Adaptive servo ventilation improves cardiac pre and after load in heart failure patients with Cheyne-Stokes respiration Makiko Miyata, Akiomi Yoshihisa, Takamasa Sato, Satoshi Suzuki, Koichi Sugimoto, Hiroyuki Kunii, Kazuhiko Nakazato, Hitoshi Suzuki, Shu-ichi Saitoh, Yasuchika Takeishi Department of Cardiology and Hematology Department of Advanced Cardiac Therapeutics Fukushima Medical University, Japan
Background Benefical effects of non-invasive ventilation in acute heart failure has been recognized. In chronic heart failure (CHF), adaptive servo ventilation (ASV) has been used for CHF with Cheyne-Stokes respiration (CSR). However, its acute effect on LV mechanics still remains unclear. Yoshihisa A, et al. Int Heart J 52: 218-223, 2011 Cul-Lian W, et al. Ann Inter Med. 152: 590-600,2010 Kasai T, et al. Circ Heart Fail. 3:140-8,2010 Phillippe C, et al. HEART 92: 337-342,2006 Arzt M, et al. Circulation 115: 3173-3180,2007 Oldenburg O, et al. Eur J Heart Fail. 10: 581-586,2008
Purpose The aim of this study was to examine acute effects of ASV on LV mechanics in CHF with Cheyne-Stokes respiration by impedance cardiography (ICG).
Methods Hospitalization (ADHF or CHF) Optimize Medication Device therapy Polysomnography CSA-CSR (AHI>15/h, CSA>50%) ASV under ICG monitoring Thirty seven patients with CHF and CSR (mean age 65.1 years, mean ejection fraction 39.5%, mean brain natriuretic peptide (BNP) 544.4 pg/ml, mean apnea hypopnea index (AHI) 38.2 times/hr, mean central apnea index (CAI) 20.4 times/hr) were enrolled in this study. We introduced adaptive servo ventilation (ASV) under Impedance Cardiography (ICG) monitoring for 10 min before, on ASV and after ASV.
Algorithm Pressure (cm H 2 O) 15 8 5 Adaptive servo ventilation Normal breath central apnea PS EEP central apnea hypopnea ASV Device VPAP TM Adavt SV (Resmed/ Fukuda) AutoSet TM CS (Resmed/ Teijin) Setting EEP 5 cm H 2 O Min PS 3 cm H 2 O Max PS 10 cm H 2 O
Impedance Cardiography (ICG) Pre ASV 10 min Post Blood pressure (BP), heart rate (HR), oxygen saturation (SpO2), stroke volume (SV), cardiac output (CO), cardiac index (CI), SVR (systemic vascular resistance), SVRI, TFC (thoracic fluid content) Bio Z
Patient characteristics Age (years) 65.1±13.5 Male (n,%) 27, 73.0 BMI 24.9±4.3 SBP (mmhg) 107.6±23.4 DBP (mmhg) 67.5±14.3 HR (beats/min) 70.6±13.6 Rhythm Sinus (%) 19 (51.4) Atrial fiblitation (%) 18 (48.6) NYHA Functional class (Ⅰ/Ⅱs/Ⅱm/Ⅲ/Ⅳ) (0/6/16/14/1) Etiology Cardiomyopathy (%) 26 (70.3) Ischmic (%) 6 (16.2) Valve (%) 5 (13.5) Device Pacemaker (%) 3 (8.1) ICD (%) 2 (5.4) CRT (%) 12 (32.4)
Blood examination PaCO 2 (mmhg) 36.4 ±4.0 BNP (pg/ml) 544.4 ±625.4 BUN (mg/dl) 22.4 ±9.3 Crea (mg/dl) 1.2 ±0.9 Na (meq/l) 139.5 ±3.1 Estimated GFR (ml/min/1.73m 2 ) 59.9 ±22.5 Hb (g/dl) 12.8 ±2.2 TP (g/dl) 6.8 ±0.9 Alb (g/dl) 3.8 ±0.6 AST (IU/L) 30.5 ±17.9 ALT (IU/L) 27.8 ±18.6 TB (mg/dl) 1.0 ±0.5 DB (mg/dl) 0.2 ±0.2 TG (mg/dl) 108.2 ±54.3 TC (mg/dl) 183.5 ±44.2 LDL (mg/dl) 99.5 ±35.5 HDL (mg/dl) 43.0 ±15.5 HbA1c (%) 5.7 ±0.8
Echocardiography LVEDVI (ml/m 2 ) 82.1 ±31.6 LVESVI (ml/m 2 ) 52.9 ±28.6 EF (%) 39.5 ±15.0 LVMI (g/m 2 ) 157.5 ±55.5 E Dct (msec) 183.4 ±74.5 E/e' 13.1 ±7.2 LAVI (ml/m 2 ) 47.3 ±24.0 RVPS (mmhg) 39.9 ±19.3 LVEDVI, Left ventricular end diastolic volume index; LVESVI, Left ventricular end systolic volume index; EF, Ejection fraction; LVMI, Left ventricular mass index; E Dct, LV inflow E wave deceleration time; LAVI, Left atrial volume index; RVPs, Right ventricular systolic pressure
Polysomnography AHI (times/h) 38.2 ±17.3 CAI (times/h) 20.4 ±13.8 CAI/AHI (%) 53.4 Obstructive apnea index (OAI; times/h) 4.1 ±5.9 Arousal index (times/h) 23.8 ±10.5 3%Oxidative desaturation index (ODI) 25.5 ±17.1 Min SPO 2 (%) 80.1 ±9.8 Mean SPO 2 (%) 95.0 ±2.8 CT 90 (%) 12.2 ±17.1 CT 95 (%) 38.3 ±31.0 Slow wave sleep (SWS; %) 3.3 ±6.1 REM (%) 17.8 ±7.3 Sleep efficacy (SE; %) 63.9 ±13.8
Acute effect of ASV on blood pressure Systolic blood pressure Diastolic blood pressure (mmhg) P<0.05 P<0.05 (mmhg)
Acute effect of ASV on heart rate and SPO 2 (bpm) Heart rate (%) SPO 2 P<0.01
Acute effect of ASV on stroke volume (ml) Stroke volume P<0.01
Acute effect of ASV on cardiac output (ml/min) Cardiac output P<0.01 (ml/min/m 2 ) Cardiac index P<0.05
Acute effect of ASV on vascular resistance Systemic vascular resistance (dyne sec cm- 5 ) (dyne sec cm- 5 /m 2 ) P<0.05 Systemic vascular resistance index P<0.01 P<0.05 P<0.05
Acute effect of ASV on thoracic fluid content Thoracic fluid content P<0.05
Results Stroke volume, cardiac index and SpO2 were significantly increased on ASV. In addition, systemic vascular resistance (SVR) and thoracic fluid content (TFC) were significantly decreased on ASV.
Conclusions We demonstrated that ASV has acute beneficial effects on LV pre and after load.