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INTERPRETATION AND PROGNOSTIC VALUE OF CPET IN CONGENITAL HEART DISEASE
Dr. L. Demulier
BWGACHD symposium
10/06/2017
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INDICATIONS
Fletcher et al. Circulation 2013 ; 128:873-934
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ERGOMETERS
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SPIROMETRY SETUP
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PROGNOSTIC VALUE OF INDIVIDUAL CPET PARAMETERS
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O2-uptake
Courtesy of Acertys
Peak VO2 = aerobic power = maximum O2 uptake
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Peak VO2 = excellent measure of ex capacity
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Peak VO2 : DETERMINANTS
o Age
o Gender
o Body weight
o Physical activity
o Genetic predisp
o Morbidity
- 10% / decade above 30 y ml/min
Fletcher et al. Circulation 2013 ; 128:873-934
ml/kg/min Cop
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t Dr.
Demuli
er
SPIROMETRY REPORT
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Peak VO2 in ACHD
Kempny et al. EHJ 2012;33:1386-96
4415 ACHD pts
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Prognostic value of peak VO2 in ACHD
2005 ; 112:828-835
335 ACHD pts
VO2 < 15.5 ml/kg/min
Risk hospitalization or death
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HEART RATE RESPONSE
Normal ≥ 85% predicted value
Predicted value 220 – age (SD 10 bpm) (210 – 0.65 x leeftijd)
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HEART RATE RESERVE (HRR)
Definition Observed Peak HR – Resting HR
HEART RATE RECOVERY (at 1 or 3 min)
Normal > 12 bpm 1st min of recovery parasympathetic activiation
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Independent of AAD, NYHA, peak VO2
JACC 2006;48:1250-6
727 ACHD pts
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JACC 2006;48:1250-6
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VENTILLATORY RESPONSE : VE/VCO2-slope
NORMAL SLOPE < 30 THE STEEPER = THE WORSE
Mezzani et al. EJCPR 2009
Pulmonary VQ mismatch – chemoreceptor derangement
PROGNOSTIC
o Heart failure
o HCMP
o PHT
o COPD
o ILD
o Congenital HD
(also submax test)
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VENTILLATORY RESPONSE : VE/VCO2-slope
Rhodes et al. Circulation 2010;122:1957-67
Pulmonary VQ match
Pulmonary valve dilation in TOF patient
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Dimopoulos et al. Circulation 2006;113:2796-2802
VE/VCO2-slope in ACHD
560 ACHD pts
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Dimopoulos et al. Circulation 2006;113:2796-2802
Prognostic value of VE/VCO2-slope in non-cyanotic ACHD
Mortality risk x 10
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SPIROMETRY AT REST
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Prognostic value of FVC in ACHD
Moderate to severely impaired lung function
= FVC < 60%
Alonso-Gonzalez et al. Circulation 2013; 127: 882-890
1188 ACHD pts
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PROGNOSTIC VALUE OF COMBINED CPET PARAMETERS
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Combination of Peak VO2 and HRR
Inuzuka et al. Circulation 2012
Prediction model
Estimated
5y survival charts
Adjustment
o Cyanosis
o NCA
Maximal ex-test
1375 ACHD pts
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Combination of Peak VO2 and MAP : Peak circulatory power (mmHg ml O2/kg/min)
432 ACHD pts
Giardini et al. Am Heart J. 2007; 154: 441-447
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Combination of Peak VO2 (%) and VE/VCO2-slope and prognosis after atrial switch repair for TGA
Giardini et al. JACC 2009;53: 1548-55 274 ACHD pts – 4y FU
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Combination of Peak VO2 (%) and VE/VCO2-slope and prognosis after atrial switch repair for TGA
Giardini et al. JACC 2009;53: 1548-55 274 ACHD pts – 4y FU
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PROGNOSTIC VALUE OF COMBINATION OF CPET AND NON-EXERCISE PARAMETERS
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Combination of Peak VO2 (%) and QRS-duration after surgical repair of TOF
Müller J, …, Roselien Buys, Luc Vanhees et al. IJC 2015:158-164 875 ACHD pts
QRS ≥ 170 ms
AND
Peak VO2 ≤ 65% pred
(VO2 ~ 23.5 ml/kg/min)
HR death or sust VT x 11
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Combination of Peak VO2 (%), VE/VCO2-slope and QRS-duration after surgical repair of TOF
Müller J, …, Roselien Buys, Luc Vanhees et al. IJC 2015:158-164 875 ACHD pts
RISK FACTORS for
cardiac death or events:
QRS ≥ 170 ms
Peak VO2 ≤ 65% pred
VE/VCO2-slope ≥ 31
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THANK YOU FOR YOUR ATTENTION !
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DEEL 1 : INTRODUCTIE TOT CPET
DEEL 2 : PRAKTISCHE APPLICATIE UZG CYCLO-SPIRO
PROGRAMMA EN ACHTERGROND INFORMATIE
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Bloeddrukrespons
Normaal SBP ↑ 10 mmHg per 3.5 ml O2/kg/min
DBP idem of ↓
Hoog ♂ SBP > 210 mmHg ♀ SBP > 190 mmHg
Laag ‘Blunted’ : SBP ↑ ≤ 20 mmHg
‘Hypotensive’ : SBP ex < SBP rust
EACPR/AHA Position statement ; EHJ Sep 2012
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Peak VO2 : referentiewaarden
Gewicht, lengte, leeftijd, geslacht
Wasserman et al. Principles of exercise testing and interpretation. Fifth Edition.
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4415 ACHD pten
50% literatuur
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4415 ACHD pten
50% literatuur
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RESPIRATORY EQUIVALENT RATIO (RER)
INDICATOR VOOR MAX INSPANNING ≥ 1.1
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METABOLE EQUIVALENTEN (MET)
1 MET = 3.5 ml/kg/min VO2
AANTAL MET = VO2 (ml/kg/min) / 3.5
MET = VO2 in basale omstandigheden (♂ 40j ; 70 kg)
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ZUURSTOFSATURATIE
NORMAAL ≥ 95% rust / insp
PATHOLOGISCH ↓ > 5%
Pulmonale pathologie / PHT / Congenitaal hartlijden
Guazzi et al. Circulation 2012
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ZUURSTOF POLS (VO2/HR)
VO2 = CO X C(a-v)02
VO2 / HR = SV X C(a-v)02
Maat voor slagvolume respons tijdens inspanning
Wasserman et al. Principles of exercise testing and interpretation. Fifth Edition.
OAD : obstructief longlijden HD : heart disease
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MAXIMALE VENTILLATIE (VE max) (L/min)
MVV (12s x 5)
FEV1 x 35 (37.5)
Breathing reserve : VEmax pred - VEmax obs / VEmax pred x 100
Respiratoire limitering: BR< 15% en afwijkende FEV
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FEV1 : kijk naar de curve !
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OUES : Oxygen Uptake Efficiency Slope
Mezzani et al. EJCPR 2009
Efficiëntie van zuurstof extractie en opname
Index voor CV, musculoskeletale en pulmonale functie
Toepasbaar bij submax inspanning
HOE VLAKKER (LAGER) , HOE SLECHTER
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SPIRO RAPPORT
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SPIRO RAPPORT
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SPIRO RAPPORT
HR/VO2 slope
NORMAAL : 3.5 à 4 <2 : sign chronotrope incompetentie
Optimalisatie PM rate response
RCP
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CARDIOVASCULAIRE VS PULMONALE LIMITERING
Balady et al. Circulation 2010
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