Delayed improvement in skeletal muscle metabolism and exercise capacity in patients with mitral stenosis following immediate hemodynamic amelioration by percutaneous transvenous mitral commissurotomy

doi:10.1016/S0002-9149(97)89343-5

The American Journal of Cardiology

Volume 77, Issue 7, 1 March 1996, Pages 492-497

https://doi.org/10.1016/S0002-9149(97)89343-5 Get rights and content

Abstract

The abrupt improvement in hemodynamics after successful percutaneous transvenous mitral commissurotomy (PTMC) does not immediately enhance exercise capacity. Improved exercise capacity several months after PTMC has been reported. We hypothesized that the delayed improvement in exercise capacity is due partly to the slow improvement in the metabolism of skeletal muscle. This study examined the short- and long-term effects of PTMC on exercise capacity and skeletal muscle metabolism in patients with mitral stenosis. Treadmill exercise testing with respiratory gas analysis was performed in 11 patients with symptomatic mitral stenosis before and 3, 30, and 90 days after successful PTMC. On the same schedule, forearm metabolism of high-energy phosphates was measured by magnetic resonance spectroscopy during and after handgrip exercise. Ten healthy volunteers were also examined. PTMC resulted in an immediate symptomatic improvement. However, exercise capacity and skeletal muscle metabolism remained unchanged 3 days after PTMC. At 30 days after PTMC, there were significant improvements in peak oxygen consumption (p < 0.05), intracellular pH at end-exercise (p < 0.05), and time constant for phosphocreatine recovery (mean ± SD 88.9 ± 11.3 vs 106.3 ± 11.7 seconds, p < 0.01) compared with these baseline values. These improvements remained even at 90 days after PTMC. Exercise capacity improved with some time delay after immediate hemoaynamic amelioration by PTMC. Long-term improvement in exercise capacity depends partly on the slowly progressing improvement in skeletal muscle metabolism after long-standing mitral stenosis.

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Effects of cardiac rehabilitation on physical function and exercise capacity in elderly cardiovascular patients with frailty
2021, Journal of Cardiology
Citation Excerpt :
Moreover the improvement in the physical function needs to precede improvement of exercise capacity, thus accounting for the difference of time duration in improvement between physical function and exercise capacity. Yasu et al. reported that recovery of exercise capacity required the preceding regain of skeletal muscle function as physical function [20]. Furthermore the improvement in exercise capacity by CR in the elderly patients over 75 years has been reported to be almost equivalent to that of younger patients however, elderly patients need to participate in longer-time CR programs over several months to get a similar effect [1,21].
The effects of cardiac rehabilitation (CR) on long-term prognosis of cardiovascular disease (CVD) are well known. However, the effect of CR on frail CVD patients has not been fully addressed.
This study consisted of 89 CVD patients with their age ≥65 years old (68 males, 75 ± 6 years), who participated in the outpatient CR program for 3 months. All the patients underwent cardiopulmonary exercise testing and the physical frailty was assessed using the Japanese Version of the Cardiovascular Health Study Standard before and after CR. Based on the assessment of frailty before CR, the patients were divided into the following two groups: frailty group (n = 23) and non-frailty group (n = 66: robust in 10 and pre-frail in 56 patients).
In the frailty group, 20 patients (87%) improved from frail status after CR, and usual walking speed, maximal grip strength, and lower extremity strength were significantly improved (1.06±0.20 vs. 1.20±0.18 m/sec, p<0.001; 21.7 ± 5.5 vs. 23.6 ± 6.3 kg, p<0.01; 0.37±0.09 vs. 0.43±0.11 kgf/kg, p = 0.001, respectively), but peak VO₂ did not change after CR (15.9 ± 3.1 vs. 16.2 ± 3.8 ml/min/kg, NS). In the non-frailty group, all these parameters were significantly improved after CR (1.24±0.19 vs. 1.29±0.23 m/sec, p<0.05, 28.7 ± 7.0 vs. 30.2 ± 7.3 kg, p<0.001, 0.50±0.18 vs. 0.54±0.13 kgf/kg, p<0.05, 17.7 ± 4.7 vs 18.5 ± 4.2 ml/min/kg, p<0.01, respectively).
Short-term CR could obtain the improvement of the physical function, providing the prerequisite step for possibly following improvement of exercise capacity in elderly CVD patients with frailty. It may be inferred that longer duration of CR would be needed to obtain the improvement of exercise capacity in these patients, being the future consideration to be determined.
2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease)
2008, Journal of the American College of Cardiology
Citation Excerpt :
It is recognized that patients with such severe pulmonary hypertension are rarely asymptomatic. Symptomatic improvement occurs almost immediately after successful percutaneous balloon valvotomy or surgical commissurotomy, although objective measurement of maximum oxygen consumption may continue to improve over several months postoperatively owing to slowly progressive improvement in skeletal muscle metabolism (469). Hemodynamic measurements before and after either percutaneous valvotomy or surgical commissurotomy have confirmed a decrease in left atrial pressure, pulmonary artery pressure, and pulmonary arteriolar resistance and an improvement in cardiac output (470–473).
Usefulness of short-term symptomatic status as a predictor of mid- and long-term outcome after balloon mitral valvuloplasty
2001, American Journal of Cardiology
Lung water, hemodynamics and dyspnea before and after valvuloplasty in mitral stenosis
2000, International Journal of Cardiology
Summary: The investigation was to elucidate the role of the reduction of extravascular pulmonary fluid in the immediate symptomatic improvement and its impact on hemodynamics in patients with mitral stenosis treated by percutaneous transluminal valvuloplasty. Methods: In a prospective study of 12 patients with severe mitral stenosis extravascular pulmonary fluid volume was determined by a combined dye and thermodilution technique (COLD Z-021^TM Version 5.x, Pulsion^®) before and after valvuloplasty. Cardiac output, left atrial pressures, atrial V-waves, diastolic transmitral gradients and their respiratory changes were measured. Dyspnea was assessed by validated questionnaires. Results: Symptomatic improvement correlated (r=0. 808) with a decrease of extravascular lung water, but not with either an increase or a decrease of cardiac output or left atrial filling pressures. The decrease of the lung water index may be predicted from the lung water index before valvuloplasty, the final left atrial mean pressure and the cardiac index prior to intervention. The change of the mean difference between inspiratory and expiratory mitral gradient demonstrated a significant inverse correlation with the change of mean left atrial filling pressures (r=−0.778) and with extravascular lung water after valvuloplasty (r=−0.871). Conclusion: There is a complex relationship between left atrial filling pressures, extravascular lung water, respiratory changes of gradients, and dyspnea that need further investigation.
Determinants of delayed improvement in exercise capacity after percutaneous transvenous mitral commissurotomy
2000, American Heart Journal
Background Percutaneous transvenous mitral commissurotomy (PTMC) results in short-term hemodynamic and symptomatic improvements. We have previously shown that the immediate symptomatic relief is related to the improvement in excessive exercise ventilation. The exercise capacity, however, does not improve in the short term but does improve gradually over several months. The pathophysiologic basis for the delayed improvement in exercise capacity has not been fully evaluated.
Methods To elucidate the determinants of improvement in exercise capacity late after PTMC, maximal ergometer exercise with respiratory gas analysis and exercise hemodynamic measurements were performed in 22 patients with symptomatic mitral stenosis before, immediately after, and 7 months after PTMC.
Results Mitral valve area increased from 0.9 ± 0.2 cm² to 1.7 ± 0.4 cm² after PTMC (P < .01). Significant improvements were observed in symptoms, cardiac output at peak exercise (6.6 ± 1.5 L/min vs 8.6 ± 1.9 L/min, P < .01), and mean pulmonary artery pressure at peak exercise (54.1 ± 15.6 mm Hg vs 42.3 ± 9.5 mm Hg, P < .01) immediately after PTMC. Excessive exercise ventilation, as assessed by the slope of the regression line between expired minute ventilation and carbon dioxide out (VE-VCo₂), decreased significantly from 38.2 ± 8.2 to 33.3 ± 4.9 (P < .01). There were no significnat changes in peak oxygen uptake (from 17.5 ± 3.2 mL/kg per minute to 17.9 ± 3.6 mL/kg per minute) immediately after PTMC. At 7 months, improved mitral valve area, symptoms, cardiac output at peak exercise, mean pulmonary artery pressure at peak exercise, and VE-VCo₂ were unchanged compared with values immediate after PTMC. Significant improvement was observed in peak oxygen uptake (19.7 ± 3.0 mL/kg per minute [P < .01] compared with pre-PTMC or immediate post-PTMC values]). The increase in exercise cardiac output or the decrease in pulmonary artery pressure was not correlated with the improvement in peak oxygen uptake. The short- or long-term improvements in VE-VCo₂, however, were significantly correlated with the late improvement in peak oxygen uptake.
Conclusions Our results suggest that ventilatory improvement, not increased exercise cardiac output, contributed at least in part to the late improvement in exercise capacity after PTMC.
Immediate and delayed effects of successful percutaneous transvenous mitral commissurotomy on global right ventricular function in patients with isolated mitral stenosis
1999, International Journal of Cardiology
Global right ventricular function of the pressure-overloaded right ventricle in patients with mitral stenosis and pulmonary hypertension after successful percutaneous transvenous mitral commissurotomy (PTMC) has not been well-defined. With the use of a recently developed Doppler method for estimating right ventricular function in human beings, we studied 25 consecutive patients with isolated rheumatic mitral stenosis before, immediately after (mean, 40±12 h) and at a mean follow-up of 11.5 months after PTMC. Immediately after percutaneous mitral commissurotomy, there was a significant increase in mitral valve area (P=0.000017) along with a decrease in mean pulmonary pressure (P=0.001). The index was not affected immediately after successful PTMC (0.70±0.25 vs, 0.58±0.18; P=0.06); however, at follow-up of about one year, the index showed a significant decrease (0.697±0.28 vs. 0.380±0.13; P=0.0008, n=24). The change in the index was characterised by a significant prolongation of the right ventricular ejection time, with a decrease in the isovolumic intervals. The Doppler index of combined right ventricular function was significantly correlated to the mean pulmonary artery pressure (r=0.695, P<0.001) and systolic pulmonary artery pressure (r=0.60, P=0.007) before PTMC and also immediately after the procedure; however, at follow-up, the index had no correlation with the Doppler estimated pulmonary artery systolic pressure (r=0.07). Despite a larger mitral valve area following PTMC, right ventricular isovolumic indices remain abnormal on mid-term follow-up, although global function tends to normalise in two-thirds of the patients.

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Delayed improvement in skeletal muscle metabolism and exercise capacity in patients with mitral stenosis following immediate hemodynamic amelioration by percutaneous transvenous mitral commissurotomy

Abstract

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Am Heart J

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Improvement in exercise capacity and exercise hemodynamics 3 months after double-balloon, catheter balloon valvuloplasty treatment of patients with symptomatic mitral stenosis

Circulation

Improvement in mitral flow dynamics during exercise after percutaneous transvenous mitral commissurotomy: noninvasive evaluation using continuous wave Doppler technique

Circulation

Contribution of intrinsic skeletal muscle changes to 31P NMR skeletal muscle metabolic abnormalities in patients with chronic heart failure

Circulation

Role of skeletal muscle metabolism in exercise capacity of patients with myocardial infarction studied by phosphorus-31 nuclear magnetic resonance

Jpn Circ J

Equipment and protocols to evaluate the exercise response

Measurement of the physiological response to exercise

First-order kinetics of muscle oxygen consumption, and an equivalent proportionality between QO2 and phosphorylcreatine level: implications for the control of respiration

J Gen Physiol

Contribution of intrinsic skeletal muscle changes to ³¹P NMR skeletal muscle metabolic abnormalities in patients with chronic heart failure

First-order kinetics of muscle oxygen consumption, and an equivalent proportionality between Q_O2 and phosphorylcreatine level: implications for the control of respiration