Influence of impaired right ventricular contractile reserve on exercise capacity in patients with precapillary pulmonary hypertension: A study with exercise stress echocardiography

Abstract

Objectives Right ventricular (RV) contractile reserve reflects the ability of RV to accommodate the increased afterload and may play an essential role in the evaluation of precapillary pulmonary hypertension (PH). This study aimed to assess RV contractile reserve based on exercise stress echocardiography (ESE) and to determine the echocardiographic determinants of exercise capacity in patients with precapillary PH. Methods A total of 31 patients with precapillary PH and 15 age‐ and sex‐matched healthy control subjects were prospectively recruited. All subjects underwent ESE to assess RV function at rest and under peak exercise. Changes in these parameters during exercise were calculated to quantify the RV contractile reserve. Patients with precapillary PH also underwent cardiopulmonary exercise test (CPET), and data pertaining to peak oxygen uptake (peak VO2) and minute ventilation/carbon dioxide production (VE/VCO2) were collected. Results Right ventricular contractile reserve including change in tricuspid annular plane systolic excursion (∆TAPSE), change in RV fractional area change (∆RVFAC), and change in Doppler‐derived tricuspid lateral annular peak systolic velocity (∆S′) was significantly depressed in precapillary PH patients compared with control subjects (P < 0.05). Parameters of RV function and RV contractile reserve were markedly associated with maximal exercise capacity (P < 0.05). ∆RVFAC was an independent predictor of peak VO2 (r2 = 0.601, P < 0.05). Conclusions Assessment of RV contractile reserve facilitates identification of subclinical dysfunction and evaluation of clinical status and severity of precapillary PH. ESE as a noninvasive method may provide a comprehensive clinical assessment and facilitate therapeutic decision‐making for these patients.

Systolic and diastolic functional reserve of the subpulmonary and systemic right ventricles as assessed by pharmacologic and exercise stress: A systematic review

“…Of the 913 records initially identified, 56 23–78 studies with a total of 1730 patients were included in the qualitative synthesis (Figure 1). Of these 56 studies, 23 23–45 studied subpulmonary RV reserve in patients with repaired TOF, 19 46–64 assessed systemic RV reserve, and 14 65–78 assessed subpulmonary RV reserve with or without RV‐pulmonary arterial coupling in patients with PAH.…”

“…Pharmacologic stress with continuous infusion of incremental dose of dobutamine was employed in 22 studies 23–33,46–52,65–68 . On the other hand, exercise stress with either bicycle 34–45,53–64,69–76 or treadmill exercise testing 77,78 was used in 34 studies.…”

“…The following echocardiographic parameters had been used to assess RV functional reserve: (i) 2‐dimensional echocardiography based‐parameters including RV fractional area change (FAC), ejection fraction (EF), and stroke volume (SV), 23,24,36,55,67,70,71,77 (ii) M‐mode derived ventricular diameters, 55 tricuspid annular peak systolic excursion (TAPSE) 36–38,40,46,55,65–67,70,71,77 and fractional shortening of the RV outflow tract, 37 (iii) conventional Doppler‐derived RV dP/dt, 24,34,35 RV systolic pressure, 34–36 and myocardial performance index, 71 (iv) tissue Doppler‐derived tricuspid annular isovolumic acceleration (IVA) 37 and peak systolic ( s ), early ( e ) and late ( a ) diastolic myocardial velocities, 24,25,34,35,37,39,40,46,47,53,55,65,66,71,77 and (v) speckle tracking‐derived RV strain 39,40,53,55 and strain rates 53 . Cardiac magnetic resonance was used to measure RV volumes, 26–28,30,31,41,43,48–52,54,56,58,59,68,72 FAC, 42 EF, 27,30–33,41,43,48–52,56,59,68,72 cardiac index, 27,29,42,49,51,58,68 wall thickening and motion, 57 and RNA had been used to quantify RV EF 60–64,78 .…”

Right Heart Size and Right Ventricular Reserve in Pulmonary Hypertension: Impact on Management and Prognosis

“…Compared with controls, pulmonary hypertension and PAH patients presented with a significantly lower combined change in tricuspid annular plane systolic excursion (∆TAPSE), change in RV fractional area change (∆RVFAC), and change in Doppler-derived tricuspid lateral annular peak systolic velocity (∆S') [33,34]. RV function and RV output reserve showed to be associated with maximal exercise capacity [33].…”

“…Noninvasive approaches to estimate RV output reserve include change of systolic pulmonary arterial pressure during exercise [32] and a combination of echocardiographic parameters including change in tricuspid annular plane systolic excursion (∆TAPSE), change in RV fractional area change (∆RVFAC), and change in Doppler-derived tricuspid lateral annular peak systolic velocity (∆S') [33,34]. The idea behind this concept is, that patients with low cardiac output increase during exercise cannot increase their systolic pulmonary arterial pressure.…”