Response of the right ventricle to exercise in isolated mitral stenosis

Eight patients in sinus rhythm, with varying degrees of isolated mitral stenosis (mitral valve area 0.6 to 1.3 cm 2 and total pulmonary vascular resistance 5.0 to 17.5 U-m 2), underwent supine rest and symptom-limited exercise radionuclide ventriculography to determine right ventricular (RV) and left ven-tricular ejection fraction (EF). Cardiac catheterization with hemodynamic measurements at rest and at peak exercise was performed within 24 hours of radionuclide ventriculography. Four of the 8 patients underwent corrective mitral surgery resulting in normal mean pulmonary artery pressures and total pulmonary vascular resistance at rest. These 4 patients had repeat radionuclide ventriculography at rest and during exercise 1 to 2 months after surgery. Preoperatively, all 8 patients had an abnormal exercise RVEF response (mean change ± standard deviation [SD], −5.0 ± 4.5%), coincident with an increase in mean pulmonary artery pressure during exercise (mean change, 15 ± 5.0 mm Hg). The change in RVEF from rest to exercise, corrected for duration of exercise, correlated with peak exercise mean pulmonary artery pressure (r = −0.71, p = 0.05), as well as total pulmonary vascular resistance at rest (r = −0.82, p = 0.02). Postoperatively, all 4 patients who underwent surgical correction showed a normal RVEF response during exercise (mean change ± SD, +6.8 ± 4.0%). Thus, in patients with acquired mitral stenosis and no coronary artery disease (1) loading conditions and not contractility are prime determinants of RV exercise response, and (2) an exercise-induced decrease in RVEF may be a sensitive marker for increased total pulmonary vascular resistance and pulmonary hypertension.