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Upright treadmill vs. semi-supine bicycle exercise echocardiography to provoke obstruction in symptomatic
Patricia Reant1,2,3,4, Maxence Dufour1,2, Jerome Peyrou1,2
1CHU de Bordeaux, Hôpital Cardiologique Haut-Lévêque, 1 avenue de Magellan, 33600 Pessac, France.
Insights
Treadmill exercise echocardiography (EE) provoked significantly higher left ventricular outflow tract (LVOT) gradients in hypertrophic cardiomyopathy (HCM) patients compared to semi-supine bicycle EE. This suggests treadmill EE is more valuable for assessing maximum LVOT obstruction in HCM.
Area of Science:
- Cardiology
- Cardiovascular Imaging
- Exercise Physiology
Background:
- Hypertrophic cardiomyopathy (HCM) is associated with left ventricular outflow tract obstruction (LVOTO).
- Hemodynamic assessment in HCM, particularly concerning LVOTO, is influenced by preload and exercise.
- Different exercise modalities may differentially affect peripheral vascular beds and provoke LVOTO.
Purpose of the Study:
- To compare the effectiveness of upright treadmill exercise echocardiography (EE) versus semi-supine bicycle EE in provoking maximal left ventricular outflow tract (LVOT) gradients in patients with hypertrophic cardiomyopathy (HCM).
- To evaluate the relationship between exercise type, preload conditions, and the manifestation of LVOTO in HCM.
Main Methods:
- A prospective study involving 22/23 patients with New York Heart Association functional Class II hypertrophic cardiomyopathy (HCM).
- Patients underwent both semi-supine bicycle and upright treadmill exercise echocardiography (EE).
- Measurements included LVOT gradients at rest (supine, standing, Valsalva) and during/after exercise, maximal exercise capacity, and blood pressure response.
Main Results:
- Mean maximal peak exercise LVOT gradient was significantly higher during treadmill EE (87.5 ± 42.1 mmHg) compared to semi-supine bicycle EE (54.6 ± 38.2 mmHg) (P < 0.01).
- A substantial proportion of patients demonstrated significant LVOT gradients at rest (41%) and during provocative maneuvers (Valsalva 41%, standing 55%).
- Treadmill exercise provoked higher LVOT gradients, with 91% of patients showing gradients ≥50 mmHg at peak exercise and 95% during recovery.
Conclusions:
- Upright treadmill exercise echocardiography appears to be more effective than semi-supine bicycle exercise in provoking maximal left ventricular outflow tract (LVOT) gradients in patients with hypertrophic cardiomyopathy (HCM).
- This pilot study suggests that treadmill EE may be a more valuable tool for assessing the severity of LVOTO in HCM.
Aims:
Recent findings regarding hypertrophic cardiomyopathy (HCM) haemodynamics emphasized the relationship between symptoms, left ventricular outflow tract obstruction (LVOTO), and the preload condition as the venous return level. As various types of exercises have different effects on peripheral vascular beds, this study sought to compare upright treadmill exercise echocardiography (EE) to semi-supine bicycle EE in maximum provoked LVOTO in HCM patients.
Methods And Results:
Semi-supine bicycle and upright treadmill EE were prospectively performed in HCM patients with New York Heart Association functional Class II. Maximal LVOT gradient at rest in the supine and standing position, and during Valsalva manoeuvre, LVOT gradients of both semi-supine bicycle and treadmill exercise at peak and post-exercise, maximal exercise levels, and blood pressure adaptation were recorded. One patient was excluded for not sufficient image quality during treadmill. We studied 22/23 patients (mean age: 54.9 ± 12.3 yrs; 55% male). The supine position at rest displayed a mean maximal LVOT gradient of 46.1 ± 44.8 mmHg, which increased to 51.6 ± 41.2 mmHg during Valsalva (P = 0.066), and to 55.1 ± 37.8 mmHg in the standing position (P = 0.053). Mean maximal peak exercise LVOT gradient with semi-supine bicycle was significantly lower than in treadmill EE (54.6 ± 38.2 mmHg vs. 87.5 ± 42.1 mmHg, respectively, P < 0.01). Among these patients, 41% exhibited LVOT gradient ≥ 30 mmHg at rest. Moreover, 41% exhibited LVOT gradient ≥ 50 mmHg during Valsalva, 55% in resting standing position, 41% at peak semi-supine bicycle exercise, 91% at peak treadmill exercise, and 95% in standing position during treadmill recovery period.
Conclusion:
This pilot study may suggest treadmill's greater value compared to semi-supine bicycle EE for determining maximum LVOT gradient in HCM.
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