CTED and the Value of Exercise Testing

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2 CTED and the Value of Exercise Testing leveraging cardiopulmonary physiology to uncover a disease even more elusive than CTEPH Paul Forfia, MD Professor of Medicine Director, PH, RHF, and PTE Programs Temple University Hospital Philadelphia, PA 10:40-11:00 am

3 CTEPH D CTEPH but without the PH Partial or complete obstruction of pulmonary vascular segments does NOT always mean you will have PH. PV obstruction in areas of normal ventilation will lead to dead space ventilation (V/Q>>1) which contributes to dyspnea, hypoxia. (Paulie F s criteria) for CTED: 1. Symptomatic patient 2. Lung imaging with chronic PE 3. No resting PH 4. Objective demonstration of disease within the pulmonary circulation: A. exercise PH B. evidence of ventilatory inefficiency/increased dead space ventilation.

4 Question 1 Which patient is more short of breath in the setting of large segmental perfusion defects in the right lung? A. PAP 70/30, PVR 8, CI 2.2 B. PAP 50/25, PVR 5, CI 2.6 C. PAP 30/12, PVR 2.5, CI 2.4 D. You cannot tell

5 Which VQ and CTA images are CTED versus CTEPH? A. B.

6 Surely you can match the VQ and CTA to the hemodynamics? PAP 70/30, PVR 8, CI 2.0 PAP 50/25, PVR 5, CI 2.6? PAP 30/12, PVR 2.5, CI 2.8 Surely you CANNOT predict the hemodynamics associated with the imaging And stop calling me Shirley

7 History of prior PE (DVT) No history of prior PE (DVT) Dyspnea Echocardiogram Significant PH is obvious Suspect CTEPH VQ scan PH not obvious Undifferentiated dyspnea Abnormal RVOT Doppler CTEPH Suspect (mild) CTEPH or CTED VQ scan

8 So ya do the VQ

9 and the RHC Patient A Patient B (Paulie F s criteria) for CTED: RA 5 RA 2 PA 40/15 (23) PA 15/10 WP 8 WP 5 CO 5 CO 5 PVR 3 PVR Symptomatic patient 2. Lung imaging with chronic PE 3. No resting PH 4. Objective demonstration of disease within the pulmonary circulation: A. exercise PH B. evidence of ventilatory inefficiency /increased dead space ventilation. hint, one person s CTED may be a little more obvious than the other

10 Exercise Cath No! Graded exercise Quantifiable Controlled practical Yes

11 VE/VCO 2 -a physiologic signature of pulmonary vascular disease

12 Hybrid method 1 Standard RHC rest Graded cycle ergometer exercise Example: supine ergometer, 5 Watt per minute ramp (40-60 rpm) Submaximal but significant exercise *Most patients cannot exceed 50 Watts *A good marker is an SVO2 of <40% Rest PH CTEPH Rest RHC No rest PH Method 1 Ex RHC Repeat pressure measures at peak + TD CO at rest TD CO at peak Noninvasive CPET TM Bike VE/VCO2 >34 ETCO2 < 30

13 Hybrid method 2 (Fick) Standard RHC rest Graded cycle ergometer exercise Example: supine ergometer, 5 Watt per minute ramp(40-60 rpm) Submaximal but significant exercise Most patients cannot exceed 50 Watts A good marker is an SVO2 of <40% Repeat pressure measures at peak Fick CO at rest Fick CO at peak Exercise plus direct VO2 for Fick CO measurement

14 Rest RHC Rest PH CTEPH No rest PH Method 2 Ex RHC + Noninvasive CPET TM Bike VE/VCO2 >34 ETCO2 < 30

15 Method 3 (the invasive CPET) Standard RHC rest Graded cycle ergometer exercise Example: supine ergometer, 5 Watt per minute ramp (RPM 40-60) Submaximal but significant exercise Most patients cannot exceed 50 Watts A good marker is an SVO2 of <40% RER > 1.0 Repeat pressures at peak Fick CO at rest Exercise plus full gas exchange assessment for CO, and VI measures Fick CO at peak Incorporation of VE/VCO2, ETCO2, Gas exchange variables into hemodynamic assessment.

16 Method 3 (the invasive CPET)-one stop shopping Case example 19 yo woman. College student. Picture of health. Progressive dyspnea. Normal exam. Normal ECG. Normal spirometry. Echo shows normal RV size, function. No PH. History of PE 18 months prior. Prior history of OC use.

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18 No notch but, look at the shape again. Still not normal

19 RHC data: PA 35/13 (21) RA 6 WP 11 CI 2.3 PVR 2.2 This may be CTED Let s exercise

20 5 Watt/minute ramp Exercise to RER 1.0 or more (possible in vast majority) SVO2 < 40% Recording real time gas exchange Parameters -VO2 -VE -VE/VCO2 -ETCO2

21 REST EXERCISE RA 6 PA 35/13 (21) PAWP 8 CO 5 CI 2.3 PVR 2.2 RA 10 PA 60/25 (37) PAWP 8 CO 8 CI 4.0 PVR 3.6

22 Gas exchange testing the key is ventilatory inefficiency. Look for the dead space! +/- Blunted rise in O2 pulse ***High VE/VCO2 Lack of fall in VD/Vt Desaturation

23 Ramped cycle ergometer protocol (during cath) with CPET 5 Watt/minute ramp Exercised to near maximal SVO2 down to 35% VO2 15 ml O2/kg/min (55% max) *****VE/VCO2 50 (marked ventilatory inefficiency)

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25 What is NOT CTED (one example) REST RA 6 EXERCISE RA 8 ETCO X X X X X X X X X X X X PA 40/15 (23) PAWP 14 CO 5 PA 60/27 (39) PAWP 23 CO CI 1.9 PVR 2.2 CI 5 PVR 1.6 VE/VCO X X X X X X X X X X X X REST EXERCISE

26 CTED 1. Symptomatic patient 2. Lung imaging with chronic PE 3. No resting PH 4. Objective demonstration of disease within the pulmonary circulation: A. exercise PH B. evidence of ventilatory inefficiency/increased dead space ventilation. *CTED Type 1: CTED with exercise PH and VI CTED Type 2: CTED without exercise PH, but with VI

27 Summary CTED is CTEPH but without the PH CTED requires: 1. chronic pulmonary vascular obstruction 2. 1 of 2 demonstrations of abnormal pulmonary vascular function -exercise PH -ventilatory inefficiency (VI) Both exercise PH and evidence of VI require exercise Methods 1 and 2: Exercise CATH + noninvasive CPET Method 3: combines exercise CATH + CPET (invasive CPET) Not all exercise PH is someone with chronic PE is CTED

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