Persistent exercise limitation after successful pulmonary endoarterectomy: frequency and determinants

Corsico, Angelo Guido; D’Armini, Andrea Maria; Conio, Valentina; Sciortino, Antonio; Pin, Maurizio; Grazioli, Valentina; Vincenzo, Giulia Di; Domenica, Rita Di; Celentano, A.; Vanini, Benedetta; Grosso, Amelia; Gini, Erica; Albicini, Federica; Merli, Vera N.; Ronzoni, Vanessa; Ghio, Stefano; Klersy, Catherine; Cerveri, Isa

doi:10.1186/s12931-019-1002-5

Cited by 9 publications

(7 citation statements)

References 19 publications

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“…Chronic thromboembolic pulmonary hypertension patients treated with PEA had a worsened lung diffusion capacity, while patients with CTEPH treated with BPA had an improved lung ventilation. Previous studies have revealed that the lung diffusion capacity in CTEPH patients decreased in the short term (3 weeks) after PEA ( 14 ), and could persist for more than 1 year ( 31 ), which were consistent with our study ( Table 2 ). Compared with the deterioration of the lung diffusion capacity in CTEPH patients treated with PEA, the impaired lung diffusion capacity was not changed ( P = 0.679, Supplementary Table 1 ) in CTEPH patients treated with BPA in both our study and previous studies ( 26 , 32 ).…”

Section: Discussionsupporting

confidence: 93%

Different response of the oxygen pathway in patients with chronic thromboembolic pulmonary hypertension treated with pulmonary endarterectomy versus balloon pulmonary angioplasty

Tao

Xie

et al. 2022

Front. Cardiovasc. Med.

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BackgroundOxygen pathway limitation exists in chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary endarterectomy (PEA) and balloon pulmonary angioplasty (BPA) are two effective interventions for CTEPH, but their effects and comparison of these two interventions on the oxygen pathway are not well demonstrated.MethodsCTEPH patients with available pulmonary function test, hemodynamics, and blood gas analysis before and after the interventions were included for comparison of oxygen pathway in terms of lung ventilation, lung gas exchange, oxygen delivery, and oxygen extraction between these two interventions.ResultsThe change in the percentage of the predicted forced expiratory volume in the 1 s (−3.4 ± 12.7 vs. 3.8 ± 8.7%, P = 0.006) and forced vital capacity (−5.5 ± 13.0 vs. 4.2 ± 9.9%, P = 0.001) among the PEA group (n = 24) and BPA group (n = 46) were significantly different. Patients in the PEA group had a significant increase in their arterial oxygen saturation (from 92.5 ± 3.6 to 94.6 ± 2.4%, P = 0.022), while those in the BPA group had no change, which could be explained by a significant improvement in ventilation/perfusion (−0.48 ± 0.53 vs. −0.17 ± 0.41, P = 0.016). Compared with patients post-BPA, patients post-PEA were characterized by higher oxygen delivery (756.3 ± 229.1 vs. 628.8 ± 188.5 ml/min, P = 0.016) and higher oxygen extraction (203.3 ± 64.8 vs. 151.2 ± 31.9 ml/min, P = 0.001).ConclusionPartial amelioration of the oxygen pathway limitations could be achieved in CTEPH patients treated with PEA and BPA. CTEPH patients post-PEA had better performance in lung gas exchange, oxygen delivery, and extraction, while those post-BPA had better lung ventilation. Cardiopulmonary rehabilitation may assist in improving the impairment of the oxygen pathway.

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Section: Discussionsupporting

confidence: 93%

Different response of the oxygen pathway in patients with chronic thromboembolic pulmonary hypertension treated with pulmonary endarterectomy versus balloon pulmonary angioplasty

Tao

Xie

et al. 2022

Front. Cardiovasc. Med.

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“…More consistent correlations were reported between exercise parameters and pulmonary arterial compliance [26,27]. In a recent study, 41% of patients were reported to have persistent exercise limitation 12 months after PEA, as defined by a distance walked <400 m in a modified Bruce protocol [28]. However, the cut-off of 400 m was somewhat arbitrary, and based on the median distance walked in their previous analysis [29].…”

Section: Discussionmentioning

confidence: 85%

Persistent exercise intolerance after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension

et al. 2020

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AimHaemodynamic normalisation is the ultimate goal of pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). However, whether normalisation of haemodynamics translates into normalisation of exercise capacity is unknown. The incidence, determinants and clinical implications of exercise intolerance after PEA are unknown. We performed a prospective analysis to determine the incidence of exercise intolerance after PEA, assess the relationship between exercise capacity and (resting) haemodynamics and search for preoperative predictors of exercise intolerance after PEA.MethodsAccording to clinical protocol all patients underwent cardiopulmonary exercise testing (CPET), right heart catheterisation and cardiac magnetic resonance (CMR) imaging before and 6 months after PEA. Exercise intolerance was defined as a peak oxygen consumption (V′O2) <80% predicted. CPET parameters were judged to determine the cause of exercise limitation. Relationships were analysed between exercise intolerance and resting haemodynamics and CMR-derived right ventricular function. Potential preoperative predictors of exercise intolerance were analysed using logistic regression analysis.Results68 patients were included in the final analysis. 45 (66%) patients had exercise intolerance 6 months after PEA; in 20 patients this was primarily caused by a cardiovascular limitation. The incidence of residual pulmonary hypertension was significantly higher in patients with persistent exercise intolerance (p=0.001). However, 27 out of 45 patients with persistent exercise intolerance had no residual pulmonary hypertension. In the multivariate analysis, preoperative transfer factor of the lung for carbon monoxide (TLCO) was the only predictor of exercise intolerance after PEA.ConclusionsThe majority of CTEPH patients have exercise intolerance after PEA, often despite normalisation of resting haemodynamics. Not all exercise intolerance after PEA is explained by the presence of residual pulmonary hypertension, and lower preoperative TLCO was a strong predictor of exercise intolerance 6 months after PEA.

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“…Furthermore, autonomic balance [24, 25] and endothelial [26] and skeletal muscle function [27] can be improved by increasing oxygen delivery and by reversing both systemic and local inflammatory processes. Therefore, exercise training may be a useful add-on therapy to PEA to also further improve those exercise-limiting factors which persist even after the normalisation of haemodynamics, as described by Corsico et al [10] in up to 40% of patients. Specialised rehabilitation programs have also shown to significantly improved exercise capacity in other conditions post-surgery, such as after heart transplantation [28].…”

Section: Discussionmentioning

confidence: 99%

“…A recent study of 251 CTEPH patients with follow-up until 12 months after PEA showed a persistent exercise limitation in almost 40% of patients despite normalisation of PVR and haemodynamics [10]. This limitation was characterised by a multifactorial aetiology also involving respiratory function abnormalities.…”

Section: Introductionmentioning

confidence: 99%

Supervised Exercise Training in Patients with Chronic Thromboembolic Pulmonary Hypertension as Early Follow-Up Treatment after Pulmonary Endarterectomy: A Prospective Cohort Study

et al. 2020

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Background: Data on exercise training in chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary endarterectomy (PEA) as well as data on clinical and haemodynamic changes shortly after PEA are lacking. Objective: The objective of this prospective study was to analyse the safety, feasibility, and the effectiveness of combined supervised inpatient rehabilitation in patients with CTEPH directly after PEA. Methods: CTEPH patients started a 19-week rehabilitation program (3 weeks as inpatients and continued at home for another 16 weeks) with supervised exercise training as follow-up treatment shortly after PEA. Haemodynamics were assessed by right heart catheterisation before PEA and 22 weeks after PEA. Non-invasive assessments as trans-thoracic echocardiography and 6-min walking distance (6MWD) were performed before PEA and after 3 (that is, beginning of rehabilitation), 6, and 22 weeks following PEA. Adverse events were recorded throughout the study. Results: Forty-five CTEPH patients were included (49% female, 57.6 ± 12.4 years old, 60% WHO functional class III). Rehabilitation was started 3.3 ± 0.9 weeks after PEA. Exercise training was well tolerated in all patients without severe side effects. Haemodynamics measured by right heart catheterisation significantly improved from pre-PEA to 22 weeks post-PEA in cardiac output (+1.2 ± 1.5 L/min, 33.4%, p = 0.001) and mean pulmonary arterial pressure (-19 ± 13 mm Hg,-39.6%, p < 0.0001). Right heart size measured by echocardiography, 6MWD, quality of life, and oxygen saturation significantly improved not only within the first 3 weeks after PEA but also during the following 19 weeks of exercise training. Conclusions: Supervised exercise training was feasible as early follow-up treatment after PEA. Further controlled studies are needed to discriminate the effects of PEA and early followup rehabilitation. Trial Registration: The study was regis-Nagel et al.

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Persistent exercise limitation after successful pulmonary endoarterectomy: frequency and determinants

Cited by 9 publications

References 19 publications

Different response of the oxygen pathway in patients with chronic thromboembolic pulmonary hypertension treated with pulmonary endarterectomy versus balloon pulmonary angioplasty

Different response of the oxygen pathway in patients with chronic thromboembolic pulmonary hypertension treated with pulmonary endarterectomy versus balloon pulmonary angioplasty

Persistent exercise intolerance after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension

Supervised Exercise Training in Patients with Chronic Thromboembolic Pulmonary Hypertension as Early Follow-Up Treatment after Pulmonary Endarterectomy: A Prospective Cohort Study

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