Hostname: page-component-848d4c4894-2pzkn Total loading time: 0 Render date: 2024-05-25T04:20:07.268Z Has data issue: false hasContentIssue false
  • English
  • Français

Optimised rate-responsive pacing does not improve either right ventricular haemodynamics or exercise capacity in adults with a systemic right ventricle

Published online by Cambridge University Press:  11 May 2010

Anselm Uebing ,
Gerhard-Paul Diller ,
Wei Li ,
Mark Maskell ,
Konstantinos Dimopoulos  and
Michael A. Gatzoulis
Anselm Uebing*
Affiliation:
Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and the National Heart and Lung Institute at Imperial College, Sydney Street, London, United Kingdom Children’s Heart Centre, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller Strasse 3, Germany
Gerhard-Paul Diller
Affiliation:
Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and the National Heart and Lung Institute at Imperial College, Sydney Street, London, United Kingdom
Wei Li
Affiliation:
Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and the National Heart and Lung Institute at Imperial College, Sydney Street, London, United Kingdom
Mark Maskell
Affiliation:
Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and the National Heart and Lung Institute at Imperial College, Sydney Street, London, United Kingdom
Konstantinos Dimopoulos
Affiliation:
Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and the National Heart and Lung Institute at Imperial College, Sydney Street, London, United Kingdom
Michael A. Gatzoulis
Affiliation:
Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and the National Heart and Lung Institute at Imperial College, Sydney Street, London, United Kingdom
*
Correspondence to: Dr Anselm Uebing, MD, Children’s Heart Centre, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller Strasse 3, House 9, 24105 Kiel, Germany. Tel: +44 431 597 1728; Fax: +44 431 597-1828; E-mail: uebing@pedcard.uni-kiel.de
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Inappropriate heart rate response to exercise – chronotropic incompetence – and exercise intolerance are common in patients with a systemic right ventricle. We aimed to assess the relationship between heart rate increase, oxygen consumption, and timing of the right ventricular cardiac cycle in this cohort.

Methods

We prospectively studied nine patients with systemic right ventricles and pre-existing pacemakers using Doppler-echocardiography and treadmill exercise testing. Echocardiography was performed at increasing heart rates. Exercise tests were performed with baseline pacemaker settings and with optimised heart rate response in random order. In addition, eight age- and gender-matched controls underwent exercise testing using a similar exercise protocol.

Results

Patients with a systemic right ventricle had significantly lower peak oxygen consumption compared to controls – 12.6 plus or minus 6.8 versus 31.4 plus or minus 6.6 metres per kilogram per minute (p = 0.0006) – at baseline and active pacemaker reprogramming failed to increase peak oxygen consumption in this cohort – 12.6 plus or minus 6.8 versus 12.4 plus or minus 4.9 millilitres per kilogram per minute (p = NS) at baseline and with reprogramming, respectively. We found not only a marked increase in total isovolumic time but also a significant reduction in total filling time and the aortic velocity time integral, p-value is less than 0.001 for all, at higher heart rates compared to baseline conditions.

Conclusion

This study suggests that despite chronotropic incompetence at baseline, rate-responsive pacing does not improve exercise capacity in patients with a systemic right ventricle. It further indicates that high heart rates may be detrimental in these patients by reducing diastolic filling and stroke volume. These findings may have clinical implications when considering implantation of a permanent pacemaker in this cohort.

Keywords

Chronotropic incompetencesystemic right ventriclepacemaker therapyexercise physiology
Type
Original Articles
Information
Cardiology in the Young , Volume 20 , Issue 5 , October 2010 , pp. 485 - 494
Copyright
Copyright © Cambridge University Press 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Diller, GP, Dimopoulos, K, Okonko, D, et al. Heart rate response during exercise predicts survival in adults with congenital heart disease. J Am Coll Cardiol 2006; 48: 1250–1256.CrossRefGoogle ScholarPubMed
2. Fredriksen, PM, Veldtman, G, Hechter, S, et al. Aerobic capacity in adults with various congenital heart diseases. Am J Cardiol 2001; 87: 310–314.CrossRefGoogle ScholarPubMed
3. Hechter, SJ, Webb, G, Fredriksen, PM, et al. Cardiopulmonary exercise performance in adult survivors of the Mustard procedure. Cardiol Young 2001; 11: 407–414.CrossRefGoogle ScholarPubMed
4. Li, W, Hornung, TS, Francis, DP, et al. Relation of biventricular function quantified by stress echocardiography to cardiopulmonary exercise capacity in adults with Mustard (atrial switch) procedure for transposition of the great arteries. Circulation 2004; 110: 1380–1386.CrossRefGoogle ScholarPubMed
5. Derrick, GP, Narang, I, White, PA, et al. Failure of stroke volume augmentation during exercise and dobutamine stress is unrelated to load-independent indexes of right ventricular performance after the Mustard operation. Circulation 2000; 102 (Suppl 3): III154–III159.CrossRefGoogle ScholarPubMed
6. Oechslin, E, Jenni, R. 40 years after the first atrial switch procedure in patients with transposition of the great arteries: long-term results in Toronto and Zurich. Thorac Cardiovasc Surg 2000; 48: 233–237.CrossRefGoogle ScholarPubMed
7. Porszasz, J, Casaburi, R, Somfay, A, Woodhouse, LJ, Whipp, BJ. A treadmill ramp protocol using simultaneous changes in speed and grade. Med Sci Sports Exerc 2003; 35: 1596–1603.CrossRefGoogle ScholarPubMed
8. Jones, NL, Summers, E, Killian, KJ. Influence of age and stature on exercise capacity during incremental cycle ergometry in men and women. Am Rev Respir Dis 1989; 140: 1373–1380.CrossRefGoogle ScholarPubMed
9. Kindermann, M, Schwaab, B, Finkler, N, Schaller, S, Bohm, M, Frohlig, G. Defining the optimum upper heart rate limit during exercise: a study in pacemaker patients with heart failure. Eur Heart J 2002; 23: 1301–1308.CrossRefGoogle ScholarPubMed
10. Lissin, LW, Li, W, Murphy, DJ Jr, et al. Comparison of transthoracic echocardiography versus cardiovascular magnetic resonance imaging for the assessment of ventricular function in adults after atrial switch procedures for complete transposition of the great arteries. Am J Cardiol 2004; 93: 654–657.CrossRefGoogle ScholarPubMed
11. Bolger, AP, Sharma, R, Li, W, et al. Neurohormonal activation and the chronic heart failure syndrome in adults with congenital heart disease. Circulation 2002; 106: 92–99.CrossRefGoogle ScholarPubMed
12. Deanfield, J, Camm, J, Macartney, F, et al. Arrhythmia and late mortality after Mustard and Senning operation for transposition of the great arteries. An eight-year prospective study. J Thorac Cardiovasc Surg 1988; 96: 569–576.CrossRefGoogle ScholarPubMed
13. Hayes, CJ, Gersony, WM. Arrhythmias after the Mustard operation for transposition of the great arteries: a long-term study. J Am Coll Cardiol 1986; 7: 133–137.CrossRefGoogle ScholarPubMed
14. Lange, R, Horer, J, Kostolny, M, et al. Presence of a ventricular septal defect and the Mustard operation are risk factors for late mortality after the atrial switch operation: thirty years of follow-up in 417 patients at a single center. Circulation 2006; 114: 1905–1913.CrossRefGoogle ScholarPubMed
15. Connelly, MS, Liu, PP, Williams, WG, Webb, GD, Robertson, P, McLaughlin, PR. Congenitally corrected transposition of the great arteries in the adult: functional status and complications. J Am Coll Cardiol 1996; 27: 1238–1243.CrossRefGoogle ScholarPubMed
16. Fredriksen, PM, Chen, A, Veldtman, G, Hechter, S, Therrien, J, Webb, G. Exercise capacity in adult patients with congenitally corrected transposition of the great arteries. Heart 2001; 85: 191–195.CrossRefGoogle ScholarPubMed
17. Hauser, M, Bengel, FM, Hager, A, et al. Impaired myocardial blood flow and coronary flow reserve of the anatomical right systemic ventricle in patients with congenitally corrected transposition of the great arteries. Heart 2003; 89: 1231–1235.CrossRefGoogle ScholarPubMed
18. Giardini, A, Lovato, L, Donti, A, et al. A pilot study on the effects of carvedilol on right ventricular remodelling and exercise tolerance in patients with systemic right ventricle. Int J Cardiol 2006; 114: 241–246.CrossRefGoogle Scholar
19. Duncan, AM, O’Sullivan, CA, Gibson, DG, Henein, MY. Electromechanical interrelations during dobutamine stress in normal subjects and patients with coronary artery disease: comparison of changes in activation and inotropic state. Heart 2001; 85: 411–416.CrossRefGoogle ScholarPubMed
20. Duncan, A, Francis, D, Gibson, D, Pepper, J, Henein, M. Electromechanical left ventricular resynchronisation by coronary artery bypass surgery. Eur J Cardiothorac Surg 2004; 26: 711–719.CrossRefGoogle ScholarPubMed
21. Wasserman, K, Hansen, JE, Sue, DY, Stringer, WW, Whipp, BJ. Principles of exercise testing and interpretation: Including pathohysiology and clinical applications. Lippincott Williams & Wilkins, Philadelphia, PA, 2004.Google Scholar