Protocol for Exercise Hemodynamic Assessment: Performing an Invasive Cardiopulmonary Exercise Test in Clinical Practice

Abstract

Invasive cardiopulmonary exercise testing (iCPET) combines full central hemodynamic assessment with continuous measurements of pulmonary gas exchange and ventilation to help in understanding the pathophysiology underpinning unexplained exertional intolerance. There is increasing evidence to support the use of iCPET as a key methodology for diagnosing heart failure with preserved ejection fraction and exercise-induced pulmonary hypertension as occult causes of exercise limitation, but there is little information available outlining the methodology to use this diagnostic test in clinical practice. To bridge this knowledge gap, the operational protocol for iCPET at our institution is discussed in detail. In turn, a standardized iCPET protocol may provide a common framework to describe the evolving understanding of mechanism(s) that limit exercise capacity and to facilitate research efforts to define novel treatments in these patients.

Rest and exercise hemodynamic and metabolic findings in active duty soldiers referred for cardiac catheterization to exclude heart disease: Insights from past invasive cardiopulmonary exercise testing using multisensor high fidelity catheters

“…This may also be related to the difference in workloads between studies. Far greater decreases in PVR are expected with maximal exercise .…”

“…Although this retrospective review of cardiac catheterization records from a young military population is unique and provides hemodynamic recordings superior to present day fluid‐filled catheter systems, the metabolic data were obtained primarily for the Fick determination of cardiac output and not for delineating the spectrum of cardiopulmonary diseases or the subtle early changes in disease process that are targeted by modern invasive CPET . While treadmill stress tests were routinely performed prior to cardiac catheterization in our patients, the test results were not available and their functional aerobic capacity was unknown for this review.…”

“…Dynamic assessments using fluid challenges, vasoactive medications, or exercise have become common in the evaluation of pulmonary hypertension, heart failure with preserved ejection fraction, and valvular heart disease . Coupling direct hemodynamic measurements with metabolic gas exchange has also emerged as a definitive method to investigate unexplained exercise intolerance . There are, however, few studies that provide normal reference values for simultaneous metabolic and left and right heart hemodynamic measurements.…”

Accuracy of Echocardiography to Estimate Pulmonary Artery Pressures With Exercise

“…The test consisted of concomitant invasive hemodynamic and echocardiographic evaluation at rest and during exercise in the upright position as previously described 24 . Patients in whom tricuspid regurgitation spectral Doppler signal (TR) was not available at rest and peak exercise (either due to not being assessed or not detectable) were excluded.…”

Development of a Right Ventricular Outflow Tract Gradient During Upright Exercise

“…Testing was performed as previously described (2). RVOT gradient was calculated as the difference between simultaneously transduced RV and PA systolic pressures.…”