Surrogate endpoints of exercise-induced pulmonary hypertension and utility of low-workload exercise echocardiography in mitral regurgitation

Patient characteristics

The overall baseline characteristics are presented in Table 1. The patients were divided according to the occurrence of EIPH into 2 groups: patients with PEITE at peak workload (TRPG ≥ 50 mmHg, PEITE group, n = 57) and patients without EIPH at peak workload (TRPG

Table 1 Basic characteristics.

Comparison of symptoms and vital signs at peak workload between the EIPH group and the group without EIPH

There was no difference in workload at peak exertion (79.0 ± 25.4 vs 85.2 ± 29.1 W, p = 0.21), Borg scale values related to dyspnea (16.0 ± 2.2 vs 16.1 ± 2.4, p = 0.80) and leg fatigue (15.8 ± 2.7 vs 16.5 ± 2.4, p = 0.13) and vital signs at peak workload between the CIPH and without CIPH groups (Table 2).

Table 2 Hemodynamics at peak workload.

Association Between Clinical Outcomes and EIPH at Peak Workload

Of 57 patients with EIPH at peak workload, early surgery was indicated in 38 patients (67%), and the remaining 19 patients (33%) were observed using the watchful waiting strategy. Conversely, of 66 patients without EIPH, early surgery was indicated in 27 patients (41%), and the remaining 39 patients (59%) were observed using the watchful waiting strategy. The reasons for early surgical intervention in patients without EIPH were as follows; exercise-evoked symptoms were in 8 patients (30%), new-onset atrial fibrillation during exercise was in 3 patients (11%), and LA dilation (≥ 60 mL/m2) was in 16 patients (59%). In total, early surgery was performed in 65 patients (53%).

Of 58 patients (47%) with the watchful waiting strategy (EIPH group; 19 patients, group without EIPH; 39 patients), the median follow-up period was 1.5 years (interquartile range: 0.9–1 ,9). During follow-up, endpoint occurred in 14 patients [EIPH group; 11 patients (58%), no-EIPH group; 3 patients (8%)]; death in one patient, hospitalization for heart failure in 5 patients and worsening of symptoms in 8 patients. Event-free survival was lower in an EIPH group than in a group without EIPH (48.1 versus 97.0% at 1 year, p

Figure 1

A Kaplan-Meier curve of the cumulative event-free survival rates of the endpoint for 2 groups of patients with or without EIPH at maximum workload. EIPH exercise-induced pulmonary hypertension.

ESE Data at Rest and at Light Workload

ESE data at rest and at low workload are shown in Tables 3 and 4. LV and AL size and quantitative MR assessment at rest were similar between the EIPH and no EIPH groups. . Resting ejection fraction and TRPG values ​​at low workload were higher and resting eʹ was lower in a EIPH group than in a group without EIPH (resting ejection fraction, 64.1 ± 3, 5 vs 62.9 ± 2.4%, p = 0.030; TRPG at low workload, 46.7 ± 10.0 vs 35.4 ± 9.8 mmHg, p

Table 3 Hemodynamic and echocardiographic data at rest.
Table 4 Parameters associated with low workload.

Relationship between the TRPG at peak load and parameters at rest or at low load

The TRPG at peak load showed a moderate correlation with the TRPG at light load (r = 0.70, p

Figure 2
Figure 2

Relationship between TRPG at maximum workload and low workload. A significant correlation was found between TRPG at peak workload and TRPG at low workload (r = 0.70, p TRPG tricuspid regurgitation peak gradient.

Table 5 Variables associated with TRPG at maximum workload.

Association between prognosis in patients with the watchful waiting strategy and TRPG at peak or low workload

Analysis of receptor operating characteristics was performed to predict prognosis at 2 years after performing ESE in 58 patients with the watchful waiting strategy. The area under the curve based on TRPG at maximum workload and TRPG at low workload was 0.89 (95% confidential interval, 0.78–0.99) and 0.80 (confidential interval at 95%, 0.69–0.91), respectively. In contrast, e′ at rest (AUC 0.72; 95% confidential interval, 0.57–0.87) did not discriminate prognosis significantly at 2 years after performing ESE in patients waiting under surveillance. TRPG at maximal workload ≥ 49.5 mmHg predicted prognosis with 92% sensitivity and 81% specificity and the cut-off value was nearly identical to the definition of EIPH (TRPG 50 mmHg at maximal workload). maximum work). Low-workload TRPG ≥ 35.0 mmHg predicted prognosis with 100% sensitivity and 65% specificity. Event-free survival was lower in patients with low-workload TRPG ≥ 35.0 mmHg than in patients with low-workload TRPG

picture 3
picture 3

A Kaplan-Meier curve of cumulative event-free survival rates of the endpoint for 2 groups of patients with or without TRPG ≥ 35.0 mmHg at low workload. TRPG tricuspid regurgitation peak gradient.

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