Right Ventricular Function During Exercise After Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension

BACKGROUND: Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension improves resting hemo-dynamics and right ventricular (RV) function. Because exercise tolerance frequently remains impaired, RV function may not have completely normalized after PEA. Therefore, we performed a detailed invasive hemodynamic study to investigate the effect of PEA on RV function during exercise. METHODS AND RESULTS: In this prospective study, all consenting patients with chronic thromboembolic pulmonary hypertension eligible for surgery and able to perform cycle ergometry underwent cardiac magnetic resonance imaging, a maxi-mal cardiopulmonary exercise test, and a submaximal invasive cardiopulmonary exercise test before and 6 months after PEA. Hemodynamic assessment and analysis of RV pressure curves using the single-beat method was used to determine load-independent RV contractility (end systolic elastance), RV afterload (arterial elastance), RV– arterial coupling (end systolic elastance– arterial elastance), and stroke volume both at rest and during exercise. RV rest-to-exercise responses were compared before and after PEA using 2-way repeated-measures analysis of variance with Bonferroni post hoc correction. A total of 19 patients with chronic thromboembolic pulmonary hypertension completed the entire study protocol. Resting hemodynamics improved significantly after PEA. The RV exertional stroke volume response improved 6 months after PEA (79±32 at rest versus 102±28 mL during exercise; P<0.01). Although RV afterload (arterial elastance) increased during exer-cise, RV contractility (end systolic elastance) did not change during exercise either before (0.43 [0.32– 0.58] mm Hg/mL versus 0.45 [0.22– 0.65] mm Hg/mL; P=0.6) or after PEA (0.32 [0.23– 0.40] mm Hg/mL versus 0.28 [0.19– 0.44] mm Hg/mL; P=0.7). In addition, mean pulmonary artery pressure– cardiac output and end systolic elastance– arterial elastance slopes remained unchanged after PEA. CONCLUSIONS: The exertional RV stroke volume response improves significantly after PEA for chronic thromboembolic pulmonary hypertension despite a persistently abnormal afterload and absence of an RV contractile reserve. This may suggest that at mildly elevated pulmonary pressures, stroke volume is less dependent on RV contractility and afterload and is primarily determined by venous return and conduit function.