Two Distinct Responses of Left Ventricular End-Diastolic Pressure to Leg-Raise Exercise in Euvolemic Patients with Exertional Dyspnea

Abstract

Background and ObjectivesFew studies have invasively assessed diastolic functional reserve and serial changes in left ventricular hemodynamics in euvolemic patients with exertional dyspnea. In this study, sequential changes in left ventricular end-diastolic pressure (LVEDP) to leg-raise exercise were measured invasively in patients with early heart failure with preserved ejection fraction (HFpEF) to determine the association between these serial changes and echocardiographic results or clinical features.Subjects and MethodsDuring their hospital stay, 181 patients with early HFpEF underwent left cardiac catheterization, coronary angiography, and transthoracic echocardiography (TTE). Leg-raise exercise was performed in two stages: during cardiac catheterization and again during TTE.ResultsCompared with the initial values, all the invasively measured LVEDP values increased significantly during the leg-raise exercise, whereas the septal e/e' ratio remained unchanged. Active leg-raise led to increased LVEDP, which caused dyspnea. The severity of symptoms correlated with the level and extent of changes in LVEDP. At the end of active leg-raise, LVEDP decreased in 40 patients (22.1%), who were younger and had significantly lower e/e' ratios. On multivariate analysis to predict the response of LVEDP to active leg-raise, age and the septal e/e' ratio remained significant predictors.ConclusionDespite having similar LVEDP values at rest, patients may respond to exercise with different LVEDP levels and clinical manifestations, depending on their diastolic capacity. The leg-raise exercise in early HFpEF can elucidate individual diastolic profiles, and the LVEDP response to the leg-raise test may serve as a useful criterion in stratifying patients with early HFpEF with respect to functional reserve.

What Is the Evidence That the Tissue Doppler Index E/e′ Reflects Left Ventricular Filling Pressure Changes After Exercise or Pharmacological Intervention for Evaluating Diastolic Function? A Systematic Review

“…Maeder et al found decreased E/e′ septal with exercise and no correlation between poststress E/e′ septal and PCWP. In the largest exercise study in patients with exertional dyspnea (N=181), Choi et al recorded no change of E/e′ septal despite a significant elevation of LV end diastolic pressure with passive and active leg raise.…”

“…Most of these studies had a low sample size (median N = 22 with interquartile range of 11–82). Three of these studies had subjects perform exercise stress echocardiography using a supine bicycle or passive and then active leg‐raise for evaluating patients with suspected HFpEF. There was an increase in invasive LVFP but no consistent relationship for the changes in E/e′ postintervention in these 3 studies.…”

Can Doppler echocardiography estimate raised pulmonary capillary wedge pressure provoked by passive leg lifting in suspected heart failure?

“…Finally, studies have proposed a pivotal role for PLL in demonstrating abnormal elevation in PCWP in HFpEF (Borlaug et al ., ). This pressure provocation is easy to perform by PLL, thus useful to apply in order to identify patients with unstable LV filling pressures (Choi et al ., ; Thomas, ; Choi et al ., ; Obokata et al ., ), as was the case in our patients.…”

Passive leg-lifting in heart failure patients predicts exercise-induced rise in left ventricular filling pressures

“…A number of explanations for this relationship need to be discussed, in particular the effect of venous return and ventricular-arterial coupling, commonly known to be disturbed in HF [20,21]. With PLL, and during exercise, the venous return to the heart increases, which, in the presence of a stiff LV cavity, is coupled to an increase in LA pressures hence a subsequent rise in PCWP [8,[22][23][24]. However, exercise also influences afterload.…”

“…Recent studies have endorsed the use of invasive exercise hemodynamic examinations to accurately assess LV compliance in patients with inconclusive resting-RHC which remains limited by exertional dyspnea [7]. Passive leg-lifting (PLL) during RHC can identify patients with a "stiff" LV who develop raised LVFPs, venous hypertension and dyspnea on exertion [8][9][10][11]. However, the exact relationship between PLLs and LVFPs during exercise remains unknown and further investigation is required.…”