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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

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SLIDE 1

INTERPRETATION AND PROGNOSTIC VALUE OF CPET IN CONGENITAL HEART DISEASE

  • Dr. L. Demulier

BWGACHD symposium 10/06/2017

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SLIDE 2

INDICATIONS

Fletcher et al. Circulation 2013 ; 128:873-934

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SLIDE 3

ERGOMETERS

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SLIDE 4

SPIROMETRY SETUP

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SLIDE 5

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SLIDE 6

PROGNOSTIC VALUE OF INDIVIDUAL CPET PARAMETERS

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SLIDE 7

O2-uptake

Courtesy of Acertys

Peak VO2 = aerobic power = maximum O2 uptake

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SLIDE 8

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SLIDE 9

Peak VO2 = excellent measure of ex capacity

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SLIDE 10

Peak VO2 : DETERMINANTS

  • Age
  • Gender
  • Body weight
  • Physical activity
  • Genetic predisp
  • Morbidity
  • 10% / decade above 30 y

ml/min

Fletcher et al. Circulation 2013 ; 128:873-934

ml/kg/min

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SLIDE 11

SPIROMETRY REPORT

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SLIDE 12

Peak VO2 in ACHD

Kempny et al. EHJ 2012;33:1386-96

4415 ACHD pts

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SLIDE 13

Prognostic value of peak VO2 in ACHD

2005 ; 112:828-835

335 ACHD pts

VO2 < 15.5 ml/kg/min

Risk hospitalization

  • r death

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SLIDE 14

HEART RATE RESPONSE

Normal

≥ 85% predicted value

Predicted value

220 – age (SD 10 bpm) (210 – 0.65 x leeftijd)

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SLIDE 15

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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SLIDE 16

Independent of AAD, NYHA, peak VO2

JACC 2006;48:1250-6

727 ACHD pts

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SLIDE 17

JACC 2006;48:1250-6

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SLIDE 18

VENTILLATORY RESPONSE : VE/VCO2-slope

NORMAL SLOPE < 30 THE STEEPER = THE WORSE

Mezzani et al. EJCPR 2009

Pulmonary VQ mismatch – chemoreceptor derangement

PROGNOSTIC

  • Heart failure
  • HCMP
  • PHT
  • COPD
  • ILD
  • Congenital HD

(also submax test)

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SLIDE 19

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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SLIDE 20

Dimopoulos et al. Circulation 2006;113:2796-2802

VE/VCO2-slope in ACHD

560 ACHD pts

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SLIDE 21

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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SLIDE 22

SPIROMETRY AT REST

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SLIDE 23

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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SLIDE 24

PROGNOSTIC VALUE OF COMBINED CPET PARAMETERS

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SLIDE 25

Combination of Peak VO2 and HRR

Inuzuka et al. Circulation 2012

Prediction model Estimated 5y survival charts Adjustment

  • Cyanosis
  • NCA

Maximal ex-test

1375 ACHD pts

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SLIDE 26

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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SLIDE 27

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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SLIDE 28

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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SLIDE 29

PROGNOSTIC VALUE OF COMBINATION OF CPET AND NON-EXERCISE PARAMETERS

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SLIDE 30

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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SLIDE 31

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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SLIDE 32

THANK YOU FOR YOUR ATTENTION !

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SLIDE 33

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SLIDE 34

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SLIDE 35

DEEL 1 : INTRODUCTIE TOT CPET DEEL 2 :

PRAKTISCHE APPLICATIE UZG CYCLO-SPIRO PROGRAMMA EN ACHTERGROND INFORMATIE

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SLIDE 36

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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SLIDE 37

Peak VO2 : referentiewaarden

Gewicht, lengte, leeftijd, geslacht

Wasserman et al. Principles of exercise testing and interpretation. Fifth Edition.

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SLIDE 38

4415 ACHD pten 50% literatuur

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SLIDE 39

4415 ACHD pten 50% literatuur

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SLIDE 40

RESPIRATORY EQUIVALENT RATIO (RER)

INDICATOR VOOR MAX INSPANNING ≥ 1.1

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SLIDE 41

METABOLE EQUIVALENTEN (MET)

1 MET = 3.5 ml/kg/min VO2 AANTAL MET = VO2 (ml/kg/min) / 3.5 MET = VO2 in basale omstandigheden (♂ 40 40j j ; ; 70 kg 0 kg)

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SLIDE 42

ZUURSTOFSATURATIE NORMAAL ≥ 95% rust / insp PATHOLOGISCH ↓ > 5%

Pulmonale pathologie / PHT / Congenitaal hartlijden

Guazzi et al. Circulation 2012

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SLIDE 43

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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SLIDE 44

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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SLIDE 45

FEV1 : kijk naar de curve !

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SLIDE 46

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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SLIDE 47

SPIRO RAPPORT

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SLIDE 48

SPIRO RAPPORT

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SLIDE 49

SPIRO RAPPORT

HR/VO2 slope NORMAAL : 3.5 à 4 <2 : sign chronotrope incompetentie Optimalisatie PM rate response

RCP

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SLIDE 50

CARDIOVASCULAIRE VS PULMONALE LIMITERING

Balady et al. Circulation 2010

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