Exercise and fluid challenge during right heart catheterisation for evaluation of dyspnoea

Abstract

This prospective study compared exercise test and intravenous fluid challenge in a single right heart catheter procedure to detect latent diastolic heart failure in patients with echocardiographic heart failure with preserved ejection function. We included 49 patients (73% female) with heart failure with preserved ejection function and pulmonary artery wedge pressure ≤15 mmHg. A subgroup of 26 patients had precapillary pulmonary hypertension. Invasive haemodynamic and gas exchange parameters were measured at rest, 45° upright position, during exercise, after complete haemodynamic and respiratory recovery in lying position, and after rapid infusion of 500 mL isotonic solution. Most haemodynamic parameters increased at both exercise and intravenous fluid challenge, with the higher increase at exercise. Pulmonary vascular resistance decreased by –0.21 wood units at exercise and –0.56 wood units at intravenous fluid challenge ( p = 0.3); 20% (10 of 49) of patients had an increase in pulmonary artery wedge pressure above the upper limit of 20 mmHg at exercise, and 20% above the respective limit of 18 mmHg after intravenous fluid challenge. However, only three patients exceeded the upper limit of pulmonary artery wedge pressure in both tests, i.e. seven patients only at exercise and seven other patients only after intravenous fluid challenge. In the subgroup of pulmonary hypertension patients, only two patients exceeded pulmonary artery wedge pressure limits in both tests, further five patients at exercise and four patients after intravenous fluid challenge. A sequential protocol in the same patient showed a significantly higher increase in haemodynamic parameters at exercise compared to intravenous fluid challenge. Both methods can unmask diastolic dysfunction at right heart catheter procedure, but in different patient groups.

Correlation of Hemodynamic and Respiratory Parameters in Invasive Cardiopulmonary Exercise Testing (iCPET)

“…This study found a correlation of both methods for distensibility, but we still consider iCPET as indispensable because this correlation becomes blurred if the healthy control subjects in this study are omitted. This is in line with our own findings [ 16 ] that exercise and fluid challenge activate different pathophysiological pathways and unmask diastolic dysfunction in different patient groups.…”

“…All catheter procedures were performed in hospitalized patients and followed the guidelines of the ESC/ERS [ 14 ] and German recommendations [ 15 ]. We have published the detailed course of the exercise RHC previously [ 16 ]. In brief, this procedure starts with a hemodynamic measurement at rest in a supine position (labelled in the following “baseline”) and a second measurement at rest in a semi-supine position (“45° at rest”), followed by unloaded cycling in a semi-supine position for 3 to 5 min (“unloaded cycling”), and 3 to 5 min cycling at 25 W. If both anaerobic threshold (in the literature, synonymously “first ventilatory threshold”) was not reached and dyspnea reported was only mild to moderate, a 50 W step was appended.…”

Comparison between thermodilution and Fick methods for resting and exercise‐induced cardiac output measurement in patients with chronic dyspnea

“…An exercise RHC with a simultaneous measurement of oxygen uptake was performed in patients with a suspected multifactorial etiology of dyspnea, based on the findings of the preceding noninvasive examinations (echocardiography, CPET, and body plethysmography). We previously published a detailed description of the exercise RHC procedure 3 . Briefly, the procedure began with the measurement of hemodynamic parameters at rest with the patient in the supine position (0°); a second measurement of hemodynamic parameters was performed at rest with the patient in a semi‐supine position (45°).…”

“…We previously published a detailed description of the exercise RHC procedure. 3 Briefly, the procedure began with the measurement of hemodynamic parameters at rest with the patient in the supine position (0°); a second measurement of hemodynamic parameters was performed at rest with the patient in a semi‐supine position (45°). CO was next measured during unloaded cycling in a semi‐supine position for 3–5 min (45° at 0 W), and finally during 25‐W exercise in a semi‐supine position for 5 min; in some cases, patients underwent exercise with intensity exceeding 50 W. The level of exercise in the final step corresponded to 58 ± 19% of the maximum oxygen uptake (peakVO 2 ) achieved by the patient during cycle ergometry in the sitting position, performed on average 12 days beforehand.…”

Übersicht über die Entwicklung der invasiven Spiroergometrie (iCPET)

“…Die Nutzung des PVR setzt die Messung des PCWP (eine valide Messung unter Belastung ist an eine Reihe von Konditionen gebunden, wie Druckaufnehmer in Höhe des mittleren Thorax, Mittelung über mehrere Herzschläge, keine Durchführung von Atemmanövern u. a. m.) voraus, wobei es kaum Konsens zur altersabhängigen oberen Grenze dieses Wertes gibt [143]. Nach Durchsicht der Literatur haben wir uns für einen Grenzwert von 20 mmHg als "oberen Normalwert" bei körperlicher Belastung entschieden [144].…”