Persistent exercise limitation after successful pulmonary endoarterectomy: frequency and determinants

Abstract

Background: After successful pulmonary endoarterectomy (PEA), patients may still suffer from exercise limitation, despite normal pulmonary vascular resistance. We sought to assess the proportion of these patients after the extension of PEA to frail patients, and the determinants of exercise limitation.

Methods: Out of 553 patients treated with PEA from 2008 to 2016 at our institution, a cohort of 261 patients was followed up at 12 months. They underwent clinical, haemodynamic, echocardiographic, respiratory function tests and treadmill exercise testing. A reduced exercise capacity was defined as Bruce test distance < 400 m.

Results: Eighty patients did not had exercise testing because of inability to walk on treadmill and/or ECG abnormalities Exercise limitation 12 months after PEA was present in 74/181 patients (41, 95%CI 34 to 48%). The presence of COPD was more than double in patients with exercise limitation than in the others. Patients with persistent exercise limitation had significantly higher mPAP, PVR, HR and significantly lower RVEF, PCa, CI, VC, TLC, FEV1, FEV1/VC, DLCO, HbSaO2 than patients without. The multivariable model shows that PCa at rest and TAPSE are important predictors of exercise capacity. Age, COPD, respiratory function parameters and unilateral surgery were also retained.

Conclusions: After successful PEA, most of the patients recovered good exercise tolerance. However, about 40% continues to suffer from limitation to a moderate intensity exercise. Besides parameters of right ventricular function, useful information are provided by respiratory function parameters and COPD diagnosis. This could be useful to better address the appropriate therapeutic approach.

Keywords: Embolism; Hypertension, pulmonary; Physical exertion; Surgical procedures.

Conflict of interest statement

Ethics approval and consent to participate

All patients signed an informed consent agreement, approved by the institutional review board of Fondazione IRCCS Policlinico San Matteo (Pavia, Italy) for longitudinal, nonpharmacological, non-sponsored studies, which complies with the Italian legislation (Codex on Privacy, D. Lgs. 30 June 2003, n. 196).

Consent for publication

Not applicable.

Competing interests

AMD reports grants and personal fees from Actelion Pharmaceuticals Ltd., from Bayer HealthCare, from Merk Sharp Dohme, outside the submitted work. Dr. Ghio reports grants from Actelion Pharmaceuticals Ltd. and from Merk Sharp Dohme, outside the submitted work. All the other authors have nothing to disclose.

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Figures

Fig. 1

Diagram for flow of study participants

Fig. 2

Forest plot of the multivariable logistic regression model for predicting reduced exercise capacity (definition based on distance walked) after pulmonary endarterectomy