Magnetic Resonance–Augmented Cardiopulmonary Exercise TestingCLINICAL PERSPECTIVE: Comprehensively Assessing Exercise Intolerance in Children With Cardiovascular Disease

Background— Conventional cardiopulmonary exercise testing can objectively measure exercise intolerance but cannot provide comprehensive evaluation of physiology. This requires additional assessment of cardiac output and arteriovenous oxygen content difference. We developed magnetic resonance (MR)–augmented cardiopulmonary exercise testing to achieve this goal and assessed children with right heart disease. Methods and Results— Healthy controls (n=10) and children with pulmonary arterial hypertension (PAH; n=10) and repaired tetralogy of Fallot (n=10) underwent MR-augmented cardiopulmonary exercise testing. All exercises were performed on an MR-compatible ergometer, and oxygen uptake was continuously acquired using a modified metabolic cart. Simultaneous cardiac output was measured using a real-time MR flow sequence and combined with oxygen uptake to calculate arteriovenous oxygen content difference. Peak oxygen uptake was significantly lower in the PAH group (12.6±1.31 mL/kg per minute; P =0.01) and trended toward lower in the tetralogy of Fallot group (13.5±1.29 mL/kg per minute; P =0.06) compared with controls (16.7±1.37 mL/kg per minute). Although tetralogy of Fallot patients had the largest increase in cardiac output, they had lower resting (3±1.2 L/min per m 2 ) and peak (5.3±1.2 L/min per m 2 ) values compared with controls (resting 4.3±1.2 L/min per m 2 and peak 6.6±1.2 L/min per m 2 ) and PAH patients (resting 4.5±1.1 L/min per m 2 and peak 5.9±1.1 L/min per m 2 ). Both the PAH and tetralogy of Fallot patients had blunted exercise–induced increases in arteriovenous oxygen content difference. However, only the PAH patients had significantly reduced peak values (6.9±1.3 mlO2/100 mL) compared with controls (8.4±1.4 mlO2/100 mL; P =0.005). Conclusions— MR-augmented cardiopulmonary exercise testing is feasible in both healthy children and children with cardiac disease. Using this novel technique, we have demonstrated abnormal exercise patterns in oxygen uptake, cardiac output, and arteriovenous oxygen content difference.