r e i l u m e D Dr. L. Demulier . r BWGACHD symposium D - PowerPoint PPT Presentation

INTERPRETATION AND PROGNOSTIC VALUE OF CPET IN CONGENITAL HEART DISEASE r e i l u m e D Dr. L. Demulier . r BWGACHD symposium D 10/06/2017 t h g i r y p o C

INDICATIONS r e i l u m e D . r D t h g i r y p o C Fletcher et al. Circulation 2013 ; 128:873-934

ERGOMETERS r e i l u m e D . r D t h g i r y p o C

SPIROMETRY SETUP r e i l u m e D . r D t h g i r y p o C

r e i l u m e D . r D t h g i r y p o C

r e i l u m PROGNOSTIC VALUE OF INDIVIDUAL e CPET PARAMETERS D . r D t h g i r y p o C

Peak VO 2 = aerobic power = maximum O 2 uptake r e i l u m e O 2 -uptake D . r D t h g i r y p o C Courtesy of Acertys

r e i l u m e D . r D t h g i r y p o C

Peak VO 2 = excellent measure of ex capacity r e i l u m e D . r D t h g i r y p o C

Peak VO 2 : DETERMINANTS r e i l u o Age m o Gender e D o Body weight . r o Physical activity D t o Genetic predisp h g o Morbidity i r y p o C - 10% / decade above 30 y ml/min ml/kg/min Fletcher et al. Circulation 2013 ; 128:873-934

SPIROMETRY REPORT r e i l u m e D . r D t h g i r y p o C

Peak VO 2 in ACHD r e i 4415 ACHD pts l u m e D . r D t h g i r y p o C Kempny et al. EHJ 2012;33:1386-96

Prognostic value of peak VO 2 in ACHD 335 ACHD pts r e i l u m VO2 < 15.5 ml/kg/min e D . Risk hospitalization r D or death t h g i r y p o C 2005 ; 112:828-835

r e i l u m e D HEART RATE RESPONSE . r D t 220 – age (SD 10 bpm) h Predicted value g (210 – 0.65 x leeftijd) i r y p o Normal ≥ 85% predicted value C

r e i l u m e D HEART RATE RESERVE (HRR) . r D t h Definition Observed Peak HR – Resting HR g i r y p o HEART RATE RECOVERY (at 1 or 3 min) C > 12 bpm 1 st min of recovery Normal parasympathetic activiation

r e i JACC 2006;48:1250-6 l u m e D . r 727 ACHD pts D t h g i r y p o C Independent of AAD, NYHA, peak VO 2

r e i JACC 2006;48:1250-6 l u m e D . r D t h g i r y p o C

VENTILLATORY RESPONSE : VE/VCO 2 -slope Pulmonary VQ mismatch – chemoreceptor derangement r e i l u PROGNOSTIC m o Heart failure e D o HCMP . r o PHT D o COPD t h g o ILD i r o Congenital HD y p o C (also submax test) NORMAL SLOPE < 30 THE STEEPER = THE WORSE Mezzani et al. EJCPR 2009

VENTILLATORY RESPONSE : VE/VCO 2 -slope Pulmonary VQ match r e i l u m e D . r Pulmonary valve dilation D in TOF patient t h g i r y p o C Rhodes et al. Circulation 2010;122:1957-67

VE/VCO 2 -slope in ACHD r e i l u m e D . r D t h g i r y p o C 560 ACHD pts Dimopoulos et al. Circulation 2006;113:2796-2802

Prognostic value of VE/VCO 2 -slope in non-cyanotic ACHD r e i l u m e D . r D t h g i r y p Mortality risk x 10 o C Dimopoulos et al. Circulation 2006;113:2796-2802

SPIROMETRY AT REST r e i l u m e D . r D t h g i r y p o C

Prognostic value of FVC in ACHD 1188 ACHD pts r e i l u m e D Moderate to severely . r D impaired lung function t = FVC < 60% h g i r y p o C Alonso-Gonzalez et al. Circulation 2013; 127: 882-890

r e i l u m PROGNOSTIC VALUE OF COMBINED e CPET PARAMETERS D . r D t h g i r y p o C

Combination of Peak VO 2 and HRR 1375 ACHD pts r e i l Prediction model u m Estimated e D 5y survival charts . r D Adjustment t h o Cyanosis g i r o NCA y p o C Maximal ex-test Inuzuka et al. Circulation 2012

Combination of Peak VO 2 and MAP : Peak circulatory power (mmHg ml O 2 /kg/min) r e i l u m e D . r D t h g i r y p o C 432 ACHD pts Giardini et al. Am Heart J. 2007; 154: 441-447

Combination of Peak VO 2 (%) and VE/VCO 2 -slope and prognosis after atrial switch repair for TGA r e i l u m e D . r D t h g i r y p o C 274 ACHD pts – 4y FU Giardini et al. JACC 2009;53: 1548-55

Combination of Peak VO 2 (%) and VE/VCO 2 -slope and prognosis after atrial switch repair for TGA r e i l u m e D . r D t h g i r y p o C 274 ACHD pts – 4y FU Giardini et al. JACC 2009;53: 1548-55

r e i l u m PROGNOSTIC VALUE OF COMBINATION OF e CPET AND NON-EXERCISE PARAMETERS D . r D t h g i r y p o C

Combination of Peak VO 2 (%) and QRS-duration after surgical repair of TOF r e i l u QRS ≥ 170 ms m e AND D Peak VO 2 ≤ 65% pred . r D (VO2 ~ 23.5 ml/kg/min) t h g HR death or sust VT x 11 i r y p o C 875 ACHD pts Müller J, …, Roselien Buys, Luc Vanhees et al. IJC 2015:158-164

Combination of Peak VO 2 (%), VE/VCO 2 -slope and QRS-duration after surgical repair of TOF r e RISK FACTORS for i l u m cardiac death or events: e D . QRS ≥ 170 ms r D Peak VO 2 ≤ 65% pred t h VE/VCO 2 - slope ≥ 31 g i r y p o C 875 ACHD pts Müller J, …, Roselien Buys, Luc Vanhees et al. IJC 2015:158-164

THANK YOU FOR YOUR ATTENTION ! r e i l u m e D . r D t h g i r y p o C

r e i l u m e D . r D t h g i r y p o C

r e i l u m e D . r D t h g i r y p o C

DEEL 1 : INTRODUCTIE TOT CPET r e i l u m e D . r D DEEL 2 : t PRAKTISCHE APPLICATIE UZG CYCLO-SPIRO h g PROGRAMMA EN ACHTERGROND INFORMATIE i r y p o C

Bloeddrukrespons r e i l u m e SBP ↑ 10 mmHg per 3.5 ml O 2 /kg/min D Normaal DBP idem of ↓ . r D t ♂ SBP > 210 mmHg h Hoog g ♀ SBP > 190 mmHg i r y p o ‘Blunted’ : SBP ↑ ≤ 20 mmHg Laag C ‘Hypotensive’ : SBP ex < SBP rust EACPR/AHA Position statement ; EHJ Sep 2012

Peak VO 2 : referentiewaarden r e i l u m e D . r D t h g i r y p o C Gewicht, lengte, leeftijd, geslacht Wasserman et al. Principles of exercise testing and interpretation. Fifth Edition.

r e i l u m e 4415 ACHD pten D . 50% literatuur r D t h g i r y p o C

r e i l u m e 4415 ACHD pten D . 50% literatuur r D t h g i r y p o C

RESPIRATORY EQUIVALENT RATIO (RER) r e i l u m e D . r D t h g i r y p o C INDICATOR VOOR MAX INSPANNING ≥ 1.1

METABOLE EQUIVALENTEN (MET) 1 MET = 3.5 ml/kg/min VO2 r e i l u m MET = VO 2 in basale omstandigheden ( ♂ 40 40j j ; ; 70 kg 0 kg) e D . r AANTAL MET = VO 2 (ml/kg/min) / 3.5 D t h g i r y p o C

ZUURSTOFSATURATIE r e i l u m e D . r D NORMAAL ≥ 95% rust / insp t h g i PATHOLOGISCH ↓ > 5% r y p o C Pulmonale pathologie / PHT / Congenitaal hartlijden Guazzi et al. Circulation 2012

ZUURSTOF POLS (VO2/HR) VO 2 = CO X C (a-v) 0 2 VO 2 / HR = SV X C (a-v) 0 2 r e i l u m e OAD : obstructief longlijden D HD : heart disease . r D t h g i r y p o C Maat voor slagvolume respons tijdens inspanning Wasserman et al. Principles of exercise testing and interpretation. Fifth Edition.

MAXIMALE VENTILLATIE (V E max) (L/min) r e i l u m e D . r D t h FEV 1 x 35 (37.5) g MVV (12s x 5) i r y p o C Breathing reserve : V Emax pred - V Emax obs / V Emax pred x 100 Respiratoire limitering: BR< 15% en afwijkende FEV

FEV 1 : kijk naar de curve ! r e i l u m e D . r D t h g i r y p o C

OUES : Oxygen Uptake Efficiency Slope Efficiëntie van zuurstof extractie en opname r e i l u Index voor CV, musculoskeletale en pulmonale functie m e D Toepasbaar bij . r submax inspanning D t h g i r y p o C HOE VLAKKER (LAGER) , HOE SLECHTER Mezzani et al. EJCPR 2009

SPIRO RAPPORT r e i l u m e D . r D t h g i r y p o C

SPIRO RAPPORT r e i l u m e D . r D t h g i r y p o C

SPIRO RAPPORT r e i l u m e D . r D t h g i r RCP y p o C NORMAAL : 3.5 à 4 HR/VO 2 slope <2 : sign chronotrope incompetentie Optimalisatie PM rate response

CARDIOVASCULAIRE VS PULMONALE LIMITERING r e i l u m e D . r D t h g i r y p o C Balady et al. Circulation 2010