Exercise Oscillatory Ventilation Research Articles

Exercise chronotropic incompetence phenotypes the level of cardiovascular risk and exercise gas exchange impairment in the general population. An analysis of the Euro-EX prevention trial.

Chronotropic insufficiency (CI) is defined as the inability of the heart to increase its rate commensurate with increased demand. Exercise CI is an established predictor of major adverse cardiovascular events in patients with cardiovascular diseases. The aim of this study was to evaluate how exercise CI phenotypes different levels of cardiovascular risk and how it may better perform in defining cardiovascular risk when analysed in the context of cardiopulmonary exercise test (CPET)-derived measures and standard echocardiography in a healthy population with variable cardiovascular risk profile. Apparently healthy individuals (N = 702, 53.8% females) with at least one major cardiovascular risk factor (MCVRF; hypertension, diabetes, tabagism, dyslipidaemia, body mass index > 25), enrolled in the Euro-EX prevention trial, underwent CPET. CI was defined as the inability to reach 80% of the chronotropic index, that is, the ratio of peak heart rate - rest heart rate/peak heart rate - age predicted maximal heart rate (AMPHR: 220 - age), they were divided into four groups according to the heart rate reserve (<80%>) and respiratory gas exchange ratio (RER; < 1.05>) as a marker of achieved maximal performance. Subjects with a RER < 1.05 (n = 103) were excluded and the final population (n = 599) was divided into CI group (n = 472) and no-CI group (n = 177). Compared with no-CI, CI subjects were more frequently females with a history of hypertension in a high rate. CI subjects also exhibited a significantly lower peak oxygen uptake (VO2) and circulatory power and an echocardiographic pattern indicative of higher left atrial volume index and left ventricular mass index. An inverse stepwise relationship between heart rate reserve and number of MCVRFs was observed (one MCVRF: 0.71 ± 0.23; two MCVRFs: 0.68 ± 0.24, three MCVRFs: 0.64 ± 0.20; four MCVRFs: 0.64 ± 0.23; five MCVRFs: 0.57 ± 18; p < 0.01). In multivariate analysis the only variable found predicting CI was peak VO2 (p < 0.05; odds ratio 0.91; confidence interval 0.85-0.97). In a population of apparently healthy subjects, exercise CI is common and phenotypes the progressive level of cardiovascular risk by a tight relationship with MCVRFs. CI patients exhibit some peculiar abnormal exercise gas exchange patterns (lower peak VO2 and exercise oscillatory ventilation) and echo-derived measures (higher left atrium size and left ventricle mass) that may well anticipate evolution toward heart failure.

EXERCISE ECHOCARDIOGRAPHY OR CARDIOPULMONARY EXERCISE TEST TO DETECT HEART FAILURE WITH PRESERVED EJECTION FRACTION?

Objective: Diagnosis of heart failure with preserved ejection fraction (HFpEF) is complex, especially in its earlier, pre-clinical stage. Stress tests have been suggested as possible tools to improve the diagnosis of HFpEF, albeit with contrasting and debated evidences. We sought to evaluate the diagnostic performance of stress tests in consecutive ambulatory patients evaluated for exertional breathlessness. Design and method: Retrospective analysis of data in patients with unexplained dyspnea who underwent 1) echocardiography at rest and 2) exercise echo combined with cardiopulmonary exercise test (CPET). Diastolic function at rest and at exercise was scored according to 2016 ASE/EACVI criteria. Exercise oscillatory ventilation (EOV+) was chosen as a CPET marker of high filling pressure during effort. Diagnosis of HFpEF was established by a right heart catheterization (RHC) demonstrating a pulmonary artery wedge pressure (PAWP) > 15 mmHg at rest and/or a PAWP>=25 mmHg at peak exercise. Results: 72 patients in sinus rhythm with normal left ventricular ejection fraction (68+/-10 years old, 68% females, BMI 27+/-5 Kg/m2) were evaluated. At rest, 82% of patients had either normal diastolic function or grade I diastolic dysfunction or indeterminate diastolic function, while 18% had estimation of high filling pressure (figure 1). Exercise stress echo was positive in 5 cases (7%), while diastolic function during effort resulted “indeterminate” in 93% of patients. EOV+ was found in 15 cases (21%), i.e. in 4/5 patients with positive exercise echocardiography and in 11/67 with indeterminate diastolic function at exercise. Twenty patients (26%) underwent RHC as clinically indicated, including 19 RHC during exercise (figure 1). RHC revealed HFpEF in 17 cases (85%). Both exercise echo and EOV+ at CPET had a 100% specificity and positive predictive value to noninvasively detect HFpEF. However, sensitivity of exercise echo was only 13%, compared with 53% of EOV+ at CPET (p < 0.05).Conclusions: Our preliminary results: confirm the limitations of echocardiography for the diagnosis of HFpEF; suggest that EOV+ at CPET may have higher sensitivity than exercise echocardiography for the noninvasive detection of HFpEF, maintaining an excellent specificity.

Relationship Between Exercise Oscillatory Ventilation Loop and Prognosis of Heart Failure.

The cardiopulmonary exercise test (CPX) is a tool for evaluating disease severity and limitations in activities of daily living in patients with cardiac disorders. However, few studies have evaluated the association between exercise oscillatory ventilation (EOV) severity and prognosis in heart failure (HF) patients with EOV. EOV severity can be evaluated by detecting endtidal CO2pressure (PETCO2, an indicator of the arterial partial pressure of CO2(PaCO2)) and minute ventilation, which is a reflection of the respiratory response to elevated CO2. We hypothesized that the magnitude of EOV severity can predict the severity and prognosis of cardiac disorders and aimed to validate this hypothesis.Methods and Results:In total, 2,043 patients who underwent symptom-limited maximal CPX between 2010 and 2016 were evaluated. We enrolled 70 patients who had HF with reduced ejection fraction (HFrEF) and EOV. The endpoint was cardiovascular death. During a median follow-up of 4.3 years, 34 participants died (48%). Those who died showed significantly larger EOV loop size and lower hemoglobin (Hb) levels than those who survived (17.3±7.0 cm2vs. 12.8±6.1 cm2, P<0.001; 12.2±1.2 g/dL vs. 13.2±2.9 g/dL, P=0.004). Cox regression analyses revealed Hb levels and EOV loop size as independent predictors of cardiovascular death in HFrEF patients with EOV. EOV loop size was associated with cardiovascular death of HFrEF patients with EOV.

Observations of Late-Onset Exercise Oscillatory Ventilation

Exercise oscillatory ventilation (EOV) is characterized by regular waxing and waning of ventilation without apnea during exercise. In patients with heart failure (HF) development of EOV is a robust predictor of mortality. EOV is typically reported during the early stages of exercise and dissipates during the later stages of exercise. We have recently identified a cohort of diagnostically diverse patients that present EOV during the late stages of exercise. This late-onset pattern is contradictory to the common pattern of EOV, thus we termed it late-onset EOV. PURPOSE: To retrospectively analyze clinical characteristics, demographics and breathing patterns of patients who presented with late-onset EOV. METHODS: The medical records of eleven patients (6M/5F, 53±19 yrs, BMI: 29±12 kg/m2) demonstrating late-onset EOV during clinically indicated cardiopulmonary exercise testing were retrospectively analyzed. The amplitude of cycles were calculated as peak VE minus nadir VE during each cycle. The period of each cycle was calculated measuring the time from nadir to nadir. VE/VCO2 slope was calculated as (VEpeak – VErest)/(VCO2peak – VCO2rest). Late-onset EOV was defined as ≥3 amplitudes of ≥ 25% of the average VE for 3 consecutive cycles with the EOV originating ≥50% VO2 peak. RESULTS: Diagnoses included heart failure (n=6), diabetes (n=4), exercise induced arrhythmia (n=7), hypertension (n=4) and hyperlipidemia (n=4) and medications included beta-blockers (n=7), aspirin (n=6), diuretics (n=5) and statins (n=5); however, no diagnosis or medication were common across all patients. The VO2 peak was 20±7 mL/kg/min (72±28% predicted VO2peak). None of the patients demonstrated oscillatory ventilation at rest, while all of the patients exhibited EOV at >50% VO2 peak (amplitude of mean VE=44.7%, period=40.4s). VE/VCO2 slope had a positive correlation with EOV amplitude (r=0.74, p=0.01). The % predicted VO2 peak had a negative relationship with EOV period (r= -0.64, p=0.04). CONCLUSION: Our data demonstrate, in a diverse patient population, that the onset of EOV can occur during late stages of exercise and is related to metrics of exercise intolerance. No clear diagnosis or medication was common among these patients. Additional research is required to elucidate the mechanisms contributing to late-onset EOV.

HFA Committee on Comorbidities-report of a meeting on physiological monitoring in the complex multi-morbid heart failure patient.

One of the largest and most active committees of the Heart Failure Association (HFA) is the Committee on Comorbidities, which I have the honour to chair. It is in fact multiple committees, because its remit is so broad, covering study groups looking at Cardio-Oncology (Alex Lyon), Diabetes & Hypertension (Giuseppe Rosano), Cardiorenal Dysfunction (Wilfried Mullens), Heart & Brain (Andrew Coats), Cachexia, Sarcopenia and Frailty (Ewa Jankowska), and Lung Disease and Sleep Disorders (Mitja Lainscak). Co-morbidities are increasingly recognized as crucial components of the heart failure (HF) syndrome, especially in typical older patients (unlike the very highly selected patients who make in into randomized controlled trials). There has been much work published about these issues in the European Journal of Heart Failure recently.1-7 February 28, 2019 saw many of the members of the Committee on Comorbidities come together to tackle a very clinically relevant topic, that of producing an official position paper on how to monitor all these co-morbidities (using simple physiological measurements) in the typical HF patient, if such a person exists. Getting together in the wonderful setting of the eternal city of Rome, we saw the following members work on this topic, along with many more who could not attend in person: Andrew Coats, Maurizio Volterrani, Loreena Hill, Massimo Piepoli, Ovidiu Chioncel, Ewa Jankowska, Mitja Lainscak, Stefan Anker, Marco Metra, Piotr Ponikowski and Petar Seferovic. ECG – patterns, rhythms and conduction - Should we simply do opportunistic ECGs or should we recommend routine ECGs on regular follow-up and should we recommend wearable devices for ECG recordings, looking for example for things such as We then turned our attention to ventricular function, the most important of course being left ventricular function, discussing the role of echocardiography and other imaging techniques, when they should be used and how frequently, and important clinical questions such as what are the recommendations for routine echo follow-up in HFrEF or HFpEF, for valve lesions complicating HF, and whether other circumstances justify routine echo during follow-up, e.g. looking for forms of amyloid, myocarditis etc., and whether we should re-check echo after cardiac resynchronization therapy or drug therapy changes. Another important and frequently clinically relevant topic in transplant and ventricular assist device assessment clinics is that of monitoring of functional capacity, covering topics such as the prognostic value of exercise tolerance, and especially of peak oxyen uptake and other measurements derived from formal cardiopulmonary exercise testing (CPET), such as VE/VCO2 slope, exercise oscillatory ventilation, along with a discussion of the potential for wearable devices and the possibility of daily activity monitoring. Under the heading of advanced forms of monitoring, we considered plasma biomarkers, including their diagnostic role, prognostic value, value as inclusion criteria for certain therapies (e.g. sacubitril/valsartan) and the choice of the optimal biomarkers for HFrEF or HFpEF. Another large topic was the role of remote monitoring and telemedicine—both non-invasive and using implanted technologies (pulmonary artery pressure monitoring and loop recorders). What should we say about recommending remote non-invasive telemonitoring, given the recent TIM-HF2 trial?8, 9 A very important question that will be addressed on the final paper is the issue of what clinical trials and with what endpoints will be needed to get the proof we need to routinely recommend monitoring by implantable devices, and who will pay for this on-going monitoring effort. We finished by reviewing the specific challenges of monitoring the advanced HF patient—given that we all agreed sicker patients need more intense monitoring. This covered emerging topics such as lung congestion or total body water monitoring, along with prevalent co-morbidities, renal impairment, haemoglobin and serum iron, transferrin and transferrin saturation, sodium, potassium (with the advent of potassium binders into our treatment options), sleep disordered breathing, where differentiating central from obstructive sleep apnoea is essential to choose the right therapy for a HF patient with sleep disordered breathing, and of course monitoring diabetic control. We then finished with a discussion about the growing incidence of co-existing cancer and heart disease and need to develop evidence-based strategies for monitoring and protecting cardiac function during many modern anti-cancer regimes. The one thing that became increasingly obvious was that this area is enormously complex and the need for future reach is growing ever more urgent. Andrew J.S. Coats University of Warwick, Coventry, UK ajscoats@aol.com

Prevalence of exertional oscillatory ventilation in continuous-flow left ventricular assist device recipients.

Exercise oscillatory ventilation is an ominous outcome sign in heart failure due to reduced left ventricular ejection fraction; currently, the prevalence of exercise oscillatory ventilation is unknown in left ventricular assist device recipients. We studied cardiopulmonary exercise testing in heart failure due to reduced left ventricular ejection fraction or left ventricular assist device patients and exercise oscillatory ventilation was defined according to Kremser's criteria. The occurrence of exercise oscillatory ventilation was similar in either heart failure due to reduced left ventricular ejection fraction (192 patients, 8%) or left ventricular assist device patients (85 recipients, 10%), even though the mean peak oxygen consumption and elevated ventilatory response to exercise slope was lower and higher in left ventricular assist device recipients, respectively, but the occurrence of exercise oscillatory ventilation was comparable among heart failure patients due to reduced left ventricular ejection fraction and left ventricular assist device, if those with impaired exercise capacity were considered. Of note, left ventricular assist device recipients with exercise oscillatory ventilation had a higher end-diastolic left ventricular volume and systolic pulmonary artery pressure at rest. Using the largest cohort of left ventricular assist device patients performing cardiopulmonary exercise testing, we demonstrated that the occurrence of exercise oscillatory ventilation is similar in heart failure due to reduced left ventricular ejection fraction and left ventricular assist device patients. Recipients with exercise oscillatory ventilation might have haemodynamic and ventilatory dysfunction during exercise, but other factors could play a role, i.e. the duration and severity of heart failure before left ventricular assist device implantation together with the coexistence of morbidity.

A flattening oxygen consumption trajectory phenotypes disease severity and poor prognosis in patients with heart failure with reduced, mid-range, and preserved ejection fraction.

In heart failure (HF), a flattening oxygen consumption (VO2 ) trajectory during cardiopulmonary exercise test (CPET) reflects an acutely compromised cardiac output. We hypothesized that a flattening VO2 trajectory is helpful in phenotyping disease severity and prognosis in HF with either reduced (HFrEF), mid-range (HFmrEF), or preserved (HFpEF) ejection fraction. Overall, 319 HF patients (198 HFrEF, 80 HFmrEF, and 41 HFpEF) underwent CPET. A flattening VO2 trajectory was tracked and defined as an inflection of VO2 linearity as a function of work rate with a second slope downward inflection >35% extent of the first one. Peak VO2 , the minute ventilation/carbon dioxide production (VE/VCO2 ) slope, and the presence of exercise oscillatory ventilation (EOV) were also determined. Pulmonary artery systolic pressure (PASP) and tricuspid annular plane systolic excursion (TAPSE) were measured by echocardiography. A flattening VO2 occurred in 92 patients (28.8%). PASP and TAPSE at rest were significantly higher and lower (P < 0.001), respectively. The primary outcome was the combination of all-cause death, heart transplantation and left ventricular assist device implantation. The secondary outcome was the primary outcome plus hospitalization for cardiac reasons. In the multivariate model including peak VO2 , VE/VCO2 slope, EOV and VO2 trajectory, a flattening VO2 trajectory and EOV were retained in the regression for primary (X2 = 35.78, and 36.36, respectively; P < 0.001) and secondary (X2 = 12.45 and 47.91, respectively; P < 0.001) outcomes. Results point to a flattening VO2 trajectory as a likely new and strong predictor of events in HF with any ejection fraction. Given the relation of right-sided cardiac dysfunction to pulmonary hypertension, this oxygen pattern might suggest a real-time decrease in pulmonary blood flow to the left heart.

Exercise Oscillatory Ventilation: Interreviewer Agreement and a Novel Determination.

Determination of exercise oscillatory ventilation (EOV) is subjective, and the interreviewer agreement has not been reported. The purposes of this study were, among patients with heart failure (HF), as follows: 1) to determine the interreviewer agreement for EOV and 2) to describe a novel, objective, and quantifiable measure of EOV. This was a secondary analysis of the HEART Camp: Promoting Adherence to Exercise in Patients with Heart Failure study. EOV was determined through a blinded review by six individuals on the basis of their interpretation of the EOV literature. Interreviewer agreement was assessed using Fleiss kappa (κ). Final determination of EOV was based on agreement by four of the six reviewers. A new measure (ventilation dispersion index; VDI) was calculated for each test, and its ability to predict EOV was assessed with the receiver operator characteristics curve. Among 243 patients with HF (age, 60 ± 12 yr; 45% women), the interreviewer agreement for EOV was fair (κ = 0.303) with 10-s discrete data averages and significantly better, but only moderate (κ = 0.429) with 30-s rolling data averages. Prevalence rates of positive and indeterminate EOVs were 18% and 30% with the 10-s discrete averages and 14% and 13% with the 30-s rolling averages, respectively. VDI was strongly associated with EOV, with areas under the receiver operator characteristics curve of 0.852 to 0.890. Interreviewer agreement for EOV in patients with HF is fair to moderate, which can negatively affect risk stratification. VDI has strong predictive validity with EOV; as such, it might be a useful measure of prognosis in patients with HF.

Impact of cardiac rehabilitation on exercise oscillatory ventilation in patients with chronic heart failure and reduced left ventricular ejection fraction

Cardiac rehabilitation improves functional status and reduces mortality in patients with chronic heart failure with reduced left ventricular (LV) ejection fraction. The presence of exercise oscillatory ventilation (EOV), characterized by the periods of hyperpnea and hypopnea without interposed apnea, may be assessed using cardiopulmonary exercise test (CPET) and is associated with a poor prognosis. We aim to assess the effect of cardiac rehabilitation on EOV in patients with chronic heart failure. From January 2014 to March 2017, patients with chronic heart failure with ambulatory cardiac rehabilitation program in our center were included. A CPET has been performed in all patients before and after 10-week rehabilitation program. The presence of EOV was defined as duration > 60% of total exercise duration with a cycle length of more 30 s and an amplitude ≥ 15% of the averaged resting value, as recommended. Among 40 patients (mean age: 59 ± 8 years, 33 males, mean LV ejection fraction: 30 ± 9), baseline EOV was found in 26 cases (65%). There was no significant difference between patients with EOV (EOV + ) and those without EOV (EOV − ) regarding risk factors and clinical and demographic data. Before rehabilitation, patients EOV+ had significant lower peak respiratory ratio (1.14 ± 0.07 vs. 1.08 ± 0.081, respectively, P = 0.02) and a trend for lower VE/VCO 2 slope (39.9 ± 5.8 vs. 36.1 ± 4.2, respectively, P = 0.074). After cardiac rehabilitation, EOV reversed in 13 patients (50%, P = 0.001). The thirteen patients who conserved EOV have a decrease of the cycle length (44 ± 10 s vs 36 ± 5 s, P = 0.016). In patients with chronic heart failure with reduced LV ejection fraction, EOV are present in 65% of cases. A 10-week cardiac rehabilitation program reverses EOV in half of patients and decrease EOV cycle length in those with persisting EOV. Further studies are needed to confirm these results and explore the potential prognostic significance of EOV reversal.

Association of Oscillatory Ventilation during Cardiopulmonary Test to Clinical and Functional Variables of Chronic Heart Failure Patients.

ObjectiveThe aim of this study is to characterize the presence of exercise oscillatory ventilation (EOV) and to relate it with other cardiopulmonary exercise test (CET) responses and clinical variables.MethodsForty-six male patients (age: 53.1±13.6 years old; left ventricular ejection fraction [LVEF]: 30±8%) with heart failure were recruited to perform a maximal CET and to correlate the CET responses with clinical variables. The EOV was obtained according to Leite et al. criteria and VE/VCO2 > 34 and peak VO2 < 14 ml/kg/min were used to assess patients' severity.ResultsThe EOV was observed in 16 of 24 patients who performed the CET, as well as VE/VCO2 > 34 and peak VO2 < 14 ml/kg/min in 14 and 10 patients, respectively. There was no difference in clinical and CET variables of the patients who presented EOV in CET when compared to non-EOV patients. Also, there was no difference in CET and clinical variables when comparing patients who presented EOV and had a VE/VCO2 slope > 34 to patients who just had one of these responses either.ConclusionThe present study showed that there was an incidence of patients with EOV and lower peak VO2 and higher VE/VCO2 slope values, but they showed no difference on other prognostic variables. As well, there was no influence of the presence of EOV on other parameters of CET in this population, suggesting that this variable may be an independent marker of worst prognosis in HF patients.

A method for determining exercise oscillatory ventilation in heart failure: Prognostic value and practical implications

BackgroundExercise oscillatory ventilation (EOV) has been shown to be a powerful prognostic marker in chronic heart failure (CHF). However, EOV is poorly defined, its measurement lacks standardization and it is underutilized in clinical practice. The purpose of this pilot study was to investigate the prognostic value of a modified definition of EOV in patients with CHF. MethodsEighty-nine CHF patients (56.5±8.4years) (64% NYHA class III-IV) underwent cardiopulmonary exercise testing. EOV was defined as meeting all the following criteria: (1) ≥3 consecutive cyclic fluctuations of ventilation during exercise; (2) average amplitude over 3 ventilatory oscillations ≥5L; and (3) an average length of three oscillatory cycles 40s to 140s. Adverse cardiac events were tracked during 28±19months follow up. Cox proportional hazard analysis was used to determine the association between cardiac events and EOV. ResultsForty-eight patients (54%) met all three criteria and were determined to have EOV. These patients exhibited significantly increased risk for adverse cardiac events [hazard ratio=2.2, 95% CI (1.2 to 4.1), p=0.011] compared to patients without EOV. After adjusting for age and established prognostic covariates (peak VO2 and VE/VCO2 slope), the modified EOV definition was the only significant variable in the multivariate model [hazard ratio=2.0, 95% CI (1.1 to 3.7), p=0.035]. ConclusionsThe proposed method for determining EOV was independently associated with increased risk for adverse cardiac events in CHF patients. While larger prospective studies are needed, this definition provides a relatively simple and more objective characterization of EOV, suggesting its potential application in clinical practice.

Cardiopulmonary Exercise Testing: Basics of Methodology and Measurements.

Cardiopulmonary exercise testing adds measurement of ventilation and volume of oxygen uptake and exhaled carbon dioxide to routine physiological and performance parameters obtainable from conventional exercise testing, furnishing an all-around vision of the systems involved in both oxygen transport from air to mitochondria and its use during exercise. Peculiarities of cardiopulmonary exercise testing methodology are the use of ramp protocols and calibration procedures for flow meters and gas analyzers. Among the several parameters provided by this technique, peak oxygen uptake, first and second ventilatory thresholds, respiratory exchange ratio, oxygen pulse, slope of ventilation divided by exhaled carbon dioxide relationship, exercise oscillatory ventilation, circulatory power, and partial pressure of end-tidal carbon dioxide are among the most relevant in the clinical setting. The choice of parameters to be considered will depend on the indication to cardiopulmonary exercise testing in the individual subject or patient, namely, exercise tolerance assessment, prognostic stratification, training prescription, treatment efficacy evaluation, diagnosis of causes of unexplained exercise tolerance reduction, or exercise (patho)physiology evaluation for research purposes. Overall, cardiopulmonary exercise testing is a methodology now widely available and supported by sound scientific evidence. Despite this, its potential still remains largely underused. Strong efforts and future investigations are needed to address these issues and further promote the use of cardiopulmonary exercise testing in the clinical and research setting.

Nepravidelnosti dýchání při spiroergometrickém vyšetření - od mírné nepravidelnosti dechového vzoru až po periodické dýchání typu oscilující ventilace

The fluctuating course of tidal volume (VT), breathing frequency (DF) and minute ventilation (VE) during the cardio-pulmonary exercise test using a ramp incremental protocol occurs not only in patients, but relatively frequently also in healthy individuals. It can account for a number of irregularities in the course of the curves VO2, VCO2 and in particular of those of ventilatory equivalents for O2 and CO2 (EQO2, EQCO2) as well as curves of partial pressure of end-tidal oxygen and partial pressure of end-tidal carbon dioxide (PETO2, PETCO2), which are also used, inter alia, to establish ventilatory thresholds. The presence of exercise oscillatory ventilation (EOV) reflects the severity of heart failure and it is an independent predictor of the increased morbidity, cardiac and total mortality and sudden death caused by heart failure. However there is not a generally accepted universal definition of EOV available at present, as different criteria are used. We have not found a comparison which would indicate whether and how the "strength" of the prognostic criteria for EOV - established according to different methods - differs. Therefore it is very important to specify what method, or what criteria were used in the establishment of EOV.Key words: breathing pattern - EOV - exercise oscillatory ventilation - periodic breathing.

Exercise training improves characteristics of exercise oscillatory ventilation in chronic heart failure.

Background Exercise oscillatory ventilation in chronic heart failure has been suggested as a factor related to adverse cardiac events, aggravated prognosis and higher mortality. Exercise training is well known to affect exercise capacity and mechanisms of pathophysiology beneficially in chronic heart failure. Little is known, however, about the exercise training effects on characteristics of exercise oscillatory ventilation in chronic heart failure patients. Design and methods Twenty (out of 38) stable chronic heart failure patients exhibited exercise oscillatory ventilation (age 54 ± 11 years, peak oxygen uptake 15.0 ± 5.0 ml/kg per minute). Patients attended 36 sessions of high intensity interval exercise. All patients underwent cardiopulmonary exercise testing before and after the programme. Assessment of exercise oscillatory ventilation was based on the amplitude of cyclic fluctuations in breathing during rest and exercise. All values are mean ± SD. Results Exercise training reduced ( P < 0.05) the percentage of exercise oscillatory ventilation duration (79.0 ± 13.0 to 50.0 ± 25.0%), while average amplitude (5.2 ± 2.0 to 4.9 ± 1.6 L/minute) and length (44.0 ± 10.9 to 41.0 ± 6.7 seconds) did not change ( P > 0.05). Exercise oscillatory ventilation patients also increased exercise capacity ( P < 0.05). Conclusions A rehabilitation programme based on high intensity interval training improved exercise oscillatory ventilation observed in chronic heart failure patients, as well as cardiopulmonary efficiency and functional capacity.

Development of a clinical applicable graphical user interface to automatically detect exercise oscillatory ventilation: The VOdEX-tool

BackgroundCardiopulmonary exercise testing (CPET) gained importance in the prognostic assessment of especially patients with heart failure (HF). A meaningful prognostic parameter for early mortality in HF is exercise oscillatory ventilation (EOV). This abnormal respiratory pattern is recognized by hypo- and hyperventilation during CPET. Up until now, assessment of EOV is mainly done upon visual agreement or manual calculation. The purpose of this research was to automate the interpretation of EOV so this prognostic parameter could be readily investigated during CPET. Methods and resultsPreliminary, four definitions describing the original characteristics of EOV, were selected and integrated in the “Ventilatory Oscillations during Exercise-tool” (VOdEX-tool), a graphical user interface that allows automate calculation of EOV. A Discrete Meyer Level 2 wavelet transformation appeared to be the optimal filter to apply on the collected breath-by-breath minute ventilation CPET data. Divers aspects of the definitions i.e. cycle length, amplitude, regularity and total duration of EOV were combined and calculated. The oscillations meeting the criteria were visualised. Filter methods and cut-off criteria were made adjustable for clinical application and research. The VOdEX-tool was connected to a database. ConclusionsThe VOdEX-tool provides the possibility to calculate EOV automatically and to present the clinician an overview of the presence of EOV at a glance. The computerized analysis of EOV can be made readily available in clinical practice by integrating the tool in the manufactures existing CPET software. The VOdEX-tool enhances assessment of EOV and therefore contributes to the estimation of prognosis in especially patients with HF.

Physiological and sensory consequences of exercise oscillatory ventilation in heart failure-COPD

BackgroundExercise oscillatory ventilation (EOV) is associated with poor ventilatory efficiency and higher operating lung volumes in heart failure. These abnormalities may be particularly deleterious to dyspnea and exercise tolerance in mechanically-limited patients, e.g. those with coexistent COPD. MethodsVentilatory, gas exchange and sensory responses to incremental exercise were contrasted in 68 heart failure-COPD patients (12 EOV+). EOV was established by standard criteria. ResultsCompared to EOV−, EOV+ had lower exercise capacity, worse ventilatory inefficiency and higher peak dyspnea scores (p<0.05). Peak capillary PCO2 (PcCO2) was higher and end-tidal CO2 (PETCO2) was lower in EOV+. Thus, greater (i.e., more positive) P(c-ET)CO2 and dead space/tidal volume values were found in these patients compared to EOV− (p<0.05). Ventilatory inefficiency was related to increased dead space/tidal volume in EOV+ (r=0.74; p<0.01). Owing to higher operating lung volumes, inspiratory reserve volume (IRV) decreased to a greater extent in EOV+. Tidal volume oscillations consistently ceased when a “critical” IRV was reached (~0.3–0.5L); thereafter, PcCO2 stabilized or increased and dyspnea scores rose sharply. Exercise capacity was closely related to IRV decrements and peak dyspnea in EOV+ (r=−0.78 and 0.84, respectively; p<0.01). ConclusionsDyspnea and exercise tolerance are negatively influenced by EOV in heart failure patients presenting with COPD as co-morbidity. Pharmacological and non-pharmacological interventions known to decrease EOV might prove particularly valuable to mitigate symptom burden and exercise intolerance in this specific heart failure group.

216 - Long-Term Follow-Up of Chronic Heart Failure Patients Presenting with Exercise Oscillatory Ventilation

216 - Long-Term Follow-Up of Chronic Heart Failure Patients Presenting with Exercise Oscillatory Ventilation

Letter by Cornelis et al. regarding article, “Exercise oscillatory ventilation in heart failure”

Letter by Cornelis et al. regarding article, “Exercise oscillatory ventilation in heart failure”

INCREASED EXERCISE PERIPHERAL EXTRACTION IN GROUP 2 PULMONARY HYPERTENSION AND EXERCISE OSCILLATORY VENTILATION

Group 2 pulmonary hypertension (PH) and exercise oscillatory ventilation (EOV) are prognostic signs in heart failure (HF). It is unknown what may characterize the exercise response of PH patients and EOV. Aim: To define the functional pattern in HF reduced ejection fraction (HFrEF) with PH according

(1078) - Implications of Exercise Oscillatory Ventilation Post Ventricular Assist Device Implantation

(1078) - Implications of Exercise Oscillatory Ventilation Post Ventricular Assist Device Implantation