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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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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