1
|
Caspersen CK, Ingemann-Molden S, Grove EL, Højen AA, Andreasen J, Klok FA, Rolving N. Performance-based outcome measures for assessing physical capacity in patients with pulmonary embolism: A scoping review. Thromb Res 2024; 235:52-67. [PMID: 38301376 DOI: 10.1016/j.thromres.2024.01.008] [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: 08/23/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Up to 50 % of patients surviving a pulmonary embolism (PE) report persisting shortness of breath, reduced physical capacity and psychological distress. As the PE population is heterogeneous compared to other cardiovascular patient groups, outcome measures for assessing physical capacity traditionally used in cardiac populations may not be reliable for the PE population as a whole. This scoping review aims to 1) map performance-based outcome measures (PBOMs) used for assessing physical capacity in PE research, and 2) to report the psychometric properties of the identified PBOMs in a PE population. METHODS The review was conducted according to the Joanna Briggs Institute framework for scoping reviews and reported according to the PRISMA-Extension for Scoping Reviews guideline. RESULTS The systematic search of five databases identified 4585 studies, of which 243 studies met the inclusion criteria. Of these, 185 studies focused on a subgroup of patients with chronic thromboembolic pulmonary hypertension. Ten different PBOMs were identified in the included studies. The 6-minute walk test (6MWT) and cardiopulmonary exercise test (CPET) were the most commonly used, followed by the (Modified) Bruce protocol and Incremental Shuttle Walk test. No studies reported psychometric properties of any of the identified PBOMs in a PE population. CONCLUSIONS Publication of studies measuring physical capacity within PE populations has increased significantly over the past 5-10 years. Still, not one study was identified, reporting the validity, reliability, or responsiveness for any of the identified PBOMs in a PE population. This should be a priority for future research in the field.
Collapse
Affiliation(s)
| | - Stian Ingemann-Molden
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anette Arbjerg Højen
- Department of Health Science and Technology, Aalborg University, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark; Department of Health Science and Technology, Aalborg University, Denmark; Aalborg Health and Rehabilitation Centre, Aalborg Municipality, Denmark
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Nanna Rolving
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark; Department of Public Health, Aarhus University, Denmark.
| |
Collapse
|
2
|
van Kan C, Tramper J, Bresser P, J. Meijboom L, Symersky P, Winkelman JA, Nossent EJ, Aman J, Bogaard HJ, Vonk Noordegraaf A, van Es J. Patients with CTEPH and mild hemodynamic severity of disease improve to a similar level of exercise capacity after pulmonary endarterectomy compared to patients with severe hemodynamic disease. Pulm Circ 2024; 14:e12316. [PMID: 38274560 PMCID: PMC10808941 DOI: 10.1002/pul2.12316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 11/06/2023] [Accepted: 11/20/2023] [Indexed: 01/27/2024] Open
Abstract
The correlation between hemodynamics and degree of pulmonary vascular obstruction (PVO) is known to be poor in chronic thromboembolic pulmonary hypertension (CTEPH), which makes the selection of patients eligible for pulmonary endarterectomy (PEA) challenging. It can be postulated that patients with similar PVO but different hemodynamic severity have different postoperative hemodynamics and exercise capacity. Therefore, we aimed to assess the effects of PEA on hemodynamics and exercise physiology in mild and severe CTEPH patients. We retrospectively studied 18 CTEPH patients with a mild hemodynamic profile (mean pulmonary arterial pressure [mPAP] between 25 and 30 mmHg at rest) and CTEPH patients with a more severe hemodynamic profile (mPAP > 30 mmHg), matched by age, gender, and PVO. Cardiopulmonary exercise testing parameters were evaluated at baseline and 18 months following PEA. At baseline, exercise capacity, defined as oxygen uptake, was less severely impaired in the mild CTEPH group compared to the severe CTEPH group. After PEA, in the mild CTEPH group, ventilatory efficiency and oxygen pulse improved significantly (p < 0.05), however, the change in ventilatory efficiency and oxygen pulse was smaller compared to the severe CTEPH group. Only in the severe CTEPH group exercise capacity improved significantly (p < 0.001). Hence, in the present study, postoperative hemodynamic outcome and the CPET-determined recovery of exercise capacity in mild CTEPH patients did not differ from a matched group of severe CTEPH patients.
Collapse
Affiliation(s)
- Coen van Kan
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Respiratory MedicineOLVGAmsterdamThe Netherlands
| | - Jelco Tramper
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
| | - Paul Bresser
- Department of Respiratory MedicineOLVGAmsterdamThe Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear MedicineAmsterdam UMCAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Petr Symersky
- Department of Cardiothoracic SurgeryAmsterdam UMCAmsterdamThe Netherlands
- Department of Cardiothoracic SurgeryOLVGAmsterdamThe Netherlands
| | | | - Esther J. Nossent
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Jurjan Aman
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
| | - Josien van Es
- Department of Pulmonary Medicine, Amsterdam UMC, Cardiovascular SciencesVrije UniversiteitAmsterdamThe Netherlands
- Department of Respiratory MedicineOLVGAmsterdamThe Netherlands
| |
Collapse
|
3
|
Verbelen T, Godinas L, Dorfmüller P, Gopalan D, Condliffe R, Delcroix M. Clinical-radiological-pathological correlation in chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2023; 32:230149. [PMID: 38123236 PMCID: PMC10731457 DOI: 10.1183/16000617.0149-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/29/2023] [Indexed: 12/23/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and potentially life-threatening complication of acute pulmonary embolism. It is characterised by persistent fibro-thrombotic pulmonary vascular obstructions and elevated pulmonary artery pressure leading to right heart failure. The diagnosis is based on two steps, as follows: 1) suspicion based on symptoms, echocardiography and ventilation/perfusion scan and 2) confirmation with right heart catheterisation, computed tomography pulmonary angiography and, in most cases, digital subtraction angiography. The management of CTEPH requires a multimodal approach, involving medical therapy, interventional procedures and surgical intervention. This clinical-radiological-pathological correlation paper illustrates the diagnostic and therapeutic management of two patients. The first had chronic thromboembolic pulmonary disease without pulmonary hypertension at rest but with significant physical limitation and was successfully treated with pulmonary endarterectomy. The second patient had CTEPH associated with splenectomy and was considered unsuitable for surgery because of exclusive subsegmental lesions combined with severe pulmonary hypertension. The patient benefited from multimodal treatment involving medical therapy followed by multiple sessions of balloon pulmonary angioplasty. Both patients had normalised functional capacity and pulmonary haemodynamics 3-6 months after the interventional treatment. These two examples show that chronic thromboembolic pulmonary diseases are curable if diagnosed promptly and referred to CTEPH centres for specialist treatment.
Collapse
Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Laurent Godinas
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Dorfmüller
- Institut für Pathologie, Universitätsklinikum Giessen/Marburg and Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Deepa Gopalan
- Department of Radiology, Imperial College Hospital NHS Trust, London, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| |
Collapse
|
4
|
Jayasimhan D, Chieng J, Kolbe J, Sidebotham DA. Dead-Space Ventilation Indices and Mortality in Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Crit Care Med 2023; 51:1363-1372. [PMID: 37204257 DOI: 10.1097/ccm.0000000000005921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVES Acute respiratory distress syndrome (ARDS) is associated with high ventilation-perfusion heterogeneity and dead-space ventilation. However, whether the degree of dead-space ventilation is associated with outcomes is uncertain. In this systematic review and meta-analysis, we evaluated the ability of dead-space ventilation measures to predict mortality in patients with ARDS. DATA SOURCES MEDLINE, CENTRAL, and Google Scholar from inception to November 2022. STUDY SELECTION Studies including adults with ARDS reporting a dead-space ventilation index and mortality. DATA EXTRACTION Two reviewers independently identified eligible studies and extracted data. We calculated pooled effect estimates using a random effects model for both adjusted and unadjusted results. The quality and strength of evidence were assessed using the Quality in Prognostic Studies and Grading of Recommendations, Assessment, Development, and Evaluation, respectively. DATA SYNTHESIS We included 28 studies in our review, 21 of which were included in our meta-analysis. All studies had a low risk of bias. A high pulmonary dead-space fraction was associated with increased mortality (odds ratio [OR], 3.52; 95% CI, 2.22-5.58; p < 0.001; I2 = 84%). After adjusting for other confounding variables, every 0.05 increase in pulmonary-dead space fraction was associated with an increased odds of death (OR, 1.23; 95% CI, 1.13-1.34; p < 0.001; I2 = 57%). A high ventilatory ratio was also associated with increased mortality (OR, 1.55; 95% CI, 1.33-1.80; p < 0.001; I2 = 48%). This association was independent of common confounding variables (OR, 1.33; 95% CI, 1.12-1.58; p = 0.001; I2 = 66%). CONCLUSIONS Dead-space ventilation indices were independently associated with mortality in adults with ARDS. These indices could be incorporated into clinical trials and used to identify patients who could benefit from early institution of adjunctive therapies. The cut-offs identified in this study should be prospectively validated.
Collapse
Affiliation(s)
- Dilip Jayasimhan
- Cardiothoracic and Vascular Intensive Care Unit, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
- Respiratory Services, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
| | - Jennifer Chieng
- Respiratory Services, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
| | - John Kolbe
- Respiratory Services, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - David A Sidebotham
- Cardiothoracic and Vascular Intensive Care Unit, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| |
Collapse
|
5
|
Caridi-Scheible M, Leiendecker ER. Dead-Space Ventilation Indices and Mortality: Finally Addressing the Other Reason We Breathe. Crit Care Med 2023; 51:1442-1444. [PMID: 37707384 DOI: 10.1097/ccm.0000000000005965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- Mark Caridi-Scheible
- Both authors: Department of Anesthesiology, Emory Healthcare, Anesthesiology, Atlanta, GA
| | | |
Collapse
|
6
|
Daigo K, Katsumata Y, Esaki K, Iwasawa Y, Ichihara G, Miura K, Shirakawa K, Sato Y, Sato K, Fukuda K. Predictors of Improvement in Exercise Tolerance After Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. J Am Heart Assoc 2023; 12:e8137. [PMID: 36718876 PMCID: PMC9973625 DOI: 10.1161/jaha.122.027395] [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: 07/25/2022] [Revised: 10/19/2022] [Accepted: 12/06/2022] [Indexed: 02/01/2023]
Abstract
Background Balloon pulmonary angioplasty (BPA) improves exercise tolerance and hemodynamic parameters in patients with chronic thromboembolic pulmonary hypertension. However, it is still unclear which patient characteristics contribute to the improvement in exercise tolerance after BPA in chronic thromboembolic pulmonary hypertension. Methods and Results We retrospectively analyzed 126 patients with chronic thromboembolic pulmonary hypertension (aged 63±14 years; female, 65%) who underwent BPA without concomitant programmed exercise rehabilitation at Keio University between November 2012 and April 2018. Hemodynamic data and 6-minute walk distance (6MWD), as a measure of exercise tolerance, were evaluated before and 1 year after BPA. The clinical characteristics that contributed to improvement in exercise tolerance were elucidated. The 6MWD significantly increased from 372.0 m (256.5-431.3) to 462.0 m (378.8-537.0) 1 year after BPA (P<0.001). The improvement rate in the 6MWD after BPA exhibited a good correlation with age, height, mean pulmonary artery pressure, and 6MWD at baseline (Spearman rank correlation coefficients=-0.28, 0.24, -0.40, and 0.44, respectively). Additional multivariable linear regression analysis revealed that young age, tall height, high mean pulmonary artery pressure, short 6MWD at baseline, and high lung capacity at baseline were significant predictors of the improvement in 6MWD by BPA (standardized partial regression coefficient -0.39, 0.22, 0.19, -0.62, and 0.25, P<0.001, 0.007, 0.011, <0.001, and <0.001, respectively). Conclusions BPA without concomitant programmed exercise rehabilitation significantly improves exercise tolerance. This was particularly true in young patients with high stature, high mean pulmonary artery pressure, short 6MWD, and lung capacity at the time of diagnosis.
Collapse
Affiliation(s)
- Kyohei Daigo
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | | | - Kosho Esaki
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Yuji Iwasawa
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Genki Ichihara
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kotaro Miura
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kohsuke Shirakawa
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Yasunori Sato
- Department of Preventive Medicine and Public HealthKeio University School of MedicineTokyoJapan
| | - Kazuki Sato
- Institute for Integrated Sports Medicine, Keio University School of MedicineTokyoJapan
| | - Keiichi Fukuda
- Department of CardiologyKeio University School of MedicineTokyoJapan
| |
Collapse
|
7
|
Marchetta S, Verbelen T, Claessen G, Quarck R, Delcroix M, Godinas L. A Comprehensive Assessment of Right Ventricular Function in Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2022; 12:jcm12010047. [PMID: 36614845 PMCID: PMC9821031 DOI: 10.3390/jcm12010047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
While chronic thromboembolic pulmonary hypertension (CTEPH) results from macroscopic and microscopic obstruction of the pulmonary vascular bed, the function of the right ventricle (RV) and increased RV afterload are the main determinants of its symptoms and prognosis. In this review, we assess RV function in patients diagnosed with CTEPH with a focus on the contributions of RV afterload and dysfunction to the pathogenesis of this disease. We will also discuss changes in RV function and geometry in response to treatment, including medical therapy, pulmonary endarterectomy, and balloon pulmonary angioplasty.
Collapse
Affiliation(s)
| | - Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Rozenn Quarck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
| | - Marion Delcroix
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Laurent Godinas
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, 3000 Leuven, Belgium
- Correspondence:
| |
Collapse
|
8
|
McGettrick M, Dormand H, Brewis M, Johnson MK, Lang NN, Church AC. Cardiac geometry, as assessed by cardiac magnetic resonance, can differentiate subtypes of chronic thromboembolic pulmonary vascular disease. Front Cardiovasc Med 2022; 9:1004169. [PMID: 36582741 PMCID: PMC9793745 DOI: 10.3389/fcvm.2022.1004169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/22/2022] [Indexed: 12/15/2022] Open
Abstract
Background Ventricular septal flattening reflects RV pressure overload in pulmonary arterial hypertension. Eccentricity index (EI) and pulmonary artery distensibility (PAD) correlate with pulmonary artery pressure. We assessed the utility of these using cardiac magnetic resonance (CMR) to assess for pulmonary hypertension (PH) in patients with chronic thromboembolic disease. This may allow non-invasive differentiation between patients who have chronic thromboembolic pulmonary hypertension (CTEPH) and those with pulmonary vascular obstructions without PH at rest, known as chronic thromboembolic pulmonary disease (CTEPD). Methods Twenty patients without resting pulmonary hypertension, including ten with chronic thromboembolic disease, and thirty patients with CTEPH were identified from a database at the Scottish Pulmonary Vascular Unit. CMR and right heart catheter had been performed within 96 h of each other. Short-axis views at the level of papillary muscles were used to assess the EI at end-systole and diastole. Pulmonary artery distensibility was calculated using velocity-encoded images attained perpendicular to the main trunk. Results Eccentricity index at end-systole and end-diastole were higher in CTEPH compared to controls (1.3 ± 0.5 vs. 1.0 ± 0.01; p ≤ 0.01 and (1.22 ± 0.2 vs. 0.98 ± 0.01; p ≤ 0.01, respectively) and compared to those with CTED. PAD was significantly lower in CTEPH compared to controls (0.13 ± 0.1 vs. 0.46 ± 0.23; p ≤ 0.01) and compared to CTED. End-systolic EI and end-diastolic EI correlated with pulmonary vascular hemodynamic indices and exercise variables, including mean pulmonary arterial pressure (R0.74 and 0.75, respectively), cardiac output (R-value -0.4 and -0.4, respectively) NTproBNP (R-value 0.3 and 0.3, respectively) and 6-min walk distance (R-value -0.7 and -0.8 respectively). Pulmonary artery distensibility also correlated with 6-min walk distance (R-value 0.8). Conclusion Eccentricity index and pulmonary artery distensibility can detect the presence of pulmonary hypertension in chronic thromboembolic disease and differentiate between CTEPH and CTED subgroups. These measures support the use of non-invasive tests including CMR for the detection pulmonary hypertension and may reduce the requirement for right heart catheterization.
Collapse
Affiliation(s)
- Michael McGettrick
- The Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom,*Correspondence: Michael McGettrick,
| | - Helen Dormand
- The Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Melanie Brewis
- The Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Martin K. Johnson
- The Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Ninian N. Lang
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Alistair Colin Church
- The Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| |
Collapse
|
9
|
Neder JA, Phillips DB, O'Donnell DE, Dempsey JA. Excess ventilation and exertional dyspnoea in heart failure and pulmonary hypertension. Eur Respir J 2022; 60:13993003.00144-2022. [PMID: 35618273 DOI: 10.1183/13993003.00144-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023]
Abstract
Increased ventilation relative to metabolic demands, indicating alveolar hyperventilation and/or increased physiological dead space (excess ventilation), is a key cause of exertional dyspnoea. Excess ventilation has assumed a prominent role in the functional assessment of patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We herein provide the key pieces of information to the caring physician to 1) gain unique insights into the seeds of patients' shortness of breath and 2) develop a rationale for therapeutically lessening excess ventilation to mitigate this distressing symptom. Reduced bulk oxygen transfer induced by cardiac output limitation and/or right ventricle-pulmonary arterial uncoupling increase neurochemical afferent stimulation and (largely chemo-) receptor sensitivity, leading to alveolar hyperventilation in HFrEF, PAH and small-vessel, distal CTEPH. As such, interventions geared to improve central haemodynamics and/or reduce chemosensitivity have been particularly effective in lessening their excess ventilation. In contrast, 1) high filling pressures in HFpEF and 2) impaired lung perfusion leading to ventilation/perfusion mismatch in proximal CTEPH conspire to increase physiological dead space. Accordingly, 1) decreasing pulmonary capillary pressures and 2) mechanically unclogging larger pulmonary vessels (pulmonary endarterectomy and balloon pulmonary angioplasty) have been associated with larger decrements in excess ventilation. Exercise training has a strong beneficial effect across diseases. Addressing some major unanswered questions on the link of excess ventilation with exertional dyspnoea under the modulating influence of pharmacological and nonpharmacological interventions might prove instrumental to alleviate the devastating consequences of these prevalent diseases.
Collapse
Affiliation(s)
- J Alberto Neder
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Dept of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| |
Collapse
|
10
|
Li X, Duan A, Jin Q, Zhang Y, Luo Q, Zhao Q, Yan L, Huang Z, Hu M, Xiong C, Zhao Z, Liu Z. Exercise feature and predictor of prognosis in patients with pulmonary artery stenosis-associated pulmonary hypertension. ESC Heart Fail 2022; 9:4198-4208. [PMID: 36101502 PMCID: PMC9773706 DOI: 10.1002/ehf2.14154] [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: 05/28/2022] [Revised: 08/23/2022] [Accepted: 09/04/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS The prognosis is poor for patients with pulmonary artery stenosis-associated pulmonary hypertension (PAS-PH). Identifying predictors of prognosis in PAS-PH is crucial to preventing premature death, which has rarely been investigated. We aimed to explore the cardiopulmonary exercise testing (CPET) parameters to predict the prognosis of these patients. METHODS We prospectively included all patients with PAS-PH who underwent CPET between September 2014 and June 2021 in Fuwai Hospital (ClinicalTrials.gov ID: NCT02061787). The primary outcome was clinical worsening, including death, rehospitalization for heart failure, or deterioration of PH. RESULTS Seventy-two patients were included in this study. A median of 2-year follow-up revealed that 18 (25%) patients experienced clinical worsening. The 1-year, 3-year, and 5-year event-free survival rates were 92.5%, 81.7%, and 62.7%, respectively. Patients with clinical worsening demonstrated significantly worse baseline haemodynamics and poorer exercise capacity than their counterparts. Multivariable Cox regression identified that peak O2 pulse could independently predict clinical worsening [hazard ratio: 0.344, 95% confidence interval (CI) 0.188-0.631, P < 0.001], outperforming other parameters. Peak O2 pulse correlated with PH severity. Incorporating peak O2 pulse into the simplified 2015 European Society of Cardiology/European Respiratory Society risk stratification improved the accuracy for predicting clinical worsening (pre vs. post area under the curve: 0.727 vs. 0.846, P < 0.001; net reclassification index: 0.852, 95% CI 0.372-1.332, P < 0.001; integrated discrimination index 0.133, 95% CI 0.031-0.235, P = 0.011). CONCLUSIONS The prognosis is poor for PAS-PH, and exercise intolerance and ventilation inefficiency are commonly observed. Peak O2 pulse independently predicted the prognosis of these patients. A low peak O2 pulse identified patients at high risk of clinical deterioration and served for risk stratification of PAS-PH.
Collapse
Affiliation(s)
- Xin Li
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Anqi Duan
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Qi Jin
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina,Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Yi Zhang
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Qin Luo
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Qing Zhao
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Lu Yan
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhihua Huang
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Meixi Hu
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Changming Xiong
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhihui Zhao
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhihong Liu
- Center for Respiratory and Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| |
Collapse
|
11
|
Song L, Qu H, Luo J, Wang W, Zheng L, Xue M, Shi D. Cardiopulmonary exercise test: A 20-year (2002-2021) bibliometric analysis. Front Cardiovasc Med 2022; 9:982351. [PMID: 36046187 PMCID: PMC9420934 DOI: 10.3389/fcvm.2022.982351] [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: 06/30/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe clinical application value of cardiopulmonary exercise test (CPET) has increasingly attracted attention, and related research has been increasing yearly. However, there is no summary analysis of the existing CPET literature. This is the first bibliometric analysis of publications in the CPET.MethodsCPET-related articles published between 2002 and 2021 were retrieved from the Web of Science Core Collection database. The search was limited to Articles and Reviews in English. CiteSpace software was used to conduct collaborative network analysis of countries/regions, institutions, authors, the co-occurrence of subject categories and keywords, and co-citation analysis of authors, journals, and references.ResultsA total of 4,426 publications were identified. During the study period, the number of published articles increased yearly. Developed countries from the Americas and Europe led the field. The University of Milan was the most prolific institution, with Ross Arena and Wasserman K being the most prolific and co-cited authors in the field, respectively. Cardiovascular System & Cardiology and Respiratory System were the main areas involved. Moreover, heart failure, oxygen uptake, and prognostic value were the central themes.ConclusionsCPET had attracted widespread attention, and the number of publications will increase substantially according to the current growth trends. In the future, CPET is expected to be further adopted in large-scale clinical studies as a means of assessing the functional ability of patients to verify the efficacy of related interventions. High-quality evidence-based medical CPET-related indicators is expected to be used in clinical diseases risk prediction.
Collapse
Affiliation(s)
- Lei Song
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hua Qu
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinwen Luo
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wenting Wang
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Liying Zheng
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Mei Xue
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Mei Xue
| | - Dazhuo Shi
- Center of Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Dazhuo Shi
| |
Collapse
|
12
|
Chuang ML, Hsieh BYT, Lin IF. Prediction and types of dead-space fraction during exercise in male chronic obstructive pulmonary disease patients. Medicine (Baltimore) 2022; 101:e28800. [PMID: 35147114 PMCID: PMC8830857 DOI: 10.1097/md.0000000000028800] [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: 06/29/2021] [Accepted: 01/19/2022] [Indexed: 11/30/2022] Open
Abstract
A high dead space (VD) to tidal volume (VT) ratio during peak exercise (VD/VTpeak) is a sensitive and consistent marker of gas exchange abnormalities; therefore, it is important in patients with chronic obstructive pulmonary disease (COPD). However, it is necessary to use invasive methods to obtain VD/VTpeak, as noninvasive methods, such as end-tidal PCO2 (PETCO2peak) and PETCO2 adjusted with Jones' equation (PJCO2peak) at peak exercise, have been reported to be inconsistent with arterial PCO2 at peak exercise (PaCO2peak). Hence, this study aimed to generate prediction equations for VD/VTpeak using statistical techniques, and to use PETCO2peak and PJCO2peak to calculate the corresponding VD/VTpeaks (i.e., VD/VTpeakETVD/VTpeakJ).A total of 46 male subjects diagnosed with COPD who underwent incremental cardiopulmonary exercise tests with PaCO2 measured via arterial catheterization were enrolled. Demographic data, blood laboratory tests, functional daily activities, chest radiography, two-dimensional echocardiography, and lung function tests were assessed.In multivariate analysis, diffusing capacity, vital capacity, mean inspiratory tidal flow, heart rate, and oxygen pulse at peak exercise were selected with a predictive power of 0.74. There were no significant differences in the PCO2peak values and the corresponding VD/VTpeak values across the three types (both p = NS).In subjects with COPD, VD/VTpeak can be estimated using statistical methods and the PETCO2peak and PJCO2peak. These methods may have similar predictive power and thus can be used in clinical practice.
Collapse
Affiliation(s)
- Ming-Lung Chuang
- Division of Pulmonary Medicine and Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | | | - I-Feng Lin
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| |
Collapse
|
13
|
Blanquez-Nadal M, Piliero N, Guillien A, Salvat M, Thony F, Augier C, Bouvaist H, Degano B. Neural respiratory drive in chronic thromboembolic pulmonary hypertension: Effect of balloon pulmonary angioplasty. Respir Physiol Neurobiol 2022; 299:103857. [PMID: 35121103 DOI: 10.1016/j.resp.2022.103857] [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: 12/04/2021] [Revised: 01/19/2022] [Accepted: 01/30/2022] [Indexed: 10/19/2022]
Abstract
Excessive ventilation (V̇E) during exercise, ascribed to heightened neural ventilatory drive and/or to increased "wasted" ventilation, is a feature of chronic thromboembolic pulmonary hypertension (CTEPH). In selected CTEPH patients, balloon pulmonary angioplasty (BPA) allows near-normalization of resting haemodynamic parameters but does not allow excess exercise hyperventilation to normalize. Neural ventilatory drive can be estimated by studying how arterial PCO2 (PaCO2), end-tidal PCO2 (PETCO2), V̇E and CO2 output (V̇CO2) change across the exercise-to-recovery transition during a cardiopulmonary exercise test. Increased "wasted" ventilation can be quantified by the physiological dead space fraction of tidal volume (VD/VT) calculated with the Enghoff simplification of the Bohr equation. These measurements were made before and after BPA in 22 CTEPH patients without significant cardiac and/or pulmonary comorbidities. Our observations suggest that before BPA, excessive hyperventilation was secondary to both heightened neural ventilatory drive and increased "wasted" ventilation; after BPA, measurements made across the exercise-to-recovery transition suggest that heightened neural ventilatory drive was no longer present.
Collapse
Affiliation(s)
- Mathilde Blanquez-Nadal
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Nicolas Piliero
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Alicia Guillien
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Épidemiologie environnementale appliquée à la reproduction et à la santé respiratoire, INSERM, CNRS, Université Grenoble Alpes, Institut pour l'Avancée des Biosciences (IAB), U1209, Grenoble, France
| | - Muriel Salvat
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Frédéric Thony
- Pole Imagerie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Caroline Augier
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Hélène Bouvaist
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Bruno Degano
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France; Laboratoire HP2, INSERM U1042, Université Grenoble Alpes, Grenoble, France.
| |
Collapse
|
14
|
Zhu H, Sun X, Cao Y, Pudasaini B, Yang W, Liu J, Guo J. Cardiopulmonary exercise testing and pulmonary function testing for predicting the severity of CTEPH. BMC Pulm Med 2021; 21:324. [PMID: 34663275 PMCID: PMC8521985 DOI: 10.1186/s12890-021-01668-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 09/10/2021] [Indexed: 01/09/2023] Open
Abstract
Background Cardiopulmonary exercise testing (CPET) and pulmonary function testing (PFT) are noninvasive methods to evaluate the respiratory and circulatory systems. This research aims to evaluate and monitor chronic thromboembolic pulmonary hypertension (CTEPH) noninvasively and effectively by these two methods. Moreover, the research assesses the predictive value of CPET and PFT parameters for severe CTEPH. Methods We used data from 86 patients with CTEPH (55 for test set, and 31 for validation set) at the Shanghai Pulmonary Hospital Affiliated to Tongji University. The clinical, PFT and CPET data of CTEPH patients of different severity classified according to pulmonary artery pressure (PAP) (mm Hg) were collected and compared. Logistic regression analysis was performed to appraise the predictive value of each PFT and CPET parameter for severe CTEPH. The performance of CPET parameters for predicting severe CTEPH was determined by receiver operating characteristic (ROC) curves and calibration curves. Results Data showed that minute ventilation at anaerobic threshold (VE @ AT) (L/min) and oxygen uptake at peak (VO2 @ peak) (mL/kg/min) were independent predictors for severe CTEPH classified according to PAP (mm Hg). Additionally, the efficacy of VE @ AT (L/min) and VO2 @ peak (mL/kg/min) in identifying severe CTEPH was found to be moderate with the area under ROC curve (AUC) of 0.769 and 0.740, respectively. Furthermore, the combination of VE @ AT (L/min) and VO2 @ peak (mL/kg/min) had a moderate utility value in identifying severe CTEPH with the AUC of 0.843. Conclusion Our research suggests that CPET and PFT can noninvasively and effectively evaluate, monitor and predict the severity of CTEPH. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01668-3.
Collapse
Affiliation(s)
- Hanqing Zhu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Xingxing Sun
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yuan Cao
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Bigyan Pudasaini
- Department of Internal Medicine, Columbia Bainuo Clinic, Shanghai, 200040, China
| | - Wenlan Yang
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jinming Liu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| |
Collapse
|
15
|
Weatherald J, Philipenko B, Montani D, Laveneziana P. Ventilatory efficiency in pulmonary vascular diseases. Eur Respir Rev 2021; 30:30/161/200214. [PMID: 34289981 PMCID: PMC9488923 DOI: 10.1183/16000617.0214-2020] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/15/2020] [Indexed: 12/14/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) is a frequently used tool in the differential diagnosis of dyspnoea. Ventilatory inefficiency, defined as high minute ventilation (V′E) relative to carbon dioxide output (V′CO2), is a hallmark characteristic of pulmonary vascular diseases, which contributes to exercise intolerance and disability in these patients. The mechanisms of ventilatory inefficiency are multiple and include high physiologic dead space, abnormal chemosensitivity and an altered carbon dioxide (CO2) set-point. A normal V′E/V′CO2 makes a pulmonary vascular disease such as pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) unlikely. The finding of high V′E/V′CO2 without an alternative explanation should prompt further diagnostic testing to exclude PAH or CTEPH, particularly in patients with risk factors, such as prior venous thromboembolism, systemic sclerosis or a family history of PAH. In patients with established PAH or CTEPH, the V′E/V′CO2 may improve with interventions and is a prognostic marker. However, further studies are needed to clarify the added value of assessing ventilatory inefficiency in the longitudinal follow-up of patients. Ventilatory inefficiency is a hallmark feature of PH that reflects abnormal ventilation/perfusion matching, chemosensitivity and an altered CO2 set-point. Minute ventilation/CO2 production is useful in the diagnosis, management and prognostication of PH.https://bit.ly/3jnNdUG
Collapse
Affiliation(s)
- Jason Weatherald
- Dept of Medicine, Division of Respirology, University of Calgary, Cumming School of Medicine, Calgary, Canada.,Libin Cardiovascular Institute, Calgary, Canada
| | - Brianne Philipenko
- Dept of Medicine, Division of Respirology, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Dept of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Pierantonio Laveneziana
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France .,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Hôpitaux Pitié-Salpêtrière, Saint-Antoine et Tenon, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée (Département R3S), Paris, France
| |
Collapse
|
16
|
Blanquez-Nadal M, Piliero N, Guillien A, Doutreleau S, Salvat M, Thony F, Pison C, Augier C, Bouvaist H, Aguilaniu B, Degano B. Exercise hyperventilation and pulmonary gas exchange in chronic thromboembolic pulmonary hypertension: Effects of balloon pulmonary angioplasty. J Heart Lung Transplant 2021; 41:70-79. [PMID: 34742646 DOI: 10.1016/j.healun.2021.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/25/2021] [Accepted: 09/14/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Excessive ventilation (V̇E) and abnormal gas exchange during exercise are features of chronic thromboembolic pulmonary hypertension (CTEPH). In selected CTEPH patients, balloon pulmonary angioplasty (BPA) improves symptoms and exercise capacity. How BPA affects exercise hyperventilation and gas exchange is poorly understood. METHODS In this longitudinal observational study, symptom-limited cardiopulmonary exercise tests and carbon monoxide lung diffusion (DLCO) were performed before and after BPA (interval, mean (SD): 3.1 (2.4) months) in 36 CTEPH patients without significant cardiac and/or pulmonary comorbidities. RESULTS Peak work rate improved by 20% after BPA whilst V̇E at peak did not change despite improved ventilatory efficiency (lower V̇E with respect to CO2 output [V̇CO2]). At the highest identical work rate pre- and post-BPA (75 (30) watts), V̇E and alveolar-arterial oxygen gradient (P(Ai-a)O2) decreased by 17% and 19% after BPA, respectively. The physiological dead space fraction of tidal volume (VD/VT), calculated from measurements of arterial and mixed expired CO2, decreased by 20%. In the meantime, DLCO did not change. The best correlates of P(Ai-a)O2 measured at peak exercise were physiological VD/VT before BPA and DLCO after BPA. CONCLUSIONS Ventilatory efficiency, physiological VD/VT, and pulmonary gas exchange improved after BPA. The fact that DLCO did not change suggests that the pulmonary capillary blood volume and probably the true alveolar dead space were unaffected by BPA. The correlation between DLCO measured before BPA and P(Ai-a)O2 measured after BPA suggests that DLCO may provide an easily accessible marker to predict the response to BPA in terms of pulmonary gas exchange.
Collapse
Affiliation(s)
- Mathilde Blanquez-Nadal
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Nicolas Piliero
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Alicia Guillien
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Épidemiologie environnementale appliquée à la reproduction et à la santé respiratoire, INSERM, CNRS, Université Grenoble Alpes, Institut pour l'Avancée des Biosciences (IAB), Grenoble, France
| | - Stéphane Doutreleau
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France; Laboratoire HP2, INSERM U1042, Université Grenoble Alpes, Grenoble, France
| | - Muriel Salvat
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Frédéric Thony
- Pole Imagerie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Christophe Pison
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Caroline Augier
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Hélène Bouvaist
- Service de Cardiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Bernard Aguilaniu
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - Bruno Degano
- Service Hospitalier Universitaire Pneumologie Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France; Laboratoire HP2, INSERM U1042, Université Grenoble Alpes, Grenoble, France.
| |
Collapse
|
17
|
de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.
Collapse
Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
18
|
Spiesshoefer J, Bannwitz B, Mohr M, Herkenrath S, Randerath W, Sciarrone P, Thiedemann C, Schneider H, Braun AT, Emdin M, Passino C, Dreher M, Boentert M, Giannoni A. Effects of nasal high flow on sympathovagal balance, sleep, and sleep-related breathing in patients with precapillary pulmonary hypertension. Sleep Breath 2021; 25:705-717. [PMID: 32827122 PMCID: PMC8195975 DOI: 10.1007/s11325-020-02159-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/09/2020] [Accepted: 08/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND In precapillary pulmonary hypertension (PH), nasal high flow therapy (NHF) may favorably alter sympathovagal balance (SVB) and sleep-related breathing through washout of anatomical dead space and alleviation of obstructive sleep apnea (OSA) due to generation of positive airway pressure. OBJECTIVES To investigate the effects of NHF on SVB, sleep, and OSA in patients with PH, and compare them with those of positive airway pressure therapy (PAP). METHODS Twelve patients with PH (Nice class I or IV) and confirmed OSA underwent full polysomnography, and noninvasive monitoring of SVB parameters (spectral analysis of heart rate, diastolic blood pressure variability). Study nights were randomly split into four 2-h segments with no treatment, PAP, NHF 20 L/min, or NHF 50 L/min. In-depth SVB analysis was conducted on 10-min epochs during daytime and stable N2 sleep at nighttime. RESULTS At daytime and compared with no treatment, NHF20 and NHF50 were associated with a flow-dependent increase in peripheral oxygen saturation but a shift in SVB towards increased sympathetic drive. At nighttime, NHF20 was associated with increased parasympathetic drive and improvements in sleep efficiency, but did not alter OSA severity. NHF50 was poorly tolerated. PAP therapy improved OSA but had heterogenous effects on SVB and neutral effects on sleep outcomes. Hemodynamic effects were neutral for all interventions. CONCLUSIONS In sleeping PH patients with OSA NHF20 but not NHF50 leads to decreased sympathetic drive likely due to washout of anatomical dead space. NHF was not effective in lowering the apnea-hypopnoea index and NHF50 was poorly tolerated.
Collapse
Affiliation(s)
- Jens Spiesshoefer
- Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany.
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, PI, Italy.
| | - Britta Bannwitz
- Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Michael Mohr
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Muenster, Germany
| | - Simon Herkenrath
- Bethanien Hospital gGmbH Solingen, Solingen, Germany and Institute for Pneumology at the University of Cologne, Solingen, Germany
| | - Winfried Randerath
- Bethanien Hospital gGmbH Solingen, Solingen, Germany and Institute for Pneumology at the University of Cologne, Solingen, Germany
| | - Paolo Sciarrone
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, National Research Council, CNR-Regione Toscana, Pisa, Italy
| | - Christian Thiedemann
- Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Hartmut Schneider
- Sleep Disorders Center, Bayview Hospital, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew T Braun
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, PI, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, National Research Council, CNR-Regione Toscana, Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, PI, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, National Research Council, CNR-Regione Toscana, Pisa, Italy
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH, Aachen, Germany
| | - Matthias Boentert
- Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
- Department of Medicine, UKM Marienhospital, Steinfurt, Germany
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, PI, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, National Research Council, CNR-Regione Toscana, Pisa, Italy
| |
Collapse
|
19
|
Stam K, Clauss S, Taverne YJHJ, Merkus D. Chronic Thromboembolic Pulmonary Hypertension - What Have We Learned From Large Animal Models. Front Cardiovasc Med 2021; 8:574360. [PMID: 33937352 PMCID: PMC8085273 DOI: 10.3389/fcvm.2021.574360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 03/08/2021] [Indexed: 12/21/2022] Open
Abstract
Chronic thrombo-embolic pulmonary hypertension (CTEPH) develops in a subset of patients after acute pulmonary embolism. In CTEPH, pulmonary vascular resistance, which is initially elevated due to the obstructions in the larger pulmonary arteries, is further increased by pulmonary microvascular remodeling. The increased afterload of the right ventricle (RV) leads to RV dilation and hypertrophy. This RV remodeling predisposes to arrhythmogenesis and RV failure. Yet, mechanisms involved in pulmonary microvascular remodeling, processes underlying the RV structural and functional adaptability in CTEPH as well as determinants of the susceptibility to arrhythmias such as atrial fibrillation in the context of CTEPH remain incompletely understood. Several large animal models with critical clinical features of human CTEPH and subsequent RV remodeling have relatively recently been developed in swine, sheep, and dogs. In this review we will discuss the current knowledge on the processes underlying development and progression of CTEPH, and on how animal models can help enlarge understanding of these processes.
Collapse
Affiliation(s)
- Kelly Stam
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sebastian Clauss
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University Munich, Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Daphne Merkus
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| |
Collapse
|
20
|
Howden EJ, Ruiz-Carmona S, Claeys M, De Bosscher R, Willems R, Meyns B, Verbelen T, Maleux G, Godinas L, Belge C, Bogaert J, Claus P, La Gerche A, Delcroix M, Claessen G. Oxygen Pathway Limitations in Patients With Chronic Thromboembolic Pulmonary Hypertension. Circulation 2021; 143:2061-2073. [PMID: 33853383 DOI: 10.1161/circulationaha.120.052899] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Exertional intolerance is a limiting and often crippling symptom in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Traditionally the pathogenesis has been attributed to central factors, including ventilation/perfusion mismatch, increased pulmonary vascular resistance, and right heart dysfunction and uncoupling. Pulmonary endarterectomy and balloon pulmonary angioplasty provide substantial improvement of functional status and hemodynamics. However, despite normalization of pulmonary hemodynamics, exercise capacity often does not return to age-predicted levels. By systematically evaluating the oxygen pathway, we aimed to elucidate the causes of functional limitations in patients with CTEPH before and after pulmonary vascular intervention. METHODS Using exercise cardiac magnetic resonance imaging with simultaneous invasive hemodynamic monitoring, we sought to quantify the steps of the O2 transport cascade from the mouth to the mitochondria in patients with CTEPH (n=20) as compared with healthy participants (n=10). Furthermore, we evaluated the effect of pulmonary vascular intervention (pulmonary endarterectomy or balloon angioplasty) on the individual components of the cascade (n=10). RESULTS Peak Vo2 (oxygen uptake) was significantly reduced in patients with CTEPH relative to controls (56±17 versus 112±20% of predicted; P<0.0001). The difference was attributable to impairments in multiple steps of the O2 cascade, including O2 delivery (product of cardiac output and arterial O2 content), skeletal muscle diffusion capacity, and pulmonary diffusion. The total O2 extracted in the periphery (ie, ΔAVo2 [arteriovenous O2 content difference]) was not different. After pulmonary vascular intervention, peak Vo2 increased significantly (from 12.5±4.0 to 17.8±7.5 mL/[kg·min]; P=0.036) but remained below age-predicted levels (70±11%). The O2 delivery was improved owing to an increase in peak cardiac output and lung diffusion capacity. However, peak exercise ΔAVo2 was unchanged, as was skeletal muscle diffusion capacity. CONCLUSIONS We demonstrated that patients with CTEPH have significant impairment of all steps in the O2 use cascade, resulting in markedly impaired exercise capacity. Pulmonary vascular intervention increased peak Vo2 by partly correcting O2 delivery but had no effect on abnormalities in peripheral O2 extraction. This suggests that current interventions only partially address patients' limitations and that additional therapies may improve functional capacity.
Collapse
Affiliation(s)
- Erin J Howden
- Baker Heart and Diabetes Institute (E.J.H., S.R.-C., A.L.G., G.C.), Melbourne, Australia
| | - Sergio Ruiz-Carmona
- Cambridge Baker Systems Genomics Initiative (S.R.-C.), Melbourne, Australia.,Baker Heart and Diabetes Institute (E.J.H., S.R.-C., A.L.G., G.C.), Melbourne, Australia
| | - Mathias Claeys
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Ruben De Bosscher
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Rik Willems
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Bart Meyns
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Tom Verbelen
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Geert Maleux
- Imaging & Pathology (G.M., J.B.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Laurent Godinas
- Chronic Diseases and Metabolism (L.G., C.B., M.D.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Catharina Belge
- Chronic Diseases and Metabolism (L.G., C.B., M.D.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Jan Bogaert
- Imaging & Pathology (G.M., J.B.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Piet Claus
- Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Andre La Gerche
- Baker Heart and Diabetes Institute (E.J.H., S.R.-C., A.L.G., G.C.), Melbourne, Australia.,Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium
| | - Marion Delcroix
- Chronic Diseases and Metabolism (L.G., C.B., M.D.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| | - Guido Claessen
- Baker Heart and Diabetes Institute (E.J.H., S.R.-C., A.L.G., G.C.), Melbourne, Australia.,Departments of Cardiovascular Sciences (M.C., R.D.B., R.W., B.M., T.V., P.C., A.L.G., G.C.), KU Leuven, Belgium.,University Hospitals Leuven, Belgium (M.C., R.D.B., R.W., B.M., T.V., G.M., L.G., C.B., J.B., P.C., M.D., G.C.)
| |
Collapse
|
21
|
Matsuoka Y, Taniguchi Y, Miwa K, Sumimoto K, Tsuboi Y, Onishi H, Yanaka K, Emoto N, Hirata K. Assessment of oxygenation after balloon pulmonary angioplasty for patients with inoperable chronic thromboembolic pulmonary hypertension. Int J Cardiol 2021; 333:188-194. [PMID: 33684382 DOI: 10.1016/j.ijcard.2021.03.002] [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: 11/09/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy of balloon pulmonary angioplasty (BPA) in patients with inoperable chronic thromboembolic pulmonary hypertension would be promising. However, some patients showed residual dyspnea or symptoms, despite normalized hemodynamics. We aimed to clarify the clinical impact of oxygenation parameters on BPA outcome. METHOD Ninety-nine consecutive patients who underwent BPA from September 2011 to December 2019 were enrolled. We evaluated hemodynamics with right heart catheterization, arterial blood gas examination, New York Heart Association functional class (NYHA-FC), respiratory function tests, nocturnal oximetry, and exercise capacity (6-min walk test and cardiopulmonary exercise testing) at baseline and after BPA. RESULT Nearly normal hemodynamics was achieved after BPA (mean pulmonary artery pressure (PAP): 37.5 ± 10.0 to 20.6 ± 4.9 mmHg, p < 0.01). Oxygenation slightly improved (partial pressure of arterial oxygen; 61.5 ± 12.3 to 67.7 ± 12.7 mmHg, p < 0.01). Exertional desaturation remained unchanged (-8.1 ± 4.8 to -7.8 ± 5.1, p = 0.59), and this was associated with residual symptom (NYHA-FC ≥ 2) after BPA (OR 0.591, 95% CI 0.416-0.840, p = 0.003) in multivariate regression analyses. Lower vital capacity (r2 = 0.03, p = 0.01), higher mean PAP (r2 = 0.08, p = 0.02), and higher minute ventilation/carbon dioxide production (VE/VCO2) slope (r2 = 0.18, p < 0.01), the marker of ventilatory inefficiency, were correlated with exertional desaturation after BPA in multivariate linear analyses. CONCLUSION Although hemodynamics nearly normalized, oxygenation did not. Moreover, exertional desaturation remained unchanged. This might cause residual symptom after BPA. Residual pulmonary hypertension suggesting incurable arteriopathy, and higher VE/VCO2 slope suggesting ventilation-perfusion mismatch might be related to exertional desaturation. Domiciliary oxygen therapy should be continued, if necessary.
Collapse
Affiliation(s)
- Yoichiro Matsuoka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yu Taniguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan.
| | - Keisuke Miwa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Keiko Sumimoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yasunori Tsuboi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hiroyuki Onishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| |
Collapse
|
22
|
Abstract
In cardiopulmonary medicine, residual exertional dyspnea (RED) can be defined by the persistence of limiting breathlessness in a patient who is already under the best available therapy for the underlying heart and/or lung disease. RED is a challenge to the pulmonologist because the patient (and the referring physician) assumes that the "lung doctor" should invariably provide a successful plan to fight the symptom. After presenting a simplified framework to understand the neurobiological underpinnings of dyspnea in cardiorespiratory disease, I discuss the seeds of RED associated with 1) increased metabolic cost of work, 2) increased inspiratory constraints, 3) diaphragm dysfunction, 4) impaired right ventricle preload, 5) increased central and/or peripheral chemosensitivity, 6) increased physiological dead space, 7) increased pulmonary venous and/or high left ventricle filling pressures, 8) impaired chronotropic response to exertion, and 9) increased activation of the cortical-limbic circuits. I finalize by outlining the following two common coexistence of diseases in which these multiple mechanisms interact to produce severe RED: chronic obstructive pulmonary disease-heart failure with reduced ejection fraction and chronic pulmonary fibrosis-emphysema. RED exposes the important limitations of the current reductionist approach focused only on the (over)treatment of the poorly reversible cardiopulmonary disease(s). Conversely, recognizing the existence of RED sets the stage for a more holistic approach toward one of the most devastating symptoms known to man.
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Laveneziana P, Weatherald J. Pulmonary Vascular Disease and Cardiopulmonary Exercise Testing. Front Physiol 2020; 11:964. [PMID: 32848882 PMCID: PMC7425313 DOI: 10.3389/fphys.2020.00964] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) is of great interest and utility for clinicians dealing Pulmonary Hypertension (PH) in several ways, including: helping with differential diagnosis, evaluating exercise intolerance and its underpinning mechanisms, accurately assessing exertional dyspnea and unmasking its underlying often non-straightforward mechanisms, generating prognostic indicators. Pathophysiologic anomalies in PH can range from reduced cardiac output and aerobic capacity, to inefficient ventilation, dyspnea, dynamic hyperinflation, and locomotor muscle dysfunction. CPET can magnify the PH-related pathophysiologic anomalies and has a major role in the management of PH patients.
Collapse
Affiliation(s)
- Pierantonio Laveneziana
- Sorbonne Université, INSERM, UMR S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Sites Pitié-Salpêtrière, Saint-Antoine et Tenon, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée (Département R3S), Paris, France
| | - Jason Weatherald
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
25
|
Fernandes TM, Alotaibi M, Strozza DM, Stringer WW, Porszasz J, Faulkner GG, Castro CF, Tran DA, Morris TA. Dyspnea Postpulmonary Embolism From Physiological Dead Space Proportion and Stroke Volume Defects During Exercise. Chest 2019; 157:936-944. [PMID: 31759962 DOI: 10.1016/j.chest.2019.10.047] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/25/2019] [Accepted: 10/12/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Many patients with pulmonary embolism (PE) report dyspnea on exertion following long-term treatment. Increased physiological dead space proportion (VD/VT) and decreased cardiac stroke volume reserve may distinguish persistent effects of PE itself from symptoms reflecting comorbid conditions or deconditioning. METHODS This retrospective study analyzed a consecutive series of incremental symptom-limited cardiopulmonary exercise tests that had been ordered to evaluate persistent dyspnea on exertion following long-term treatment for acute PE. Physiological VD/VT was determined at anaerobic threshold from exhaled CO2 and transcutaneous Pco2 (validated against Paco2 measurements). Cardiac stroke volume reserve was estimated at rest and at anaerobic threshold by using oxygen consumption/pulse and previously validated estimates of the arteriovenous oxygen content difference. RESULTS Cardiopulmonary exercise tests were performed on 40 patients with post-PE dyspnea. In 65.0% (95% CI, 50.2-79.8), VD/VT at anaerobic threshold was abnormally elevated, stroke volume reserve was decreased, or both defects occurred. VD/VT at anaerobic threshold was abnormally elevated (≥ 0.27) in 35.0% (95% CI, 20.2-49.8). VD/VT at anaerobic threshold significantly correlated with the extent of unmatched perfusion defects on subsequent ventilation-perfusion scans (P = .0085). In 55.0% (95% CI, 39.6-70.4), stroke volume reserve at anaerobic threshold was abnormally decreased (≤ 128% of the resting value). Both defects were present in 25.0% (95% CI, 11.6-38.4). CONCLUSIONS Increased VD/VT at anaerobic threshold and decreased stroke volume reserve during exercise are common among patients with dyspnea on exertion after long-term treatment of PE. The defects can be disclosed noninvasively by using cardiopulmonary exercise testing.
Collapse
Affiliation(s)
- Timothy M Fernandes
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA
| | - Mona Alotaibi
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA
| | - Danielle M Strozza
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA
| | | | | | - Garner G Faulkner
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA
| | - Cara F Castro
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA
| | - Don A Tran
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA
| | - Timothy A Morris
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA.
| |
Collapse
|
26
|
Godinas L, Bonne L, Budts W, Belge C, Leys M, Delcroix M, Maleux G. Balloon Pulmonary Angioplasty for the Treatment of Nonoperable Chronic Thromboembolic Pulmonary Hypertension: Single-Center Experience with Low Initial Complication Rate. J Vasc Interv Radiol 2019; 30:1265-1272. [DOI: 10.1016/j.jvir.2019.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/25/2019] [Accepted: 03/17/2019] [Indexed: 01/15/2023] Open
|
27
|
Akizuki M, Sugimura K, Aoki T, Kakihana T, Tatebe S, Yamamoto S, Sato H, Satoh K, Shimokawa H, Kohzuki M. Non‐invasive screening using ventilatory gas analysis to distinguish between chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension. Respirology 2019; 25:427-434. [DOI: 10.1111/resp.13618] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/25/2019] [Accepted: 05/22/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Mina Akizuki
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
| | - Koichiro Sugimura
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Tatsuo Aoki
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Takaaki Kakihana
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
| | - Shunsuke Tatebe
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Saori Yamamoto
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Haruka Sato
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Kimio Satoh
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Masahiro Kohzuki
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
| |
Collapse
|
28
|
Vallerand JR, Weatherald J, Laveneziana P. Pulmonary Hypertension and Exercise. Clin Chest Med 2019; 40:459-469. [DOI: 10.1016/j.ccm.2019.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
29
|
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disease with significant morbidity. It is a result of an alternate natural history in which there is limited resolution of thromboemboli with pulmonary artery obstruction leading to pulmonary hypertension (PH). CTEPH requires a thorough clinical assessment including pulmonary hemodynamics and radiologic evaluation in addition to consultation with an expert center. Surgical intervention remains the optimal management strategy. Select patients may be candidates for catheter-based intervention with balloon pulmonary angioplasty in centers with clinical expertise. Inoperable patients or those with post-intervention PH are treated with pulmonary hypertension-targeted medical therapy.
Collapse
Affiliation(s)
- Jean M Elwing
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0564, Cincinnati, OH 45267, USA.
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and Pulmonary Thromboendarterectomy Program, Advanced Heart Failure and Cardiac Transplant, Temple University School of Medicine, Temple University Hospital, 9th Floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - William R Auger
- CTEPH Program, UC San Diego Health, University of California, San Diego, 9300 Campus Point Drive #7381, La Jolla, CA 92037, USA
| |
Collapse
|
30
|
Stam K, van Duin RW, Uitterdijk A, Krabbendam-Peters I, Sorop O, Danser AHJ, Duncker DJ, Merkus D. Pulmonary microvascular remodeling in chronic thrombo-embolic pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2018; 315:L951-L964. [PMID: 30260284 DOI: 10.1152/ajplung.00043.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Pulmonary vascular remodeling in pulmonary arterial hypertension involves perturbations in the nitric oxide (NO) and endothelin-1 (ET-1) pathways. However, the implications of pulmonary vascular remodeling and these pathways remain unclear in chronic thrombo-embolic pulmonary hypertension (CTEPH). The objective of the present study was to characterize changes in microvascular morphology and function, focussing on the ET-1 and NO pathways, in a CTEPH swine model. Swine were chronically instrumented and received up to five pulmonary embolizations by microsphere infusion, whereas endothelial dysfunction was induced by daily administration of the endothelial NO synthase inhibitor Nω-nitro-l-arginine methyl ester until 2 wk before the end of study. Swine were subjected to exercise, and the pulmonary vasculature was investigated by hemodynamic, histological, quantitative PCR, and myograph experiments. In swine with CTEPH, the increased right-ventricular afterload, decreased cardiac index, and mild ventilation-perfusion-mismatch were exacerbated during exercise. Pulmonary microvascular remodeling was evidenced by increased muscularization, which was accompanied by an increased maximal vasoconstriction. Although ET-1-induced vasoconstriction was increased in CTEPH pulmonary small arteries, the ET-1 sensitivity was decreased. Moreover, the contribution of the ETA receptor to ET-1 vasoconstriction was increased, whereas the contribution of the ETB receptor was decreased and the contribution of Rho-kinase was lost. A reduction in endogenous NO production was compensated in part by a decreased phosphodiesterase 5 (PDE5) activity resulting in an apparent increased NO sensitivity in CTEPH pulmonary small arteries. These findings suggest that pulmonary microvascular remodeling with a reduced activity of PDE5 and Rho-kinase may contribute to the lack of therapeutic efficacy of PDE5 inhibitors and Rho-kinase inhibitors in CTEPH.
Collapse
Affiliation(s)
- Kelly Stam
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - Richard W van Duin
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - André Uitterdijk
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - Ilona Krabbendam-Peters
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - Oana Sorop
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - A H Jan Danser
- Department of Pharmacology, Erasmus Medical Center , Rotterdam , The Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam , The Netherlands
| |
Collapse
|
31
|
Chen TX, Pudasaini B, Guo J, Gong SG, Jiang R, Wang L, Zhao QH, Wu WH, Yuan P, Liu JM. Sex-specific cardiopulmonary exercise testing indices to estimate the severity of inoperable chronic thromboembolic pulmonary hypertension. Int J Chron Obstruct Pulmon Dis 2018; 13:385-397. [PMID: 29416329 PMCID: PMC5790096 DOI: 10.2147/copd.s152971] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background Sex differences in chronic thromboembolic pulmonary hypertension (CTEPH) have been revealed in few studies. Although right heart catheterization (RHC) is the gold standard for clinical diagnosis and assessment of prognosis in pulmonary hypertension (PH), cardiopulmonary exercise testing (CPET) has been a more widely used assessment of functional capacity, disease severity, prognosis, and treatment response in PH. We hypothesized that the “sex-specific” CPET indices could estimate the severity of inoperable CTEPH. Methods Data were retrieved for 33 male (age, mean ± standard deviation [SD] =62.5±13.4 years) and 40 female (age, mean ± SD =56.3±11.8 years) patients with stable CTEPH who underwent both RHC and CPET at Shanghai Pulmonary Hospital from February 2010 to February 2016. Univariate and forward/backward multiple stepwise regression analysis was performed to assess the predictive value of CPET indices to hemodynamic parameters. Event-free survival was estimated using the Kaplan–Meier method and analyzed with the log-rank test. Cox proportional hazards models were performed to determine the independent event-free survival predictors. Results Numerous CPET parameters were different between male and female patients with CTEPH and the control group. There were no significant differences in both clinical variables and RHC parameters between male and female patients with CTEPH. O2 pulse, workload, minute ventilation (VE), and end-tidal partial pressure of O2 (PETO2) at anaerobic threshold, as well as peak O2 pulse, workload, VE, and nadir VE/CO2 were significantly higher in male patients than in female patients (P<0.05). Only oxygen uptake efficiency plateau (OUEP) showed a significantly higher difference in female than male patients (P<0.05). In addition, several CPET indices correlated with hemodynamic parameters, especially pulmonary vascular resistance (PVR), which was distinctly different between the sexes. Nadir VE/CO2 was an independent predictor of PVR in male patients with CTEPH, whereas OUEP was an independent predictor of PVR in female patients with CTEPH. Conclusion Even after confounding for age and body mass index, different CPET measurements of gas exchange efficiency correlated with PVR differently between male and female patients. This potentially could be used to estimate the severity of CTEPH.
Collapse
Affiliation(s)
- Tian-Xiang Chen
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Bigyan Pudasaini
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University, Shanghai, People's Republic of China
| |
Collapse
|