Abstract
Background: Acute effects of positive airway pressure (PAP) [including continuous PAP (CPAP) and adaptive servo-ventilation, an advanced form of bi-level PAP] on functional mitral regurgitation (fMR) in patients with heart failure (HF) with left ventricular (LV) systolic dysfunction remain unclear. Thus, whether PAP therapy reduces fMR in such patients with HF was investigated.Methods and Results: Twenty patients with HF and LV systolic dysfunction defined as LV ejection fraction (LVEF) <50% (14 men; mean LVEF, 35.0 ± 11.5%) with fMR underwent echocardiography during 10-min CPAP (4 and 8 cm H2O) and adaptive servo-ventilation. For fMR assessment, MR jet area fraction, defined as the ratio of MR jet on color Doppler to the left atrial area, was measured. The forward stroke volume (SV) index (fSVI) was calculated from the time-velocity integral, cross-sectional area of the aortic annulus, and body surface area. fMR significantly reduced on CPAP at 8 cm H2O (0.30 ± 0.12) and adaptive servo-ventilation (0.29 ± 0.12), compared with the baseline phase (0.37 ± 0.12) and CPAP at 4 cm H2O (0.34 ± 0.12) (P < 0.001). The fSVI did not change in any of the PAP sessions (P = 0.888). However, significant differences in fSVI responses to PAP were found between sexes (P for interaction, 0.006), with a significant reduction in fSVI in women (P = 0.041) and between patients with baseline fSVI ≥ and < the median value (27.8 ml/m2, P for interaction, 0.018), with a significant fSVI reduction in patients with high baseline fSVI (P = 0.028). In addition, significant differences were found in fSVI responses to PAP between patients with LV end-systolic volume (LVESV) index ≥ and < the median value (62.0 ml/m2, P for interaction, 0.034), with a significant fSVI increase in patients with a high LVESV index (P = 0.023).Conclusion: In patients with HF, LV systolic dysfunction, and fMR, PAP can alleviate fMR without any overall changes in forward SV. However, MR alleviation due to PAP might be associated with a decrease in forward SV in women with high baseline SV, whereas MR alleviation due to PAP might be accompanied by increased forward SV in patients with a dilated LV.
Highlights
We enrolled patients with systolic heart failure (HF) at Juntendo University Hospital (Tokyo, Japan) if they met following criteria: (1) men and women aged ≥20 years, (2) HF due to ischemic or nonischemic cardiomyopathy, (3) LVEF
FMR revealed a stepwise reduction as the continuous PAP (CPAP) level increased, but no difference was found between CPAP at 8 cm H2O and adaptive servo-ventilation (ASV)
No significant interactions were found between subgroups and alleviation of fMR, variations of the forward SV index (fSVI) across each step were significantly affected by sex, baseline LV end-systolic volume (LVESV) index, and baseline fSVI. fSVI increased in a subgroup of patients with a high LVESV index, whereas fSVI decreased in women and the subgroup of patients with a high baseline fSVI
Summary
Positive airway pressure (PAP) delivered by face masks has been used in the wide spectrum of heart failure (HF) care (Bradley et al, 2005; Arzt et al, 2007; Wang et al, 2007; Gray et al, 2008; Kasai et al, 2008; Kato et al, 2014; Khayat et al, 2015; Momomura et al, 2015; Nakano et al, 2015; Kinoshita et al, 2017). Adaptive servo-ventilation (ASV), which is an advanced mode of bi-level PAP and automatically provides altering PS for each inspiration with an EPAP in addition to backup ventilation with variable respiratory rates, leading to stabilization of respiration (see Figure S1), was reported to be useful for patients with acute decompensated HF (Nakano et al, 2015; Kinoshita et al, 2017). CPAP increases stroke volume (SV) in patients with HF with a high LV filling pressure and/or LV chamber size (Bradley et al, 1992; De Hoyos et al, 1995; Steiner et al, 2008; Yoshida et al, 2012) Similar responses in those patient populations were observed when bi-level PAP or ASV was applied (Philip-Joet et al, 1999; Yamada et al, 2013). Whether PAP therapy reduces fMR in such patients with HF was investigated
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