Ea < 0.8, including 8% with normal Ea. In median follow-up of 2.2 (0.8-4.6) years, 53 died, 37 received cardiac transplantation, and 33 received a left ventricular assist device. By multivariable analysis, Ea (hazard ratios [HR]: 2.01, 95% CI 1.18-3.41) and Ees:Ea (HR: 0.46, 95% CI: 0.26-0.82) were independently associated with mortality, whereas Ees was not. CONCLUSIONS Right ventricular-pulmonary vascular coupling is frequently impaired in heart failure and associated with greater mortality. Elevated pulmonary arterial elastance is associated with greater mortality even when coupling is preserved.
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Affiliation(s)
- Stephen P Wright
- Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
| | - Leah Groves
- School of Biomedical Engineering, Western University, London, Ontario, Canada
| | - Julie K K Vishram-Nielsen
- Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada; Centre for Cardiac, Vascular, Pulmonary, and Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | - Felipe H Valle
- Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
| | - Ana C Alba
- Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
| | - Susanna Mak
- Division of Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada.
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