Circulation, Vol 86, 1175-1185, Copyright © 1992 by American Heart Association
WJ Paulus, JG Bronzwaer, H Felice, N Kishan and F Wellens
BACKGROUND. The exercise-induced rise in left ventricular filling pressures
after cardiac transplantation is considered to be the result of a blunted
heart rate response, of elevated venous return, and of unfavorable passive
late-diastolic properties of the cardiac allograft. In contrast to passive
late-diastolic left ventricular properties, the effect of left ventricular
relaxation on the exercise-induced rise in left ventricular filling
pressures of the cardiac allograft has not yet been studied. In the present
study, the response of left ventricular relaxation to exercise was
investigated in transplant recipients and compared with left ventricular
relaxation observed in normal control subjects exercised to the same heart
rate. Moreover, the response of left ventricular relaxation of the cardiac
allograft to beta- adrenoreceptor stimulation, to reduced left ventricular
afterload, and to increased myocardial activator calcium was investigated
by infusion of dobutamine and of nitroprusside and by postextrasystolic
potentiation. METHODS AND RESULTS. Twenty-seven transplant recipients were
studied 1 year (n = 17), 2 years (n = 7), 3 years (n = 2), and 4 years (n =
1) after transplantation. All patients were free of rejection and of
significant graft atherosclerosis at the time of study. Tip-micromanometer
left ventricular pressure recordings and cardiac hemodynamics were obtained
at rest, during supine bicycle exercise stress testing (n = 27), during
dobutamine infusion at a heart rate matching the heart rate at peak
exercise (n = 8), during nitroprusside infusion (n = 9), and after
postextrasystolic potentiation (n = 10). Tip-micromanometer left
ventricular pressure recordings were also obtained in a normal control
group (n = 9) at rest and during supine bicycle exercise stress testing to
a heart rate, which matched the heart rate of the transplant recipient
group at peak exercise. Left ventricular relaxation rate was measured by
calculation of a time constant of left ventricular pressure decay (T)
derived from an exponential curve fit to the digitized tip-micromanometer
left ventricular pressure signal. In the transplant recipients, exercise
abbreviated T from 43 +/- 6 to 40 +/- 8 msec (p less than 0.01) and caused
a rise of left ventricular minimum diastolic pressure (LVMDP) from 5 +/- 2
to 9 +/- 6 mm Hg (p less than 0.001). In normal control subjects, exercise
induced a 2.5 times larger abbreviation of T (from 42 +/- 7 to 34 +/- 6
msec; p less than 0.001) and a small drop in LVMDP from 5 +/- 2 to 4 +/- 3
mm Hg (p less than 0.05). In the transplant recipients, the change in T
(delta T) from rest to exercise was variable ranging from an abbreviation,
as observed in normal controls, to a prolongation and was significantly
correlated with the change in RR interval (delta RR) and the change in left
ventricular end-diastolic pressure (delta LVEDP) (delta T = 0.068 delta RR
+ 0.58 delta LVEDP- 2.2; r = 0.76; p less than 0.001). In a first subset of
transplant recipients (n = 8), dobutamine infusion resulted in a heart rate
equal to the heart rate at peak exercise, a left ventricular end-diastolic
pressure (8 +/- 7 mm Hg) lower than at peak exercise (22 +/- 6 mm Hg; p
less than 0.05) and a T value (32 +/- 9 msec), which was shorter than both
resting value (44 +/- 5 msec; p less than 0.005) and value observed at peak
exercise (40 +/- 8 msec; p less than 0.01). In a second subset of
transplant recipients (n = 9), nitroprusside infusion and postextrasystolic
potentiation resulted in a significant prolongation of T from 41 +/- 7 to
56 +/- 10 msec (p less than 0.05) and a characteristic negative dP/dt
upstroke pattern with downward convexity as previously observed in left
ventricular hypertrophy. CONCLUSIONS. Exercise after cardiac
transplantation resulted in a smaller acceleration of left ventricular
relaxation than in a normal control group exercised to the same heart
rate...
ARTICLES
Deficient acceleration of left ventricular relaxation during exercise after heart transplantation
Cardiovascular Center, O.L.V. Ziekenhuis, Aalst, Belgium.
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