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Persistent exercise intolerance after pulmonary endarterectomy for CTEPH


Dieuwertje Ruigrok, Lilian J. Meijboom, Esther J. Nossent, Anco Boonstra, Natalia J. Braams, Jessie van Wezenbeek, Frances S. de Man, J. Tim Marcus, Anton Vonk Noordegraaf, Petr Symersky, Harm-Jan Bogaard

European Respiratory Journal 2020; DOI: 10.1183/13993003.00109-2020

Abstract

Aim Hemodynamic normalisation is the ultimate goal of pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). However, whether normalisation of hemodynamics 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) hemodynamics, and search for preoperative predictors of exercise intolerance after PEA.

Methods According to clinical protocol all patients underwent cardiopulmonary exercise testing (CPET), right heart catheterisation (RHC) and cardiac magnetic resonance (CMR) imaging before and 6 months after PEA. Exercise intolerance was defined as a peak VO2<80% predicted. CPET parameters were judged to determine the cause of exercise limitation. Relationships were analysed between exercise intolerance and resting hemodynamics and CMR-derived right ventricular (RV) function. Potential preoperative predictors of exercise intolerance were analysed using logistic regression analysis.

Results 68 patients were included in the final analysis. 45 patients (66%) had exercise intolerance 6 months after PEA; in 20 patients this was primarily caused by a cardiovascular limitation. The incidence of residual PH 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 PH. In the multivariate analysis, preoperative transfer factor for carbon monoxide (TLCO) was the only predictor of exercise intolerance after PEA.

Conclusions The majority of CTEPH patients has exercise intolerance after PEA, often despite normalisation of resting hemodynamics. Not all exercise intolerance after PEA is explained by the presence of residual PH, and lower preoperative TLCO was a strong predictor of exercise intolerance 6 months after PEA.

Footnotes

This manuscript has recently been accepted for publication in the European Respiratory Journal. It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article.

Conflict of interest: Dr. Ruigrok has nothing to disclose.

Conflict of interest: Dr. Meijboom has nothing to disclose.

Conflict of interest: Dr. Nossent has nothing to disclose.

Conflict of interest: Dr. Boonstra has nothing to disclose.

Conflict of interest: Dr. Braams has nothing to disclose.

Conflict of interest: Dr. van Wezenbeek has nothing to disclose.

Conflict of interest: Dr. de Man has nothing to disclose.

Conflict of interest: Dr. Marcus has nothing to disclose.

Conflict of interest: Dr. Vonk Noordegraaf reports grants from Actelion, grants from GSK, grants from Pfizer, grants from Bayer, outside the submitted work.

Conflict of interest: Dr. Symersky has nothing to disclose.

Conflict of interest: Dr. Bogaard reports grants from Actelion, grants from GSK, grants from Pfizer, grants from Bayer, grants from Therabel, outside the submitted work.

  • Received January 18, 2020.
  • Accepted March 9, 2020.
  • Copyright ©ERS 2020

sumber : https://erj.ersjournals.com/content/early/2020/03/12/13993003.00109-2020

 
 

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