Circulation, Vol 89, 2605-2615, Copyright © 1994 by American Heart Association
AC Kao, P Van Trigt 3rd, GS Shaeffer-McCall, JP Shaw, BB Kuzil, RD Page and MB Higginbotham
BACKGROUND: Functional capacity and quality of life are subjectively
improved after cardiac transplantation. However, the objective improvement
in exercise tolerance after transplantation has been disappointing. The
extent to which allograft diastolic dysfunction contributes to this
exercise intolerance has not been defined. METHODS AND RESULTS: Thirty
cardiac transplant recipients between 3 and 16 months after transplantation
and 30 age-matched normal control subjects underwent maximal
symptom-limited graded upright bicycle exercise testing with simultaneous
radionuclide angiography, invasive hemodynamic monitoring, and
breath-by-breath gas analysis. Mean blood pressure was higher in the
transplant group at supine rest (112.1 versus 97.7 mm Hg), normalized with
upright posture, and became lower than normal at peak exercise (121.1
versus 133.2 mm Hg). Systolic function as measured by ejection fraction was
normal in both groups. However, the cardiac transplant recipients had
significantly lower exercise tolerance, achieving a mean maximal work rate
of 390 kilopond- meters per minute (kpm/min), compared with 825 kpm/min in
the normal subjects. Peak oxygen consumption was 12.3 mL.min-1.kg-1 in the
transplant group, 46% lower than the normal group's value of 22.9
mL.min-1.kg-1. The transplant patients had a resting tachycardia (94 beats
per minute) and a 79% reduction in exercise heart rate reserve compared
with normal. Despite this chronotropic incompetence, stroke index response
to exercise was consistently lower after transplantation, accounting for a
41% reduction in cardiac index at maximal exercise. The lower stroke index
was accompanied by a 32% lower end-diastolic volume index at rest and a 14%
lower end-diastolic volume index at peak exercise. Despite the smaller
ventricular volumes after transplantation, pulmonary capillary wedge
pressure was 35% higher than normal at supine rest and 50% higher at
maximal exercise. Right atrial and mean pulmonary arterial pressures were
similarly elevated. The ratio of pulmonary capillary wedge pressure to
end-diastolic volume index was significantly higher during the postural
change and exercise, suggesting allograft diastolic dysfunction.
Arteriovenous oxygen difference was similar between groups at rest and with
submaximal exercise but was 24% lower at maximal exercise in the transplant
group, suggesting an abnormality in peripheral oxygen uptake or
utilization. CONCLUSIONS: Exercise tolerance is severely limited during the
first 16 months after cardiac transplantation despite preservation of
allograft left ventricular systolic function. This intolerance is due to an
inadequate cardiac index response from a combination of chronotropic
incompetence and diastolic dysfunction limiting the appropriate
compensatory use of the Starling mechanism. In addition, there is a
peripheral abnormality in oxygen transport or utilization that may
partially reflect the effects of deconditioning.
ARTICLES
Central and peripheral limitations to upright exercise in untrained cardiac transplant recipients
Department of Medicine, Duke University Medical Center, Durham, NC 27710.
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