Dynamic right ventricular function response to incremental exercise in pulmonary hypertension

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.

Diagnostic utility of sub‐maximum cardiopulmonary exercise testing in the ambulatory setting for heart failure with preserved ejection fraction

“…Maximum VO 2 is an important prognostic indicator in patients with heart failure. 25,26 In the present study, similar to prior reports, HFpEF was associated with reduced submaximum 27 and maximum VO 2 (%predicted). 28,29 Extrapolated maximum VO 2 has been shown to closely correlate with actual maximum VO 2 attained during exercise and is independent of exercise duration.…”

“…We recently showed that in HFpEF, RV function and its SV deteriorate by 50% of the peak VO 2 . 27 Consequently, the CO is insufficient to meet the increasing Fig. 1.…”

“…We recently showed that in HFpEF, RV function and its SV deteriorate by 50% of the peak VO 2 . 27 Consequently, the CO is insufficient to meet the increasing metabolic demands of exercising muscle. This reduction in O 2 delivery contributes to the earlier attainment of the anaerobic threshold (AT) and subsequent lactic acidosis.…”

Übersicht über die Entwicklung der invasiven Spiroergometrie (iCPET)

“…Pathophysiologisch konnte dieser Mechanismus bei einem Patienten mit einer durch eine retroperitoneale Fibrosierung hervorgerufenen Obstruktion der Vena cava inferior vor und nach Dilatation bestätigt werden [106]. Aus der gleichen Arbeitsgruppe folgten weitere Untersuchungen: prognostische Relevanz einer belastungsinduzierten PH [73] bei HFpEF-Patienten [107], RV-Funktion unter Belastung [83,108], Unterschiede der peripheren Sauerstoffausschöpfung unter Belastung [109]). Andere Studien dieser Autoren definieren die prognostische Bedeutung einzelner spiroergometrischer Befunde [110] bzw.…”

“…2 slope) mit zentralen Belastungsparametern (maximale Last, Spitzen-Sauerstoffaufnahme, VO 2 peak und der Sauerstoffaufnahme an der anaeroben Schwelle (VO 2 @AT), HZV, PCWP, totaler pulmonaler Widerstand, TPR und V D /VT. Bei 27 Patienten mit interstitieller Lungenkrankheit (ILD) wurde die Hämodynamik unter Belastung im Vergleich zu Kontrollen gegenüber den Nicht-PH Patienten aufwiesen[73,83].Bei 30 CHF-Patienten wurde die Beziehung zwischen VE/VCO 2 slope und der rechtsventrikulären (RV-)Funktion sowie hämodynamischer Variablen in Ruhe und unter Belastung untersucht [84]. VE/VCO 2 slope war dabei positiv korreliert mit dem PVR in Ruhe und unter Belastung sowie dem PCWP in Ruhe, und invers korre-Legende: COPD: Chronisch obstruktive Lungenerkrankung; ILD: interstitielle Lungenerkrankung; IPAH: Idiopathische Pulmonale Arterielle Hypertonie; PAH: Pulmonale Arterielle Hypertonie; HFpEF: Herzinsuffizienz mit erhaltener systolischer Pumpfunktion; CHF: Chronische Herzinsuffizienz; HFrEF: Herzinsuffizienz mit reduzierter systolischer Pumpfunktion; FM: Fickʼsche Methode; TD: Thermodilution; PH: Pulmonale Hypertonie liert mit der RV-…”