array:24 [
  "pii" => "S0870255113000747"
  "issn" => "08702551"
  "doi" => "10.1016/j.repc.2013.03.002"
  "estado" => "S300"
  "fechaPublicacion" => "2013-05-01"
  "aid" => "274"
  "copyright" => "Sociedade Portuguesa de Cardiologia"
  "copyrightAnyo" => "2011"
  "documento" => "article"
  "crossmark" => 0
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "sco"
  "cita" => "Rev Port Cardiol. 2013;32:419-23"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 8215
    "formatos" => array:3 [
      "EPUB" => 240
      "HTML" => 6840
      "PDF" => 1135
    ]
  ]
  "itemSiguiente" => array:20 [
    "pii" => "S0870255112003411"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2012.06.018"
    "estado" => "S300"
    "fechaPublicacion" => "2013-05-01"
    "aid" => "236"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Cardiol. 2013;32:425-30"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 58941
      "formatos" => array:3 [
        "EPUB" => 315
        "HTML" => 55911
        "PDF" => 2715
      ]
    ]
    "pt" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Caso cl&#237;nico</span>"
      "titulo" => "Bloqueio completo de ramo esquerdo&#44; bloqueio auriculoventricular&#44; <span class="elsevierStyleItalic">torsade de pointes</span> e QT longo&#58; ser&#225; demasiado para uma rara miocardiopatia&#63;"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => array:2 [
        0 => "pt"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "425"
          "paginaFinal" => "430"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Left bundle branch block&#44; atrioventricular block&#44; torsade de pointes and long QT syndrome&#58; is this too much for a rare cardiomyopathy&#63;"
        ]
      ]
      "contieneResumen" => array:2 [
        "pt" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0025"
          "etiqueta" => "Figura 5"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr5.jpeg"
              "Alto" => 682
              "Ancho" => 901
              "Tamanyo" => 67337
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Ecocardiograma &#40;esquerda&#41;&#58; apical 4 c&#226;maras revelando imagens compat&#237;veis com VENC a n&#237;vel apical&#59; &#40;direita&#41;&#58; realce das trabecula&#231;&#245;es em ECO 3<span class="elsevierStyleHsp" style=""></span>D &#40;seta&#41;&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Bruno Rodrigues, Emanuel Correia, Lu&#237;s Ferreira Santos, Davide Moreira, Anne Delgado, Pedro Gama, Ant&#243;nio Costa, Jo&#227;o Pipa, Oliveira Santos"
          "autores" => array:9 [
            0 => array:2 [
              "nombre" => "Bruno"
              "apellidos" => "Rodrigues"
            ]
            1 => array:2 [
              "nombre" => "Emanuel"
              "apellidos" => "Correia"
            ]
            2 => array:2 [
              "nombre" => "Lu&#237;s"
              "apellidos" => "Ferreira Santos"
            ]
            3 => array:2 [
              "nombre" => "Davide"
              "apellidos" => "Moreira"
            ]
            4 => array:2 [
              "nombre" => "Anne"
              "apellidos" => "Delgado"
            ]
            5 => array:2 [
              "nombre" => "Pedro"
              "apellidos" => "Gama"
            ]
            6 => array:2 [
              "nombre" => "Ant&#243;nio"
              "apellidos" => "Costa"
            ]
            7 => array:2 [
              "nombre" => "Jo&#227;o"
              "apellidos" => "Pipa"
            ]
            8 => array:2 [
              "nombre" => "Oliveira"
              "apellidos" => "Santos"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2174204913000846"
        "doi" => "10.1016/j.repce.2012.06.008"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913000846?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112003411?idApp=UINPBA00004E"
    "url" => "/08702551/0000003200000005/v1_201308021350/S0870255112003411/v1_201308021350/pt/main.assets"
  ]
  "itemAnterior" => array:20 [
    "pii" => "S0870255113000425"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2012.11.005"
    "estado" => "S300"
    "fechaPublicacion" => "2013-05-01"
    "aid" => "258"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Cardiol. 2013;32:415-7"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 6175
      "formatos" => array:3 [
        "EPUB" => 182
        "HTML" => 4895
        "PDF" => 1098
      ]
    ]
    "pt" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Caso cl&#237;nico</span>"
      "titulo" => "S&#237;ndrome de Brugada e uso de antigripais&#58; existe rela&#231;&#227;o&#63;"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => array:2 [
        0 => "pt"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "415"
          "paginaFinal" => "417"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Brugada syndrome after using cold medicine&#58; Is there any relation&#63;"
        ]
      ]
      "contieneResumen" => array:2 [
        "pt" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figura 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 2297
              "Ancho" => 2927
              "Tamanyo" => 489259
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Padr&#227;o ECG tipo 1 ap&#243;s infus&#227;o de procainamida 10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg em 10&#160;min&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Tiago Luiz Luz Leiria, Augusto Mantovani, Rafael de March Ronsoni, Leonardo Martins Pires, Marcelo Lapa Kruse, Gustavo Glotz de Lima"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "Tiago Luiz Luz"
              "apellidos" => "Leiria"
            ]
            1 => array:2 [
              "nombre" => "Augusto"
              "apellidos" => "Mantovani"
            ]
            2 => array:2 [
              "nombre" => "Rafael"
              "apellidos" => "de March Ronsoni"
            ]
            3 => array:2 [
              "nombre" => "Leonardo"
              "apellidos" => "Martins Pires"
            ]
            4 => array:2 [
              "nombre" => "Marcelo"
              "apellidos" => "Lapa Kruse"
            ]
            5 => array:2 [
              "nombre" => "Gustavo"
              "apellidos" => "Glotz de Lima"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2174204913000858"
        "doi" => "10.1016/j.repce.2012.11.018"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913000858?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000425?idApp=UINPBA00004E"
    "url" => "/08702551/0000003200000005/v1_201308021350/S0870255113000425/v1_201308021350/pt/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
    "titulo" => "Contribution of cardiopulmonary exercise testing to the identification of latent systolic dysfunction in chronic aortic regurgitation"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "419"
        "paginaFinal" => "423"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Giovani Luiz De Santi, Eduardo Elias Vieira de Carvalho, Daniela Caetano Costa, J&#250;lio C&#233;sar Crescencio, Minna Moreira Dias Romano, Andr&#233; Schmidt, Marcus Vin&#237;cius Sim&#245;es, Louren&#231;o Gallo"
        "autores" => array:8 [
          0 => array:4 [
            "nombre" => "Giovani Luiz"
            "apellidos" => "De Santi"
            "email" => array:1 [
              0 => "giovanidesanti&#64;usp&#46;br"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:2 [
            "nombre" => "Eduardo Elias"
            "apellidos" => "Vieira de Carvalho"
          ]
          2 => array:2 [
            "nombre" => "Daniela Caetano"
            "apellidos" => "Costa"
          ]
          3 => array:2 [
            "nombre" => "J&#250;lio C&#233;sar"
            "apellidos" => "Crescencio"
          ]
          4 => array:2 [
            "nombre" => "Minna"
            "apellidos" => "Moreira Dias Romano"
          ]
          5 => array:2 [
            "nombre" => "Andr&#233;"
            "apellidos" => "Schmidt"
          ]
          6 => array:2 [
            "nombre" => "Marcus Vin&#237;cius"
            "apellidos" => "Sim&#245;es"
          ]
          7 => array:3 [
            "nombre" => "Louren&#231;o"
            "apellidos" => "Gallo"
            "sufijo" => "Junior"
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Division of Cardiology&#44; Medical School of Ribeir&#227;o Preto&#44; University of S&#227;o Paulo&#44; S&#227;o Paulo&#44; Brazil"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#42;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "Contribui&#231;&#227;o do teste cardiopulmonar na identifica&#231;&#227;o da disfun&#231;&#227;o sist&#243;lica latente na insufici&#234;ncia a&#243;rtica cr&#244;nica"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1495
            "Ancho" => 1495
            "Tamanyo" => 141000
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">LVOT MRI image showing a severe regurgitant jet in the aortic valve with regurgitant fraction of 84&#37;&#46; AO&#58; aorta&#59; LA&#58; left atrium&#59; LV&#58; left ventricle&#59; RJ&#58; regurgitant jet&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiopulmonary exercise testing &#40;CPET&#41; is well established as a useful tool for the evaluation of functional capacity in various forms of heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Among the commonly assessed variables&#44; peak oxygen uptake &#40;VO<span class="elsevierStyleInf">2</span>&#41; is extensively used for the serial evaluation of patients with heart failure who are candidates for heart transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Emerging variables such as VE&#47;VCO<span class="elsevierStyleInf">2</span> slope and periodic breathing are valuable for the prognostic evaluation of patients with symptomatic ventricular dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Oxygen pulse&#44; defined as the ratio of oxygen uptake to heart rate and expressed as ml&#47;bpm&#44; is closely related to stroke volume&#44; and is used as a parameter for the assessment of systolic performance&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is thus a potential variable for the diagnosis of heart disease that follows a similar course with systolic dysfunction during exercise&#46; However&#44; this diagnostic application of CPET continues to be underutilized&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 58-year-old woman with a diagnosis of chronic aortic regurgitation &#40;AR&#41; in whom the behavior of CPET variables indicated the presence of latent left ventricular &#40;LV&#41; systolic dysfunction&#46; This diagnosis was confirmed by echocardiographic findings during exercise stress&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 58-year-old black woman&#44; BMI 33&#46;2 kg&#47;m<span class="elsevierStyleSup">2</span> &#40;weight 71&#46;8 kg&#59; height 1&#46;47 m&#41;&#44; with a history of hypertension and under regular treatment with losartan potassium&#44; hydrochlorothiazide and pantoprazole&#44; reported a history of progressive exertional dyspnea of six years&#8217; duration and resting dyspnea and episodes of nocturnal paroxysmal dyspnea during the last few months&#46; Physical examination revealed an active&#44; eupneic&#44; afebrile&#44; acyanotic&#44; anicteric patient with pink and moist mucous membranes and without jugular distension&#46; Pulmonary auscultation revealed no abnormalities in either lung field&#46; Cardiomegaly was absent and cardiac rhythm was regular with normal heart sounds&#44; but an early-mid-diastolic respiratory murmur was present over the aortic area &#40;2&#43;&#47;6&#43;&#41;&#46; Blood pressure was 140&#47;60 mmHg and heart rate was 76 bpm&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A conventional resting electrocardiogram showed sinus rhythm&#44; heart rate of 78 bpm and left ventricular overload&#46; A chest X-ray revealed a normal cardiothoracic index and no signs of pulmonary congestion&#46; A resting Doppler echocardiogram revealed aortic regurgitation&#44; defined as moderate based on the slope of the deceleration curve in diastole &#40;slope 354 cm&#47;s<span class="elsevierStyleSup">2</span>&#41; and no holodiastolic retrograde blood flow in the abdominal aorta &#40;score 6&#41;&#46; The eccentricity of the regurgitant jet limited the possibility of using the width and area of the aortic regurgitation jet as parameters to classify the severity of the valvulopathy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41;&#46; There was eccentric LV hypertrophy but no signs suggestive of pulmonary arterial hypertension&#46; The following chamber diameters and volumes were calculated&#58; left atrial diameter 38 mm&#44; end-diastolic LV diameter 64 mm&#44; end-systolic LV diameter 42 mm&#44; end-diastolic LV volume 142 ml&#44; and end-systolic LV volume 57 ml&#46; Global systolic function defined by ejection fraction as calculated by Simpson&#39;s method was 59&#37;&#46; Peak and mean aortic valve gradients were not calculated &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In view of this discrepancy between the symptoms reported by the patient and the echocardiographic findings&#44; CPET was scheduled in order to obtain an objective assessment of the patient&#39;s functional capacity&#46; Using the Balke protocol&#44; with a fixed speed of 2&#46;0 mph and 2&#37; slope increments per minute&#44; the maximum work achieved by the patient was 14&#37; inclination at 2&#46;0 mph&#46; The patient&#39;s heart rate showed a physiological behavior during exercise&#44; starting at a resting heart rate of 78 bpm and reaching 141 bpm at peak exercise &#40;87&#37; of maximum predicted heart rate&#41;&#46; Similarly&#44; the behavior of blood pressure during the test was normal&#44; starting exercise at a resting blood pressure of 130&#47;70 mmHg and reaching 175&#47;70 mmHg at peak exercise&#46; Throughout the test&#44; the electrocardiogram showed no changes in ventricular repolarization suggestive of myocardial ischemia&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The following maximum values of the conventional CPET variables were obtained&#58; minute ventilation &#40;VE&#41; 32&#46;7 l&#47;min&#44; VO<span class="elsevierStyleInf">2</span> 847&#46;2 ml&#47;min&#44; peak carbon dioxide production &#40;VCO<span class="elsevierStyleInf">2</span>&#41; 886&#46;2 ml&#47;min&#44; and respiratory exchange ratio 1&#46;07&#46; The ventilatory anaerobic threshold was identified at 6 minutes 16 seconds at a speed of 2&#46;0 mph and 4&#37; inclination&#44; with VO<span class="elsevierStyleInf">2</span> of 10&#46;6 ml&#47;kg&#47;min at a heart rate of 105 bpm and blood pressure of 145&#47;70 mmHg&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">During the initial phase of exercise&#44; VE and VO<span class="elsevierStyleInf">2</span> increased linearly&#59; however&#44; the VO<span class="elsevierStyleInf">2</span> curve reached a plateau after the sixth minute&#44; whereas VE maintained a linear increase &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Heart rate showed a linear increase proportional to the increase in work&#44; whereas oxygen pulse showed a plateau behavior with a slight decline at peak exercise suggestive of a fall in LV ejection volume during exercise&#46; The highest oxygen pulse value reached during exercise was 8 ml&#47;systole &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; It should be pointed out that normal values range from 4 to 6 ml&#47;systole at rest&#44; but can reach 10&#8211;20 ml&#47;systole at peak exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In order to confirm the role of systolic dysfunction during exercise as the cause of the plateau followed by a fall in oxygen pulse during CPET&#44; a Doppler echocardiographic study during dynamic physical exercise was performed using the same exercise protocol employed for CPET&#46; Under these conditions&#44; the following results were obtained at peak exercise compared to rest&#58; increases in LV end-diastolic diameter from 64 to 68 mm&#44; in LV end-systolic volume from 57 to 91 ml&#44; and in end-diastolic volume from 142 to 159 ml&#44; and a fall in ejection fraction from 59 to 42&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C&#41;&#46; LV ejection fraction was also evaluated by radioisotope ventriculography at rest and during dynamic physical exercise&#44; with 61&#37; being observed at rest and 47&#37; at peak exercise&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Cardiac MRI was also performed for comparison with the Doppler echocardiographic study in order to estimate the severity of aortic regurgitation&#44; with the following results&#58; left atrial diameter 40 mm&#44; end-diastolic volume 114&#46;3 ml&#44; end-systolic volume 47&#46;3 ml&#44; LV ejection fraction 58&#46;6&#37;&#44; anterograde flow 46&#46;5 ml&#44; retrograde flow 39&#46;0 ml&#44; and regurgitant fraction 84&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; These cardiac MRI parameters characterize the aortic regurgitation as severe&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Cardiac catheterization &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41; demonstrated coronary artery circulation free of obstructive lesions and cineventriculography revealed normal LV segmental wall motion&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">We report a clear discordance in a patient with chronic AR between the clinical manifestations and the estimated severity of valvular heart disease evaluated by initial resting Doppler echocardiographic study&#46; In this clinical context&#44; it is extremely important to characterize the symptoms meticulously&#44; especially in patients who complain of dyspnea&#44; in order to avoid over-hasty surgical indication for patients with symptoms that may not be due to valve damage&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Chronic AR influences the dynamics of homeostasis of the circulating intravascular volume and can lead to a redistribution of body fluids that may explain the nocturnal paroxysmal dyspnea that can occur as an isolated symptom in low functional class patients&#46; Dyspnea is a subjective symptom that is multifactorial in nature and the patient&#39;s sedentarism&#44; obesity and low cardiorespiratory fitness definitely influenced the sensation of resting dyspnea she reported&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Symptoms of progressive dyspnea may be attributed to heart failure with normal ejection fraction &#40;&#8220;diastolic heart failure&#8221;&#41; secondary to hypertension and LV hypertrophy&#46; However&#44; the patient did not fulfill criteria of heart failure&#44; with a normal ejection fraction being observed on Doppler echocardiographic study&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Type B natriuretic peptide was not measured&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In view of the large number of clinical conditions that can influence oxygen pulse&#44; especially pulmonary disease&#44; we performed spirometry&#44; which revealed no ventilatory disorder with an obstructive or restrictive pattern&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In this case&#44; analysis of CPET ventilatory variables demonstrated significant limitation of functional capacity&#44; reflected by low maximum oxygen uptake &#40;peak VO<span class="elsevierStyleInf">2</span> of 11&#46;8 ml&#47;kg&#47;min&#41; associated with flattening of the VO<span class="elsevierStyleInf">2</span> curve&#46; In addition&#44; the oxygen pulse curve showed a plateau followed by a fall at peak dynamic physical exercise&#46; Taken together&#44; these findings demonstrate impaired LV systolic function during exercise&#44; indicating a severe functional repercussion of aortic regurgitation&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Although the VO<span class="elsevierStyleInf">2</span> and oxygen pulse curves showed significant LV systolic dysfunction during CPET&#44; the hemodynamic parameters monitored &#40;heart rate and blood pressure&#41; presented normal behavior&#46; These findings are of major significance&#44; since a fall in blood pressure is a specific indicator of impaired ventricular function during exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; the results obtained suggest that ventilatory variables were more sensitive than hemodynamic ones in identifying LV systolic dysfunction during exercise&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The stress Doppler echocardiogram confirmed the existence of systolic LV dysfunction during dynamic physical exercise&#44; characterized by increased end-systolic volume accompanied by a marked fall in LV ejection fraction&#46; These findings were clearly correlated with those observed during CPET&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">CPET is not routinely applied in the context of valvular heart disease&#46; It is more indicated to identify reduced exercise tolerance and to trigger symptoms in patients who are apparently asymptomatic despite the presence of valvular disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Despite the scarcity of reports of this nature&#44; in this patient with chronic AR CPET was able to demonstrate not only her low functional capacity&#44; but also significant hemodynamic involvement due to valvulopathy during dynamic physical exercise&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">It should be pointed out that chronic AR is a valvulopathy of slow and insidious evolution&#44; and patients may remain asymptomatic for a long period of time&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> The complex pathophysiological mechanisms involved make it difficult to select the best therapeutic approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;12</span></a> For this reason&#44; chronic AR is a challenge for cardiologists regarding the best time for surgery&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">According to current guidelines&#44; the following clinical conditions are considered to be class I evidence recommendations for valve surgery in severe chronic AR&#58; in symptomatic patients or patients with LV ejection fraction lower than 50&#37; at rest&#44; or concomitantly with coronary artery bypass grafting or surgery on the aorta or other heart valves&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;12</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">After clinical discussion&#44; considering the symptoms reported&#44; the estimated severity of aortic regurgitation by cardiac MRI and the effects of CPET on ventilatory variables&#44; it was decided to refer the patient for valve surgery&#44; which was performed successfully&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Within this context&#44; the judicious use of CPET is presented as a method for quantification of cardiac reserve that can aid in investigation and clinical management of patients with chronic AR&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">Research supported by <span class="elsevierStyleGrantSponsor" id="gs0005">FAEPA HCFMRP-USP</span>&#44; <span class="elsevierStyleGrantSponsor" id="gs0010">FAPESP</span>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:10 [
        0 => array:2 [
          "identificador" => "xres251358"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec238956"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres251359"
          "titulo" => "Resumo"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec238957"
          "titulo" => "Palavras-chave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case report"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Funding"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflicts of interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-02-17"
    "fechaAceptado" => "2012-10-11"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec238956"
          "palabras" => array:3 [
            0 => "Chronic aortic regurgitation"
            1 => "Cardiopulmonary exercise test"
            2 => "Left ventricular dysfunction"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec238957"
          "palabras" => array:3 [
            0 => "Insufici&#234;ncia a&#243;rtica cr&#244;nica"
            1 => "Teste cardiopulmonar"
            2 => "Disfun&#231;&#227;o ventricular esquerda"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chronic aortic regurgitation &#40;AR&#41; is a valvulopathy of slow and insidious evolution&#44; and patients may remain asymptomatic for a long period of time&#46; Exercise-induced systolic dysfunction occurs during the natural history of chronic AR and is related to changes in both preload and afterload&#46; We describe the case of a 58-year-old woman with a diagnosis of chronic AR who reported progressive dyspnea of six years&#8217; duration&#46; A cardiopulmonary exercise test to assess functional capacity showed flattening of both oxygen uptake and oxygen pulse curves&#44; suggesting latent systolic dysfunction related to chronic AR&#44; which was later confirmed by stress Doppler echocardiogram with dynamic physical exercise&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A Insufici&#234;ncia A&#243;rtica Cr&#244;nica &#40;IAC&#41; &#233; uma valvulopatia de evolu&#231;&#227;o lenta e insidiosa podendo o paciente manter-se assintom&#225;tico por longo per&#237;odo de tempo&#46; A disfun&#231;&#227;o sist&#243;lica induzida pelo esfor&#231;o ocorre durante a hist&#243;ria natural da IAC estando relacionada com altera&#231;&#245;es nos componentes tanto da pr&#233;-carga quanto da p&#243;s-carga&#46; Apresentamos o caso de uma paciente do g&#233;nero feminino&#44; de 58 anos&#44; com diagn&#243;stico de IAC que referia queixa de dispneia progressiva com evolu&#231;&#227;o de seis anos&#46; O teste cardiopulmonar foi indicado com intuito de avaliar a capacidade funcional e mostrou plat&#244; das curvas de consumo de oxig&#233;nio e de pulso de oxig&#233;nio&#44; sugerindo disfun&#231;&#227;o sist&#243;lica latente relacionada &#224; insufici&#234;ncia a&#243;rtica cr&#244;nica&#59; condi&#231;&#227;o posteriormente confirmada pelo Doppler-ecocardiograma de estresse com esfor&#231;o f&#237;sico din&#226;mico&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1177
            "Ancho" => 2168
            "Tamanyo" => 216890
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Baseline Doppler echocardiogram showing aortic regurgitation jet &#40;A&#41;&#44; end-systolic volume &#40;57 ml&#41; and left ventricular ejection fraction at rest &#40;59&#37;&#41; &#40;B&#41;&#59; stress Doppler echocardiogram showing end-systolic volume &#40;91 ml&#41; and left ventricular ejection fraction at peak exercise &#40;42&#37;&#41; &#40;C&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1663
            "Ancho" => 2186
            "Tamanyo" => 219557
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Response of the ventilatory variables during CPET&#58; VE &#40;l&#47;min&#41;&#44; VO<span class="elsevierStyleInf">2</span> &#40;ml&#47;min&#41; and VCO<span class="elsevierStyleInf">2</span> &#40;ml&#47;min&#41;&#46; The vertical bars indicate the beginning and end of exercise&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1674
            "Ancho" => 2198
            "Tamanyo" => 187488
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Heart rate &#40;bpm&#41;&#44; VO<span class="elsevierStyleInf">2</span> &#40;ml&#47;min&#41; and oxygen pulse &#40;VO<span class="elsevierStyleInf">2</span>&#47;HR &#91;ml&#47;systole&#93; responses&#46; The vertical bars indicate the beginning and end of exercise&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1495
            "Ancho" => 1495
            "Tamanyo" => 141000
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">LVOT MRI image showing a severe regurgitant jet in the aortic valve with regurgitant fraction of 84&#37;&#46; AO&#58; aorta&#59; LA&#58; left atrium&#59; LV&#58; left ventricle&#59; RJ&#58; regurgitant jet&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1097
            "Ancho" => 2162
            "Tamanyo" => 181411
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cine coronary angiography images showing absence of obstructive lesions in the right &#40;A&#41; and left &#40;B&#41; coronary arteries&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:12 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Statement on cardiopulmonary exercise testing in chronic heart failure due to left ventricular dysfunction&#58; recommendations for performance and interpretation&#46; Part III&#58; Interpretation of cardiopulmonary exercise testing in chronic heart failure and future applications"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Task Force of the Italian Working Group on Cardiac Rehabilitation and Prevention &#40;Gruppo Italiano di Cardiologia Riabilitativa e Prevenzione&#44; GICR&#41;&#59; Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.hjr.0000201518.43837.bc"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Cardiovasc Prev Rehabil"
                        "fecha" => "2006"
                        "volumen" => "13"
                        "paginaInicial" => "485"
                        "paginaFinal" => "494"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16874136"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "24th Bethesda Conference&#58; cardiac transplantation&#46; Task force 3&#58; recipient guidelines&#47;priorization"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "G&#46;H&#46; Mudge"
                            1 => "S&#46; Goldstein"
                            2 => "L&#46;J&#46; Addonizio"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "1993"
                        "volumen" => "22"
                        "paginaInicial" => "21"
                        "paginaFinal" => "31"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8509544"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilatory abnormalities during exercise in heart failure&#58; a mini review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46; Arena"
                            1 => "M&#46; Guazzi"
                            2 => "J&#46; Myers"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Curr Respir Med Rev"
                        "fecha" => "2007"
                        "volumen" => "3"
                        "paginaInicial" => "179"
                        "paginaFinal" => "187"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "ATS&#47;ACCP Statement on Cardiopulmonary Exercise Testing"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.167.2.211"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "167"
                        "paginaInicial" => "211"
                        "paginaFinal" => "277"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12524257"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Bonow RO&#44; Carabello BA&#44; Chatterjee K&#44; et al&#46; Focused update incorporated into the ACC&#47;AHA 2006 guidelines for the management of patients with valvular heart disease&#46; J Am Coll Cardiol&#46; 2008&#59;52&#58;e1-142&#46;"
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "American Thoracic Society Committee on Dyspnea&#46; An official American Thoracic Society statement&#58; update on the mechanisms&#44; assessment&#44; and management of dyspnea"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;B&#46; Parshall"
                            1 => "R&#46;M&#46; Schwartzstein"
                            2 => "L&#46; Adams"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.201111-2042ST"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2012"
                        "volumen" => "185"
                        "paginaInicial" => "435"
                        "paginaFinal" => "452"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22336677"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical assessment of left ventricular diastolic function"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46;G&#46; Gibson"
                            1 => "D&#46;P&#46; Francis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Heart"
                        "fecha" => "2003"
                        "volumen" => "89"
                        "paginaInicial" => "231"
                        "paginaFinal" => "238"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12527689"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sociedade Brasileira de Cardiologia&#46; III Diretrizes da Sociedade Brasileira de Cardiologia sobre Teste Ergom&#233;trico"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46;S&#46; Meneghelo"
                            1 => "C&#46;G&#46;S&#46; Ara&#250;jo"
                            2 => "R&#46; Stein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Arq Bras Cardiol"
                        "fecha" => "2010"
                        "volumen" => "95"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "1"
                        "paginaFinal" => "26"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21340292"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Stress testing in valve disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "L&#46;A&#46; Pierard"
                            1 => "P&#46; Lancellotti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/hrt.2005.074815"
                      "Revista" => array:6 [
                        "tituloSerie" => "Heart"
                        "fecha" => "2007"
                        "volumen" => "93"
                        "paginaInicial" => "766"
                        "paginaFinal" => "772"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17502660"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Natural history of aortic and mitral valve disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "E&#46; Rappaport"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "1975"
                        "volumen" => "35"
                        "paginaInicial" => "221"
                        "paginaFinal" => "227"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1119381"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Serial long-term assessment of natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46;O&#46; Bonow"
                            1 => "E&#46; Lakatos"
                            2 => "B&#46;J&#46; Maron"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "1991"
                        "volumen" => "84"
                        "paginaInicial" => "1625"
                        "paginaFinal" => "1635"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1914102"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diretriz Brasileira de Valvopatias &#8211; SBC 2011&#47;I Diretriz Interamericana de Valvopatias &#8211; SCAR 2011"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "F&#46; Tarasoutchi"
                            1 => "M&#46;W&#46; Montera"
                            2 => "M&#46; Grinberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Arq Bras Cardiol"
                        "fecha" => "2011"
                        "volumen" => "97"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "1"
                        "paginaFinal" => "67"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22262107"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/08702551/0000003200000005/v1_201308021350/S0870255113000747/v1_201308021350/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "362"
    "tipo" => "SECCION"
    "pt" => array:2 [
      "titulo" => "Casos cl&#237;nicos"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "pt"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003200000005/v1_201308021350/S0870255113000747/v1_201308021350/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000747?idApp=UINPBA00004E"
]
Partilhar
Informação da revista
Vol. 32. Núm. 5.
Páginas 419-423 (maio 2013)
Partilhar
Partilhar
Baixar PDF
Mais opções do artigo
Visitas
13839
Vol. 32. Núm. 5.
Páginas 419-423 (maio 2013)
Case report
Open Access
Contribution of cardiopulmonary exercise testing to the identification of latent systolic dysfunction in chronic aortic regurgitation
Contribuição do teste cardiopulmonar na identificação da disfunção sistólica latente na insuficiência aórtica crônica
Visitas
13839
Giovani Luiz De Santi
Autor para correspondência
giovanidesanti@usp.br

Corresponding author.
, Eduardo Elias Vieira de Carvalho, Daniela Caetano Costa, Júlio César Crescencio, Minna Moreira Dias Romano, André Schmidt, Marcus Vinícius Simões, Lourenço Gallo Junior
Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
Este item recebeu

Under a Creative Commons license
Informação do artigo
Resume
Texto Completo
Bibliografia
Baixar PDF
Estatísticas
Figuras (5)
Mostrar maisMostrar menos
Abstract

Chronic aortic regurgitation (AR) is a valvulopathy of slow and insidious evolution, and patients may remain asymptomatic for a long period of time. Exercise-induced systolic dysfunction occurs during the natural history of chronic AR and is related to changes in both preload and afterload. We describe the case of a 58-year-old woman with a diagnosis of chronic AR who reported progressive dyspnea of six years’ duration. A cardiopulmonary exercise test to assess functional capacity showed flattening of both oxygen uptake and oxygen pulse curves, suggesting latent systolic dysfunction related to chronic AR, which was later confirmed by stress Doppler echocardiogram with dynamic physical exercise.

Keywords:
Chronic aortic regurgitation
Cardiopulmonary exercise test
Left ventricular dysfunction
Resumo

A Insuficiência Aórtica Crônica (IAC) é uma valvulopatia de evolução lenta e insidiosa podendo o paciente manter-se assintomático por longo período de tempo. A disfunção sistólica induzida pelo esforço ocorre durante a história natural da IAC estando relacionada com alterações nos componentes tanto da pré-carga quanto da pós-carga. Apresentamos o caso de uma paciente do género feminino, de 58 anos, com diagnóstico de IAC que referia queixa de dispneia progressiva com evolução de seis anos. O teste cardiopulmonar foi indicado com intuito de avaliar a capacidade funcional e mostrou platô das curvas de consumo de oxigénio e de pulso de oxigénio, sugerindo disfunção sistólica latente relacionada à insuficiência aórtica crônica; condição posteriormente confirmada pelo Doppler-ecocardiograma de estresse com esforço físico dinâmico.

Palavras-chave:
Insuficiência aórtica crônica
Teste cardiopulmonar
Disfunção ventricular esquerda
Texto Completo
Introduction

Cardiopulmonary exercise testing (CPET) is well established as a useful tool for the evaluation of functional capacity in various forms of heart disease.1 Among the commonly assessed variables, peak oxygen uptake (VO2) is extensively used for the serial evaluation of patients with heart failure who are candidates for heart transplantation.2 Emerging variables such as VE/VCO2 slope and periodic breathing are valuable for the prognostic evaluation of patients with symptomatic ventricular dysfunction.3 Oxygen pulse, defined as the ratio of oxygen uptake to heart rate and expressed as ml/bpm, is closely related to stroke volume, and is used as a parameter for the assessment of systolic performance.4 It is thus a potential variable for the diagnosis of heart disease that follows a similar course with systolic dysfunction during exercise. However, this diagnostic application of CPET continues to be underutilized.

We report the case of a 58-year-old woman with a diagnosis of chronic aortic regurgitation (AR) in whom the behavior of CPET variables indicated the presence of latent left ventricular (LV) systolic dysfunction. This diagnosis was confirmed by echocardiographic findings during exercise stress.

Case report

A 58-year-old black woman, BMI 33.2 kg/m2 (weight 71.8 kg; height 1.47 m), with a history of hypertension and under regular treatment with losartan potassium, hydrochlorothiazide and pantoprazole, reported a history of progressive exertional dyspnea of six years’ duration and resting dyspnea and episodes of nocturnal paroxysmal dyspnea during the last few months. Physical examination revealed an active, eupneic, afebrile, acyanotic, anicteric patient with pink and moist mucous membranes and without jugular distension. Pulmonary auscultation revealed no abnormalities in either lung field. Cardiomegaly was absent and cardiac rhythm was regular with normal heart sounds, but an early-mid-diastolic respiratory murmur was present over the aortic area (2+/6+). Blood pressure was 140/60 mmHg and heart rate was 76 bpm.

A conventional resting electrocardiogram showed sinus rhythm, heart rate of 78 bpm and left ventricular overload. A chest X-ray revealed a normal cardiothoracic index and no signs of pulmonary congestion. A resting Doppler echocardiogram revealed aortic regurgitation, defined as moderate based on the slope of the deceleration curve in diastole (slope 354 cm/s2) and no holodiastolic retrograde blood flow in the abdominal aorta (score 6). The eccentricity of the regurgitant jet limited the possibility of using the width and area of the aortic regurgitation jet as parameters to classify the severity of the valvulopathy (Figure 1A). There was eccentric LV hypertrophy but no signs suggestive of pulmonary arterial hypertension. The following chamber diameters and volumes were calculated: left atrial diameter 38 mm, end-diastolic LV diameter 64 mm, end-systolic LV diameter 42 mm, end-diastolic LV volume 142 ml, and end-systolic LV volume 57 ml. Global systolic function defined by ejection fraction as calculated by Simpson's method was 59%. Peak and mean aortic valve gradients were not calculated (Figure 1B).

Figure 1.

Baseline Doppler echocardiogram showing aortic regurgitation jet (A), end-systolic volume (57 ml) and left ventricular ejection fraction at rest (59%) (B); stress Doppler echocardiogram showing end-systolic volume (91 ml) and left ventricular ejection fraction at peak exercise (42%) (C).

(0.21MB).

In view of this discrepancy between the symptoms reported by the patient and the echocardiographic findings, CPET was scheduled in order to obtain an objective assessment of the patient's functional capacity. Using the Balke protocol, with a fixed speed of 2.0 mph and 2% slope increments per minute, the maximum work achieved by the patient was 14% inclination at 2.0 mph. The patient's heart rate showed a physiological behavior during exercise, starting at a resting heart rate of 78 bpm and reaching 141 bpm at peak exercise (87% of maximum predicted heart rate). Similarly, the behavior of blood pressure during the test was normal, starting exercise at a resting blood pressure of 130/70 mmHg and reaching 175/70 mmHg at peak exercise. Throughout the test, the electrocardiogram showed no changes in ventricular repolarization suggestive of myocardial ischemia.

The following maximum values of the conventional CPET variables were obtained: minute ventilation (VE) 32.7 l/min, VO2 847.2 ml/min, peak carbon dioxide production (VCO2) 886.2 ml/min, and respiratory exchange ratio 1.07. The ventilatory anaerobic threshold was identified at 6 minutes 16 seconds at a speed of 2.0 mph and 4% inclination, with VO2 of 10.6 ml/kg/min at a heart rate of 105 bpm and blood pressure of 145/70 mmHg.

During the initial phase of exercise, VE and VO2 increased linearly; however, the VO2 curve reached a plateau after the sixth minute, whereas VE maintained a linear increase (Figure 2).

Figure 2.

Response of the ventilatory variables during CPET: VE (l/min), VO2 (ml/min) and VCO2 (ml/min). The vertical bars indicate the beginning and end of exercise.

(0.21MB).

Heart rate showed a linear increase proportional to the increase in work, whereas oxygen pulse showed a plateau behavior with a slight decline at peak exercise suggestive of a fall in LV ejection volume during exercise. The highest oxygen pulse value reached during exercise was 8 ml/systole (Figure 3). It should be pointed out that normal values range from 4 to 6 ml/systole at rest, but can reach 10–20 ml/systole at peak exercise.4

Figure 3.

Heart rate (bpm), VO2 (ml/min) and oxygen pulse (VO2/HR [ml/systole] responses. The vertical bars indicate the beginning and end of exercise.

(0.18MB).

In order to confirm the role of systolic dysfunction during exercise as the cause of the plateau followed by a fall in oxygen pulse during CPET, a Doppler echocardiographic study during dynamic physical exercise was performed using the same exercise protocol employed for CPET. Under these conditions, the following results were obtained at peak exercise compared to rest: increases in LV end-diastolic diameter from 64 to 68 mm, in LV end-systolic volume from 57 to 91 ml, and in end-diastolic volume from 142 to 159 ml, and a fall in ejection fraction from 59 to 42% (Figure 1C). LV ejection fraction was also evaluated by radioisotope ventriculography at rest and during dynamic physical exercise, with 61% being observed at rest and 47% at peak exercise.

Cardiac MRI was also performed for comparison with the Doppler echocardiographic study in order to estimate the severity of aortic regurgitation, with the following results: left atrial diameter 40 mm, end-diastolic volume 114.3 ml, end-systolic volume 47.3 ml, LV ejection fraction 58.6%, anterograde flow 46.5 ml, retrograde flow 39.0 ml, and regurgitant fraction 84% (Figure 4). These cardiac MRI parameters characterize the aortic regurgitation as severe.

Figure 4.

LVOT MRI image showing a severe regurgitant jet in the aortic valve with regurgitant fraction of 84%. AO: aorta; LA: left atrium; LV: left ventricle; RJ: regurgitant jet.

(0.13MB).

Cardiac catheterization (Figure 5) demonstrated coronary artery circulation free of obstructive lesions and cineventriculography revealed normal LV segmental wall motion.

Figure 5.

Cine coronary angiography images showing absence of obstructive lesions in the right (A) and left (B) coronary arteries.

(0.17MB).
Discussion

We report a clear discordance in a patient with chronic AR between the clinical manifestations and the estimated severity of valvular heart disease evaluated by initial resting Doppler echocardiographic study. In this clinical context, it is extremely important to characterize the symptoms meticulously, especially in patients who complain of dyspnea, in order to avoid over-hasty surgical indication for patients with symptoms that may not be due to valve damage.5

Chronic AR influences the dynamics of homeostasis of the circulating intravascular volume and can lead to a redistribution of body fluids that may explain the nocturnal paroxysmal dyspnea that can occur as an isolated symptom in low functional class patients. Dyspnea is a subjective symptom that is multifactorial in nature and the patient's sedentarism, obesity and low cardiorespiratory fitness definitely influenced the sensation of resting dyspnea she reported.6

Symptoms of progressive dyspnea may be attributed to heart failure with normal ejection fraction (“diastolic heart failure”) secondary to hypertension and LV hypertrophy. However, the patient did not fulfill criteria of heart failure, with a normal ejection fraction being observed on Doppler echocardiographic study.7 Type B natriuretic peptide was not measured.

In view of the large number of clinical conditions that can influence oxygen pulse, especially pulmonary disease, we performed spirometry, which revealed no ventilatory disorder with an obstructive or restrictive pattern.

In this case, analysis of CPET ventilatory variables demonstrated significant limitation of functional capacity, reflected by low maximum oxygen uptake (peak VO2 of 11.8 ml/kg/min) associated with flattening of the VO2 curve. In addition, the oxygen pulse curve showed a plateau followed by a fall at peak dynamic physical exercise. Taken together, these findings demonstrate impaired LV systolic function during exercise, indicating a severe functional repercussion of aortic regurgitation.

Although the VO2 and oxygen pulse curves showed significant LV systolic dysfunction during CPET, the hemodynamic parameters monitored (heart rate and blood pressure) presented normal behavior. These findings are of major significance, since a fall in blood pressure is a specific indicator of impaired ventricular function during exercise.8 However, the results obtained suggest that ventilatory variables were more sensitive than hemodynamic ones in identifying LV systolic dysfunction during exercise.

The stress Doppler echocardiogram confirmed the existence of systolic LV dysfunction during dynamic physical exercise, characterized by increased end-systolic volume accompanied by a marked fall in LV ejection fraction. These findings were clearly correlated with those observed during CPET.

CPET is not routinely applied in the context of valvular heart disease. It is more indicated to identify reduced exercise tolerance and to trigger symptoms in patients who are apparently asymptomatic despite the presence of valvular disease.5,8,9

Despite the scarcity of reports of this nature, in this patient with chronic AR CPET was able to demonstrate not only her low functional capacity, but also significant hemodynamic involvement due to valvulopathy during dynamic physical exercise.

It should be pointed out that chronic AR is a valvulopathy of slow and insidious evolution, and patients may remain asymptomatic for a long period of time.10,11 The complex pathophysiological mechanisms involved make it difficult to select the best therapeutic approach.5,12 For this reason, chronic AR is a challenge for cardiologists regarding the best time for surgery.

According to current guidelines, the following clinical conditions are considered to be class I evidence recommendations for valve surgery in severe chronic AR: in symptomatic patients or patients with LV ejection fraction lower than 50% at rest, or concomitantly with coronary artery bypass grafting or surgery on the aorta or other heart valves.5,12

After clinical discussion, considering the symptoms reported, the estimated severity of aortic regurgitation by cardiac MRI and the effects of CPET on ventilatory variables, it was decided to refer the patient for valve surgery, which was performed successfully.

Within this context, the judicious use of CPET is presented as a method for quantification of cardiac reserve that can aid in investigation and clinical management of patients with chronic AR.

Funding

Research supported by FAEPA HCFMRP-USP, FAPESP.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
Task Force of the Italian Working Group on Cardiac Rehabilitation and Prevention (Gruppo Italiano di Cardiologia Riabilitativa e Prevenzione, GICR); Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology.
Statement on cardiopulmonary exercise testing in chronic heart failure due to left ventricular dysfunction: recommendations for performance and interpretation. Part III: Interpretation of cardiopulmonary exercise testing in chronic heart failure and future applications.
Eur J Cardiovasc Prev Rehabil, 13 (2006), pp. 485-494
[2]
G.H. Mudge, S. Goldstein, L.J. Addonizio, et al.
24th Bethesda Conference: cardiac transplantation. Task force 3: recipient guidelines/priorization.
J Am Coll Cardiol, 22 (1993), pp. 21-31
[3]
R. Arena, M. Guazzi, J. Myers.
Ventilatory abnormalities during exercise in heart failure: a mini review.
Curr Respir Med Rev, 3 (2007), pp. 179-187
[4]
ATS/ACCP Statement on Cardiopulmonary Exercise Testing.
Am J Respir Crit Care Med, 167 (2003), pp. 211-277
[5]
Bonow RO, Carabello BA, Chatterjee K, et al. Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol. 2008;52:e1-142.
[6]
M.B. Parshall, R.M. Schwartzstein, L. Adams, et al.
American Thoracic Society Committee on Dyspnea. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea.
Am J Respir Crit Care Med, 185 (2012), pp. 435-452
[7]
D.G. Gibson, D.P. Francis.
Clinical assessment of left ventricular diastolic function.
Heart, 89 (2003), pp. 231-238
[8]
R.S. Meneghelo, C.G.S. Araújo, R. Stein, et al.
Sociedade Brasileira de Cardiologia. III Diretrizes da Sociedade Brasileira de Cardiologia sobre Teste Ergométrico.
Arq Bras Cardiol, 95 (2010), pp. 1-26
[9]
L.A. Pierard, P. Lancellotti.
Stress testing in valve disease.
Heart, 93 (2007), pp. 766-772
[10]
E. Rappaport.
Natural history of aortic and mitral valve disease.
Am J Cardiol, 35 (1975), pp. 221-227
[11]
R.O. Bonow, E. Lakatos, B.J. Maron, et al.
Serial long-term assessment of natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function.
Circulation, 84 (1991), pp. 1625-1635
[12]
F. Tarasoutchi, M.W. Montera, M. Grinberg, et al.
Diretriz Brasileira de Valvopatias – SBC 2011/I Diretriz Interamericana de Valvopatias – SCAR 2011.
Arq Bras Cardiol, 97 (2011), pp. 1-67
Copyright © 2011. Sociedade Portuguesa de Cardiologia
Baixar PDF
Idiomas
Revista Portuguesa de Cardiologia
Opções de artigo
Ferramentas
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

Ao assinalar que é «Profissional de Saúde», declara conhecer e aceitar que a responsável pelo tratamento dos dados pessoais dos utilizadores da página de internet da Revista Portuguesa de Cardiologia (RPC), é esta entidade, com sede no Campo Grande, n.º 28, 13.º, 1700-093 Lisboa, com os telefones 217 970 685 e 217 817 630, fax 217 931 095 e com o endereço de correio eletrónico revista@spc.pt. Declaro para todos os fins, que assumo inteira responsabilidade pela veracidade e exatidão da afirmação aqui fornecida.