Eleonora Alfonzetti

Role of Right Ventricle and Dynamic Pulmonary Hypertension on Determining ΔVO2/ΔWork Rate Flattening: Insights from Cardiopulmonary Exercise Test Combined with Exercise Echocardiography

Background—Several cardiovascular diseases are characterized by an impaired O2 kinetic during exercise. The lack of a linear increase of &Dgr;oxygen consumption (VO2)/&Dgr;Work Rate (WR) relationship, as assessed by expired gas analysis, is considered an indicator of abnormal cardiovascular efficiency. We aimed at describing the frequency of &Dgr;VO2/&Dgr;WR flattening in a symptomatic population of cardiac patients, characterizing its functional profile, and testing the hypothesis that dynamic pulmonary hypertension and right ventricular contractile reserve play a major role as cardiac determinants. Methods and Results—We studied 136 patients, with different cardiovascular diseases, referred for exertional dyspnoea. Cardiopulmonary exercise test combined with simultaneous exercise echocardiography was performed using a symptom-limited protocol. &Dgr;VO2/&Dgr;WR flattening was observed in 36 patients (group A, 26.5% of population) and was associated with a globally worse functional profile (reduced peak VO2, anaerobic threshold, O2 pulse, impaired VE/VCO2). At univariate analysis, exercise ejection fraction, exercise mitral regurgitation, rest and exercise tricuspid annular plane systolic excursion, exercise systolic pulmonary artery pressure, and exercise cardiac output were all significantly (P<0.05) impaired in group A. The multivariate analysis identified exercise systolic pulmonary artery pressure (odds ratio, 1.06; confidence interval, 1.01–1.11; P=0.01) and exercise tricuspid annular plane systolic excursion (odds ratio, 0.88; confidence interval, 0.80–0.97; P=0.01) as main cardiac determinants of &Dgr;VO2/&Dgr;WR flattening; female sex was strongly associated (odds ratio, 6.10; confidence interval, 2.11–17.7; P<0.01). Conclusions—In patients symptomatic for dyspnea, the occurrence of &Dgr;VO2/&Dgr;WR flattening reflects a significantly impaired functional phenotype whose main cardiac determinants are the excessive systolic pulmonary artery pressure increase and the reduced peak right ventricular longitudinal systolic function.Background—Several cardiovascular diseases are characterized by an impaired O2 kinetic during exercise. The lack of a linear increase of Δoxygen consumption (VO2)/ΔWork Rate (WR) relationship, as assessed by expired gas analysis, is considered an indicator of abnormal cardiovascular efficiency. We aimed at describing the frequency of ΔVO2/ΔWR flattening in a symptomatic population of cardiac patients, characterizing its functional profile, and testing the hypothesis that dynamic pulmonary hypertension and right ventricular contractile reserve play a major role as cardiac determinants. Methods and Results—We studied 136 patients, with different cardiovascular diseases, referred for exertional dyspnoea. Cardiopulmonary exercise test combined with simultaneous exercise echocardiography was performed using a symptom-limited protocol. ΔVO2/ΔWR flattening was observed in 36 patients (group A, 26.5% of population) and was associated with a globally worse functional profile (reduced peak VO2, anaerobic threshold,...

Prevalence and characterization of exercise oscillatory ventilation in apparently healthy individuals at variable risk for cardiovascular disease: A subanalysis of the EURO-EX trial

Introduction There has been a greater appreciation of several variables obtained by cardiopulmonary exercise testing (CPX). Exercise oscillatory ventilation (EOV) is a CPX pattern that has gained recognition as an ominous marker of poor prognosis in cardiac patients. The purpose of the present study is to characterize whether such an abnormal ventilatory pattern may also be detected in apparently healthy subjects and determine its clinical significance. Methods The study involved 510 subjects (mean age 60 ± 14 years; 49% male) with a broad cardiovascular (CV) risk factor profile who underwent CPX. Results The population was divided into two groups according to the presence (17%) or absence of EOV. Subjects with EOV were significantly older and a higher percentage was female. Risk factor profile and medication use was significantly different between subgroups, indicating subjects with EOV had a worse CV risk factor profile and were prescribed CV-focused preventive medications at a significantly higher frequency. Subjects with EOV had comparatively poorer CPX performance and gas exchange phenotype. Multivariate binary logistic regression analysis found being female was the strongest predictor of EOV (odds ratio: 2.77, 95% confidence interval (CI): 1.66-4.61, p < 0.001). A diagnosis of diabetes (odds ratio: 2.40, 95% CI: 1.34–4.15.2, p < 0.001) added significant value for predicting EOV and was retained in the regression. The likelihood for EOV for subjects who were female and diagnosed with diabetes was 3.71 (95% CI 1.88–7.30, p < 0.001). Conclusions This is the first study to examine EOV prevalence and characterization in apparently healthy persons with results supporting an in-depth definition of abnormal exercise phenotypes.

Mitral regurgitation in heart failure: insights from CPET combined with exercise echocardiography

Aims In heart failure patients with reduced ejection fraction (HFrEF), exercise‐induced functional mitral regurgitation (MR) may affect functional capacity and outcome. We sought to study functional and cardiac phenotypes of HFrEF patients according to the MR degree. Methods and results We performed rest and exercise echocardiography (Ex‐Echo), simultaneously combined with cardiopulmonary exercise test (CPET), in 102 HFrEF patients, identifying 3 groups: non‐severe (ERO <20 mm2) MR (group A), exercise‐induced severe (ERO ≥20 mm2) MR (group B), and rest severe MR (group C). Patients were tracked for the composite end point of death and heart failure hospitalization. Group B (ERO: rest= 14 ± 5 mm2, Ex= 28 ± 6 mm2; P = < 0.001) had a functional impairment (workload = 56 ± 21 vs. 50 ± 17 watts, P = 0.42; peak VO2 = 11.8 ± 3.2 vs. 11.5 ± 3.0 mL/Kg/min, P = 0.70) similar to Group C (ERO: rest = 29 ± 7 mm2, Ex = 42 ± 7 mm2, P = < 0.001), associated with comparable advanced left ventricle remodelling (end diastolic indexed volume = 107 ± 34 vs. 115 ± 30 mL/m2, P = 0.27), characterized by exercise‐induced pulmonary hypertension (PH) (Ex systolic pulmonary pressures = 63 ± 16 mmHg). Group C showed the worse cardiac phenotype (right ventricle dilatation, dysfunction, and rest PH) with severe ventilatory impairment (VE/VCO2 = 41.2 ± 11) compared with Groups A and B. Moreover, Group C had the higher rate of death and HF hospitalization. Conclusions In HFrEF patients, severe dynamic MR produces functional limitation similar to rest severe MR, characterized by dynamic PH. Rest severe MR reflects the most advanced bi‐ventricular remodelling associated with rest PH, the most unfavourable ventilatory profile, and the worst mid‐term outcome.

CARDIAC DETERMINANTS OF FUNCTIONAL CAPACITY: CARDIOPULMONARY EXERCISE TESTING COMBINED WITH EXERCISE-ECHOCARDIOGRAPHY

Left ventricular (LV) diastolic pressure can be estimated by the echo-derived ratio of early diastolic transmitral velocity (E) and tissue septal velocity (e’). Cardiopulmonary exercise testing (CPET) provides indices of functional capacity such as peak oxygen consumption (VO2), which are related

LEFT ATRIAL DYNAMICS DURING EXERCISE IN HEART FAILURE WITH REDUCED, MID-RANGE, AND PRESERVED EJECTION FRACTION: INSIGHTS FROM EXERCISE ECHOCARDIOGRAPHY COMBINED WITH GAS EXCHANGE ANALYSIS

The hemodynamic impact of left atrial (LA) dynamic response in heart failure (HF) on cardiopulmonary function and RV-to-PC coupling at exercise is a matter of recent interest. 120 patients with HF reduced (rEF, n=70), mid-range (mrEF, n=25) and preserved (pEF, n=25) ejection fraction underwent CPET

RIGHT VENTRICULAR FUNCTION AND CARDIOPULMONARY PERFORMANCE IN CARDIAC DISEASES: THE MAINSTAY ROLE OF RIGHT VENTRICULAR AFTERLOAD

RV function is a major determinant of peak oxygen consumption (VO2) and exercise ventilation inefficiency as assessed by the rate of increase of ventilation (VE) over carbon dioxide production (VCO2). We aimed at defining the RV function determinants (preload, afterload and contractility) using 2D

EXERCISE ATRIAL FUNCTION ANALYSIS BY SPECKLE TRACKING IN HEART FAILURE: PATHOPHYSIOLOGICAL IMPLICATIONS ON RIGHT VENTRICULAR TO PULMONARY CIRCULATION UNCOUPLING

We hypothesized that a failure of left atrial contribution to left ventricular filling would be involved in the right ventricular (RV) to pulmonary circulation (PC) uncoupling and exercise ventilation inefficiency. 44 patients with heart failure reduced ejection fraction (HFrEF) and 32 controls

EXERCISE RESPONSE OF HFPEF VERSUS HFREF PATIENTS: INSIGHTS ON LEFT ATRIAL FUNCTION AND RIGHT VENTRICULAR TO PULMONARY CIRCULATION COUPLING BY COMBINING CARDIOPULMONARY EXERCISE TESTING WITH STRESS ECHO

The hemodynamic adaptation to exercise in heart failure preserved ejection fraction (HFpEF) has never been studied in terms of left atrial adaptations and right ventricular to pulmonary circulation (RV to PC) coupling. We aimed at investigating these responses. Ten HFpEF patients (LVEF >50%,

INCREASED EXERCISE PERIPHERAL EXTRACTION IN GROUP 2 PULMONARY HYPERTENSION AND EXERCISE OSCILLATORY VENTILATION

Group 2 pulmonary hypertension (PH) and exercise oscillatory ventilation (EOV) are prognostic signs in heart failure (HF). It is unknown what may characterize the exercise response of PH patients and EOV. Aim: To define the functional pattern in HF reduced ejection fraction (HFrEF) with PH according

EXERCISE VENTILATORY POWER IN HEART FAILURE PATIENTS: FUNCTIONAL PHENOTYPES DEFINITION BY COMBINING CARDIOPULMONARY EXERCISE TESTING WITH STRESS ECHOCARDIOGRAPHY

Exercise Ventilatory Power (EVP; peak systolic blood pressure/exercise ventilation to CO2 production slope) is a new powerful prognostic marker that combines ventilator abnormalities with systemic hemodynamic during exercise. The phenotype and clinical relevance of patients with a worse EVP is