The objective of this prospective study was to assess safety and efficacy of exercise training in a large cohort of patients with different forms and World Health Organization (WHO) functional classes of chronic pulmonary hypertension (PH).183 patients with PH (pulmonary arterial hypertension (PAH), chronic thromboembolic PH and PH due to respiratory or left heart diseases received exercise training in hospital for 3 weeks and continued at home. Adverse events have been monitored during the in-hospital training programme. Efficacy parameters were evaluated at baseline, and after 3 and 15 weeks.After 3 and 15 weeks, patients significantly improved the distance walked in 6 min (6MWD) compared to baseline, scores of quality of life, WHO functional class, peak oxygen consumption, oxygen pulse, heart rate and systolic pulmonary artery pressure at rest and maximal workload. The improvement in 6MWD was similar in patients with different PH forms and functional classes. Even in severely affected patients (WHO functional class IV), exercise training was highly effective. Adverse events, such as respiratory infections, syncope or presyncope, occurred in 13% of patients.Exercise training in PH is an effective but not a completely harmless add-on therapy, even in severely diseased patients, and should be closely monitored.

R ight ventricular (RV) pump function is of essential clinical and prognostic importance in a variety of heart and lung diseases and in pulmonary arterial hypertension (PAH). [1][2][3][4][5] Survival in pulmonary hypertension (PH) patients depends on the capability of the RV to adapt to chronically elevated pulmonary artery pressures. 6 Therefore, an accurate evaluation of RV pump function is crucial for screening, diagnosis, and follow-up assessment in PH. 7 However, it is difficult to assess RV function because of its complex geometry and load dependence and because of inadequate standardization of the assessment. 8 This is true for both noninvasive and invasive techniques.Evaluation of RV performance in PH patients has been recommended to be obtained at rest. 9 It is unknown whether assessment of RV function during exercise may be of additional benefit or even preferable. According to clinical experience, some PH patients with a severely enlarged right side of the heart and impaired RV pump function at rest do much better in their exercise capacity, World Health Organization functional class, and quality of life than others. They might differ in their RV reserve, defined as the ability of the ventricle to increase ejection fraction and stroke volume during exercise or pharmacological stress.10,11 RV and left ventricular (LV) contractileBackground-This study sought to analyze a new approach to assess exercise-induced pulmonary artery systolic pressure (PASP) increase by means of stress Doppler echocardiography as a possible measure of right ventricular contractile reserve in patients with severe pulmonary hypertension and right heart failure. Methods and Results-In this prospective study, patients with invasively diagnosed pulmonary arterial hypertension or inoperable chronic thromboembolic pulmonary hypertension and impaired right ventricular pump function despite a stable targeted pulmonary arterial hypertension medication underwent a broad panel of noninvasive assessments, including stress echocardiography and cardiopulmonary exercise testing. On the basis of the assumption that exerciseinduced PASP is a measure of right ventricular contractile reserve, patients were classified into 2 groups according to an exercise-induced PASP increase above or below the median. Patients were followed up for 3.0±1.8 years. Univariate and multivariate analyses were used for factors predicting survival. Of 124 patients, 66 were below the median exerciseinduced PASP increase of 30 mm Hg (low PASP), and 58 patients were above the median (high PASP). These groups were not significantly different in terms of medication and resting hemodynamics. Low PASP was associated with a significantly lower 6-minute walking distance, peak Vo 2 per kilogram, and 1-, 3-, and 4-year survival rates (92%, 69%, and 48%, respectively, versus 96%, 92%, and 89%). In the multivariate Cox model analysis adjusted for age and sex, PASP increase during exercise and peak Vo 2 per kilogram remained independent prognostic markers (hazard ratio, 2.56 for pea...