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Improvement of Cardiopulmonary Exercise Capacity
after Pulmonary Valve Replacement
and its Predictors in Patients with Pulmonary
Regurgitation after Repair of Tetralogy of Fallot
Yu Rim Shin, Hong Ju Shin, Jong Gun Kim, Young-Hwan Park, Han Ki Park
Department of Cardiovascular Surgery
Severance Cardiovascular Hospital
Yonsei University College of Medicine
Seoul, Republic of Korea
Disclosures
 The authors have nothing to disclose.
Repaired TOF
Chronic Pulmonary Regurgitation
Progressive
RV Dilatation
Exercise Intolerance
Controversial Reports on Exercise Performance
2000 Eyskens et al., Am J Cardiol
 Improvement of cardiorespiratory exercise performance
after PVR, but no correlation between RV function and
exercise performance
2007 Meadows et al., Am J Cardiol
 Oxygen consumption was correlated with RV ejection
fraction, but not with RV volume.
2012 O’Meagher et al., Heart
 Preservation of exercise capacity in repaired TOF
patients and no correlation between RV volume and
exercise capacity
Purpose of the study
To evaluate changes of exercise capacity and
their associations with preoperative
parameters in patients undergoing PVR
Cardiopulmonary Exercise Testing (CPET)
• Objective tool for assessing
exercise capacity
• Symptoms of exercise intolerance
are often preceded by impairment
of CPET results.
2014 Babu-Narayan et al, Circulation
• A potential tool for determining the
optimal timing of PVR
Severance Cardiovascular Hospital
CPET lab
Patients and Methods
 June 2005 – August 2013
 Patients selection
 Surgical PVR for chronic PR after TOF repair
 Cardiopulmonary exercise test & cardiac MRI
preoperatively and 1 year postoperatively
 Patients who had significant residual intra-cardiac
shunt were excluded.
 Retrospective review
Assessment Protocols
at Severance CV Hospital
 Echocardiography
 Holter monitoring
 Cardiopulmonary exercise testing (CPET)
 Peak VO2 (absolute, %), VE/VCO2 slope, HR reserve
 Cardiac MRI
 RV & LV volume, function, flow
 Preoperative evaluation, postoperative follow-up at 1 year,
and serial follow-up as indicated
Patients and Methods
Outcome analysis
1. Comparison of preoperative & postoperative
exercise capacity
2. Correlation analysis of exercise capacity and
associated factors
3. Risk factor analysis for improvement of exercise
capacity
- Improvement of exercise capacity was defined as
increase in peak VO2 > 10% of its preoperative
value
Results
2005-2013
185 PVRs
in repaired TOF
CPET
MRI
Preop. / 1 yr postop.
N = 40
Results
Preoperative variables
M:F
15 (38%) : 25 (62%)
Age at TOF repair, years
3.1 ± 4.5
Age at PVR, years
20.9 ± 7.9
Op. interval, years
18 ± 5.9
Body weight at PVR, kg
54 ± 13
Body surface area at PVR, m2
1.6 ± 0.22
QRS duration msec
150 ± 30
Arrhythmia
Atrial flutter/fibrillation
Frequent PVCs
4 (10%)
3 (7%)
1 (3%)
NYHA functional class
I
II
III or IV
32 (80%)
8 (20%)
0
Results
Preoperative echocardiography
RVEDD, mm
50 ± 7
RVESD, mm
36 ± 6
LVEDD, mm
41 ± 6
LVEF, %
61 ± 9
TR moderate, n
6 (15%)
Results
Operative data
Valve type, n
Tissue valve
Mechanical valve
Homograft
Valve size, median (range)
37 (93%)
2 (5%)
1 (2%)
25 (21 – 27)
Concomitant procedure, n
PA angioplasty
TV repair
Maze procedure
5 (13%)
1 (3%)
1 (3%)
1. Preop. and Postop. Comparisons
Cardiac MRI after PVR
ml/m2
200
160
%
p < 0.01
65
173
61
p < 0.01
120
57
111
80
p < 0.01
53
90
52
54
40
49
49
Preoperative
Postoperative
0
45
RVEDVI
RVESVI
ml/m2
RVEF
%
200
65
p = 0.85
160
120
80
61
p < 0.01
81
89
57
p = 0.06
40
59
53
49
34
Preoperative
Postoperative
59
37
0
45
LVEDVI
LVESVI
LVEF
1. Preop. and Postop. Comparisons
Cardiopulmonary Exercise Performance
Preop.
Postop.
p - value
28.9 ± 5.8
30.0 ± 6.4
0.16
% predicted peak VO2, %
61 ± 10
66 ± 11
0.03
VE/VCO2 slope
31 ± 7
28 ± 3
0.02
HR reserve, bpm
93 ± 23
94 ± 14
0.86
1.12 ± 0.11
1.13 ± 0.09
0.32
Peak VO2, ml/min
RER
2. Correlation Analysis
• Demographic Data
• Age at TOF repair & PVR, BW,
BSA
CPET
• Preop. and Postop.
• Peak VO2
• VE/VCO2 slope
• Heart rate reserve
• Preoperative Clinical Characteristics
• Functional class
• Echocardiographic parameters
• RV dimension, EF
• LV dimension, EF
• TR
• MRI parameters
• RVEDVI, RVESVI
• LVEDVI, LVESI
• RV & LV EF
• PR regurgitant fraction
2. Correlation Analysis
Preoperative Exercise Capacity and RV volume
2. Correlation Analysis
Postoperative Exercise Capacity and Preoperative RV volume
3. Risk Factor Analysis
Univariate Analysis for Improvement in Exercise Capacity
 Defined as an increase in peak VO2 > 10% of its preoperative value
22 patients with improvement vs. 18 patients without improvement
Odds ratio
95% CI
p - value
Age at TOF repair
1.00
0.995 – 1.008
0.64
Age at PVR
0.99
0.986 – 1.007
0.51
Valve size
0.83
0.465 – 1.485
0.83
Preop. RVEDVI
0.99
0.971 – 1.010
0.34
Preop. RVEDVI > 160 ml/m2
0.10
0.014 – 0.838
0.03
Study Limitations
 Retrospective design with a small number of patients
 Change of indications for PVR during the study period
 Arbitrarily defined ‘improvement in exercise capacity’ and
‘cutoff value of RVEDVI’
Conclusions
• The exercise capacity of patients undergoing PVR is
lower than that in normal individuals.
• Exercise capacity improves after PVR.
• Preoperative and postoperative exercise capacity show
an inverse correlation with preoperative RV volume.
• In patients with larger RVEDVI of more than 160 ml/m2,
change in exercise capacity is less likely.
• Timely operation before severe dilation of the RV may
be important in terms of exercise performance.
Patients and Methods
Assessment Protocol
 Cardiopulmonary exercise testing (CPET):
 Modified Bruce protocol
 Cardiac MRI
 Using 1.5-T MR scanner
 Measurement of ventricular volume, function and flow
Retrospective analysis
 Improvement of exercise capacity was defined as
 Increase in peak VO2 > 10% of its preoperative value
Cardiac MRI
Preop.
Postop.
P-value
RVEDV, ml
251 ± 97
170 ± 63
< 0.01
RVESV, ml
130 ± 63
84 ± 37
< 0.01
RVEDVI, ml/m2
173 ± 35
111 ± 18
< 0.01
RVESVI, ml/m2
90 ± 31
54 ± 16
< 0.01
LVEDVI, ml/m2
81 ± 14
89 ± 14
< 0.01
LVESVI, ml/m2
34 ± 10
37 ± 11
0.06
LVEF, %
59 ± 7
59 ± 6
0.85
RVEF, %
49 ± 9
52 ± 8
< 0.01
RV volume and function
200
P < 0.01
53
P < 0.01
P < 0.01
52
160
51
120
50
80
173
49
40
48
Preoperative
Postoperative
111
0
90
54
47
RVEDVI
RVESVI
49
52
RVEF
RVEDV
RVEDVI
RVESD
RVESDI
RVEF
Preoperative
251 ± 97
173 ± 35
130 ± 63
90 ± 31
49 ± 9
Postoperative
170 ± 63
111 ± 18
84 ± 37
54 ± 16
52 ± 8
< 0.01
< 0.01
< 0.01
< 0.01
< 0.01
P-value
RV volume and function
200
160
p < 0.01
65
173
p < 0.01
61
p < 0.01
120
57
111
80
53
90
52
54
40
49
49
Preoperative
Postoperative
0
45
RVEDVI
RVESVI
RVEF
RVEDV
RVEDVI
RVESD
RVESDI
RVEF
Preoperative
251 ± 97
173 ± 35
130 ± 63
90 ± 31
49 ± 9
Postoperative
170 ± 63
111 ± 18
84 ± 37
54 ± 16
52 ± 8
< 0.01
< 0.01
< 0.01
< 0.01
< 0.01
P-value
LV volume and function
100
P < 0.01
61
P = 0.06
P = 0.85
60
80
59
60
58
40
57
20
Preoperative
Postoperative
0
56
81
Postoperative
P-value
34
37
55
LVEDVI
LVEDV
Preoperative
89
LVEDVI
LVESVI
LVESD
59
59
LVEF
LVESDI
LVEF
LV volume and function
200
61
120
57
80
53
40
49
0
81
Postoperative
P-value
89
34
37
45
LVEDVI
LVEDV
Preoperative
65
P = 0.06
160
Preoperative
Postoperative
P < 0.01
LVEDVI
LVESVI
LVESD
P = 0.85
59
59
LVEF
LVESDI
LVEF
LV volume and function
200
65
p = 0.85
160
120
80
61
p < 0.01
81
89
57
p = 0.06
49
34
Preoperative
Postoperative
P-value
37
0
45
LVEDVI
LVEDV
Preoperative
59
53
40
Postoperative
59
LVEDVI
LVESVI
LVESD
LVEF
LVESDI
LVEF
Cardiac MRI after PVR
Patients and Methods
 June 2005 – August 2013
 Patients who underwent surgical PVR
after TOF repair
 Inclusion criteria
 Patients who underwent:
 Cardiopulmonary exercise test and cardiac magnetic
resonance imaging (cMRI)
 Preoperatively and 1 year postoperatively
Patients and Methods
 Exclusion criteria
 Significant right ventricular outflow tract stenosis
 Significant residual intra-cardiac shunt
 Retrospective analysis
 Improvement of exercise capacity was defined as
 Increase in peak VO2 > 10% of its preoperative value
Patients and Methods
 Correlation analysis
Cardiopulmonary Exercise P
erformance
• Peak VO2
• VE/VCO2 slope
• Heart rate reserve
• RER
Demographic Data
• Age at TOF repair & PVR , gender,
BW, BSA
Preoperative Clinical Characteristics
• Arrhythmia
• TR
• Functional class
Echocardiographic parameters
• RV dimension
• LV dimension
MRI parameters
• RVEDVI, RVESVI
• LVEDVI, LVESI
• RV & LV EF
Preop & postop