1. Comprehensive
Cardiopulmonary
Exercise Test ( CPET) in
Left Ventricular Assist Device ( LVAD)
“ Before, During & After”
2nd Saudi prevent symposium 26 -27th may 2019 Hilton Jeddah
ASADULLAH KHAN SOOMRO
ADULT CARDIOLOGIST
KING ABDULLAH MEDICAL CITY HOLLY MAKKAH
Email, hssbasadsoomro@gmail.com
2. IntroductionHeart Failure is not a disease itself but a complex and
costly life threatening syndrome with multiple etiologies.
At present ,approximately 60 million worldwide are living
with heart failure.
83 % of HF patients are hospitalized due to an acute HF
episode at least once, and nearly half (43%) are
hospitalized at least four times.
Every year, there are approximately one million
hospitalizations due to HF in the US and Europe, and on
average, a HF patient remains in hospital for 5 to 10 days.
Due to this, heart failure presents a major and growing
health-economic burden that currently costs the world
economy $108 billion every year
3. .
Cont,
The out look for such patients is poor, with survival
rates worse than many cancers.
Furthermore ,heart failure has tremendous impact on
patients, families, caregivers and healthcare system
indeed, and is predicted to increase dramatically over
the next decades to come.
Heart failure is a major public health problem with
high morbidity and mortality, KAMC being a
prestigious advanced heart center and a regional
leader indeed, has decided to initiate a heart failure
program & certification in future to come indeed.
4.
5.
6. KING ABDULLAH MEDICAL CITY
HOLLY MAKKAH
CLINICAL CARE HEART FAILURE
PROGRAME
RAHFC( RAPID ACCESS HEART FAILURE CLINIC )
“Goal is same Day “
One stop fast track heart referral from, PHC/ER to
“Best Care “ when ever and where ever requires.
( Cardio-Oncology & Cardio-obstetric services.
IN PATIENT
HEART FAILURE
CARE
COMMUNITY
HEART FAILURE
CARE
OUT PATIENT
HEART FAILURE
CARE
EMERGENCY
HEART FAILURE
CARE
Regular
Heart Failure
Clinic
Post Discharge &
Heart failure
Rehabilitation
Clinic
Nurse Led
Heart Failure
Clinic
Advanced
Heart Failure
Clinic
4
21
3
7. Advanced Heart Failure Syndrome
Subset of patients may exit the “ heart
failure natural history” after receiving
cardiac transplantation or left ventricular
assist device ( LVAD) placement, this group
currently represent a tiny subset of
heart failure population.
Those who survive require intense resource
utilization and need close follow up at
advanced heart failure clinic .
8.
9. INTERMACS
( Interagency Registry for Mechanically Assisted Circulatory Support)
Advanced heart Failure Profiles
1) Critical Cardiogenic shock. Patients with life threatening hypotension
despite rapidly escalating inotropic support, critical organ hypoperfusion, often
confirmed by worsening acidosis and /or lactate levels ” Crash and burn”.
2) Progressive decline, patient with declining function despite intravenous
inotropic support, may be manifested by worsening renal function, nutritional depletion,
inability to restore volume balance “ Sliding on inotropes”. Also describes
declining status in patients unable to tolerate inotropic therapy.
3) Stable but inotrope-dependent. Patients with stable blood pressure ,organ
function, nutrition, and symptoms on continuous intravenous inotropic support( or a
temporary circulatory support device or both),but demonstrating repeated failure to
wean from support because of recurrent symptomatic hypotension or renal dysfunction
“Dependent stability).
4) Resting Symptoms. Patients can be stabilized close to normal volume status but
experiences daily symptoms of congestion at rest or during activities of daily living. Doses of
diuretics generally fluctuate at very high levels. More intensive management and surveillance
strategies should be considered, which may in some cases reveal poor compliance that would
compromise outcomes with any therapy. Some patients may shuttle between profile 4 & 5.
10. INTERMACS
Advanced heart Failure Profiles
5) Exertion –intolerant. Comfortable at rest and with activities of daily living but
unable to engage in any other activity, living predominantly within the house. Patients are
comfortable at rest without congestive symptoms, but may have underlying refractory
elevated volume status, often with renal dysfunction. If underlying nutritional status and
organ function are marginal, patient may be more at risk than ( INTERMACS) profile 4 and
require definitive intervention.
6) Exertion Limited. Patients without evidence of fluid overload is comfortable at rest
and with activities of daily living and minor activities outside the home but fatigue after few
minutes of any meaningful activity. Attribution to cardiac limitation requires careful
measurement of peak oxygen consumption, in some cases with hemodynamic monitoring to
confirm severity of cardiac impairment “ Walking wounded”.
7) Advanced New York Heart Association Class 111. A placeholder for more
- precise specification in future ,this level includes patients who are without current or recent
episodes of unstable fluid balance ,living comfortably with meaningful activity limited to mild
physical exertion.
( Patients in Profile 4 to 7 having better survival and shorter length of stay post
implantation compared with those in patients in profile 1 to 3)
11. Cardiopulmonary exercise test
Introduction
1) The idea of CPET application in cardiology was
introduced in the early 1980 by Weber, whose work
allowed the landmark classification of patients with
HFrEF based on peak oxygen consumption ( Vo2).
2) In 1991 Mancini demonstrated that Vo2 measured at
peak exercise stratifies the risk of CV death at 1 year
in ambulatory advanced heart failure.
3) In Cardiopulmonary disorders, exercise intolerance is
a major clinical feature at early stages and becomes
a source of symptoms and reason for referral to a
physician.
12. Cardiopulmonary exercise test
“ what is its value” ?
1) What is a cardiopulmonary exercise test?
The Cardio-pulmonary Exercise Test is similar to standard exercise test
other than it is performed on a stationary bike and involves the use of mouth
piece to measure oxygen uptake. As well as diagnosing ischemia (reduced
Oxygen to the heart muscle) and shortness of breath it is a very useful test for
determining the function of the heart and is mostly used for patients with heart
failure and cardiomyopathy.
2) How is a cardiopulmonary exercise test performed?
As with a standard exercise test, small electrodes are first placed
on the chest (ECG). The mouthpiece is then attached and patient
is asked to pedal on the bike at a comfortable pace without any
resistance applied. After the warm up a small amount pedal
resistance is added very gradually at regular intervals throughout
the test ,he is asked to pedal for as long as possible and exercise
will usually last between 5 and 12 minutes
13. Cardiopulmonary exercise test
“ what is its value” ?
Why is a cardiopulmonary exercise test done?
A Cardiopulmonary exercise test is normally requested when a diagnosis of
exercise limitation is unclear or for heart failure/cardiomyopathy patients
in order to determine their exercise capacity.
Can he cope with the exercise required?
As with a standard exercise test just about everyone can cope with a
cardiopulmonary exercise test. The bike makes the test easier than walking
on a treadmill as it is a non-weight bearing activity and only slight increases
in resistance are added. The exercise intensity is increased based on patients
capabilities and at any point he would like to stop he may do so. Patient is
encouraged to do as much as he can as the more he do the more information
physician will get .
Are there any risks involved?
In the vast majority of cases the cardiopulmonary exercise test is carried out
without any problems and the risks are very similar to those of a standard
exercise test. Even when testing patients with a higher risk only 1 in 300
patients had a serious complication in a recent study. Medical help is near to
hand to deal with possible problems.
14.
15. Types of
Cardiopulmonary exercise test
in Comprehensive
cardiac rehabilitation
.
1)
Traditional
( Non
invasive )
CPET
2)
Invasive
CPET
3)
CPET
Imaging
( New
Frontier )
16. Role of Cardiopulmonary exercise test &
Comprehensive cardiac rehabilitation
in Advanced heart Failure with left
ventricular assist device ( LVAD).
1)
Advanced HF
before LVAD
implantation.
a) Diagnostic
( class 11b B)
b) Prognostic
( class 1A )
C) Therapeutic
( class 1A )
2)
CPET &
Cardiac
rehabilitation
after LVAD
implantation
3)
Role of CPET
in LVAD
explantation
17. Application of cardiopulmonary exercise test in
clinical practice, Before LVAD implantation.
Application of CPET provide 3 dimensional views in
heart failure syndromes.
1)Diagnostic role of CPET in Heart
Failure.( Class 11b B )
2)Prognostic Utility of CPET in
Heart Failure.( Class 1 A )
3)Monitoring therapeutic efficacy
with CPET in Heart Failure.( Class 1 A )
18. Application of cardiopulmonary exercise test in
clinical practice, Before LVAD implantation.
Prognostic Utility of CPET in Heart
Failure.( Class 1 A )
Among the extensive list of criteria for determining
Candidates for LVAD & heart transplantation , CPET
variables are recognized to be gold standard in
selection.
In addition to landmark studies ,a continuing wealth of
evidence has fortified the prognostic strength of peak
Vo2,so much so that the international society for heart
lung transplantation provide class 1 recommendation
for inclusion of CPET to guide transplant list with peak
Vo2 < 14ml.kg.min in absence of beta blockers and
peak Vo2 < 12ml.kg.min in presence of beta blockers.
19.
20. Application of cardiopulmonary exercise test in
clinical practice, Before LVAD implantation.
Prognostic Utility of CPET in Heart Failure.( Class 1 A )
Multiparametric color coded CPET tables provide
striking visual clues to facilitate the interpretation of
CPET.
Normal responses are identified in green, whereas
intensifying abnormalties are highlighted in yellow
,orange and red.
Despite the growing body of evidence highlighting
the greater prognostic utility of the VE/Vco2 slope
,current ACC/AHA guidelines recognize peak Vo2 as
sole CEPT outcome for transplant consideration .
21. Role of cardiopulmonary exercise test in cardiac
rehabilitation, in LVAD supported patients.
“ A snapshot from ESC affiliated countries.”
“Extra Heart Failure Survey”
170 HF centers were analyzed from 26 European countries
, 77 LVAD implanting centers participated ,45 ( 58%)
centers had exercise training ( phase 1 to phase 111 )
Cardiac rehabilitation program for LVAD patients.
Most centers 71% have an early ( phase 11, first 2-16
weeks) post discharge .
Research on this new tiny population of HF and exercise
after LVAD implantation is still under development ,however
few small studies have found exercise rehabilitation to be
beneficial for improving patient recovery , but clear
guidelines and evidence of effectiveness is lacking.
22. Role of cardiopulmonary exercise test in cardiac
rehabilitation, in LVAD supported patients.
“ A snapshot from ESC affiliated countries.”
“Extra Heart Failure Survey”
Lack of evidence based guidelines leads to uncertaininty on
optimal timing ,duration and intensity of training protocol
for rehabilitation of LVAD patients.
Most LVAD implanting centers applied aerobic endurance
training at intervals low intensity such as biking, few had
resistance and respiratory muscle training. Its heterogenous
vary from high to low volume centers ,it depends on the
physical condition of every LVAD patients ,which should be
assessed periodically ,like bicycle ergometer
cardiopulmonary exercise test in LVAD patients, is bit
complex because of device parameter changes according to
exercise intensity.
23. “Predicting Success”
LVAD Explantation using cardiopulmonary
exercise testing.
Reports of LVAD explantation rates, because of cardiac
recovery are highly variable ( ranging from 4.5% to 45% )
depending on HF pathogenesis and weaning criteria .
Institution specific LVAD explantation evaluation novel
protocols use various hemodynamic ,imaging and gas
exchange measurements in combination, during state of
rest, LVAD speed reduction ,and exercise to uniquely
characterize cardiac reserve capacity and guide LVAD
explantation decision making.
Because of high rates of HF recurrence after LVAD
explantation one should carefully assess cardiac reserve
capacity before explantation.
24. “Predicting Success”
LVAD Explantation using cardiopulmonary
exercise testing.
LVAD explantation criteria include LVEF > 45%, LVED <
60mm,PAWP < 12mm,cardiac index > 2.8 lit/min /m2,
cardiopulmonary exercise test peak Vo2 > 16ml/kg/min
or VE-VCO2 slope of < 34 .
Novel protocols remain heterogenous across
institutions, the use of peak VO2 in isolation may not
adequately reflect cardiac reserve capacity ,therefore
consideration should be given to include comprehensive
imaging assessment of biventricular performance ,CPET
based hemodynamic and gas exchange parameters to
be a successful candidate of LVAD explantation.
25.
26.
27. Conclusion
Cardiopulmonary exercise test has definitive place in
clinical practice for evaluation of cardiopulmonary
disorders especially in heart failure syndromes.
It provides a thorough assessment of the integrative
multi organ physiological response.
With introduction of invasive CPET and CPET
imaging have extended the amount of
pathophysiological and clinical information and new
insights in systemic and pulmonary hemodynamics.
28. Conclusion
Advanced HF syndrome presents a complex set of
challenges for many stakeholders, including patients
and their families, health care personnels,
pharmaceutical & device industries, researchers and
regulators indeed.
Most of the trials of novel medical therapies have
largely failed to show benefit in patients with
advanced HF syndromes.
Yet, many effective interventions can still be offered
to patients like mechanical circulatory support,
( LVAD) transplant and palliative care.
29. Conclusion
This rapidly changing field requires skill & experience, to
target patients for evaluation at early stage .
Unfortunately many patients are referred to
advanced HF centers too late or not at all .
We need to develop simplified pathway to determine which
patients are eligible for advanced HF therapies, so that the
patients, general cardiologists and advanced HF
centers can work together in determining the optimal
treatment plan.