Use of invasive cardiopulmonary exercise test in post-covid-19 fatigue: case of tired athlete

SESSION TITLE: Lung Physiology Challenges SESSION TYPE: Case Reports PRESENTED ON: 10/10/2023 08:30 am - 09:30 am INTRODUCTION: Long COVID syndrome is an emerging complication of SARS-CoV-2 infection impacting a patient's quality of life. The most common symptoms are dyspnea and fatigue which can be caused by autonomic dysfunction. We present the case of a young athlete who after recovering from COVID-19 myocarditis continued to experience fatigue and dyspnea. An invasive cardiopulmonary exercise test (iCPET) was necessary to reveal the hemodynamic changes responsible for his symptoms. CASE PRESENTATION: An 18-year-old male wrestler presented to the emergency department with headache, generalized body aches, muscle weakness, and a fever (104 oF). He tested positive for SARS-COV-2 PCR. A 2D-echo showed a left ventricular ejection fraction of 62%, and a high and possibly aneurysmal takeoff of the right coronary artery with mild ectasia of the proximal portion. A cardiac MRI revealed a focal area of epicardial to mid-myocardial enhancement within the inferolateral segments consistent with myocarditis. The patient underwent a CPET to provide clearance for return to wrestling competition. The test showed low aerobic exercise capacity, low O2 pulse (VO2/HR), low VO2 at anaerobic threshold (32% of predicted VO2 max). The respiratory variables showed adequate tidal volume, respiratory rate response, and a respiratory reserve of 47%. The VE/VCO2 declined normally at anaerobic threshold. The oxygen saturation was normal throughout exercise. The patient continued to experience fatigue and severe exertional dyspnea. Repeated Cardiac MRI revealed near resolution of the focal area of enhancement making myocarditis an unlikely culprit for the persistent fatigue. Invasive CPET showed inadequate increase in RA and PCWP and a mildly reduced peak CO percentage of predicted which suggest a degree of preload insufficiency. Recommendations included wearing compression stockings above the knee, recumbent exercise, and abundant water intake. At the 3-month follow-up the patient was still complaining of fatigue after strenuous activity, but there was a remarkable improvement in his ability to perform activities, much more similar to his pre COVID-19 baseline. DISCUSSION: We present a case of unexplained dyspnea in a young athlete patient following COVID-19. The initial CPET suggested cardiac limitation to physical activity but echo showed no significant abnormalities. The invasive CPET revealed preload insufficiency. Diagnostic criteria of preload limitations to exercise on iCPET include an unexplained abnormal cardiac limitation to exercise (Peak Oxygen Consumption < 80% predicted and Peak Cardiac Output >< 80% predicted) plus reduced ventricular preload based on the RAPmax >< 6.5 mmHg, PCWPmax <12.5 mmHg, ΔRAP >< 5.5 mmHg, or ΔPCWP < 6.75 mmHg.We hypothesize that COVID-19 precipitated his presentation and altered hemodynamics. What makes this case unique is dysautonomia resulting in preload insufficiency. There is growing evidence on the association of Long COVID syndrome with autonomic dysfunction. Advanced testing modalities – like iCPET – allow us to identify the hemodynamic profile consistent with this entity. CONCLUSIONS: Long COVID syndrome is associated with autonomic dysfunction. iCPET - is an advanced testing modality that can reveal hemodynamic alterations responsible for its symptoms. REFERENCE #1: Oldham WM, Lewis GD, Opotowsky AR, Waxman AB, Systrom DM. Unexplained exertional dyspnea caused by low ventricular filling pressures: results from clinical invasive cardiopulmonary exercise testing. Pulm Circ. 2016 Mar;6(1):55-62. doi: 10.1086/685054. PMID: 27162614; PMCID: PMC4860548. REFERENCE #2: Dani M, Dirksen A, Taraborrelli P, Torocastro M, Panagopoulos D, Sutton R, Lim PB. Autonomic dysfunction in 'long COVID': rationale, physiology and management strategies. Clin Med (Lond). 2021 Jan;21(1):e63-e67. doi: 10.7861/clinmed.2020-0896. Epub 2020 Nov 26. PMID: 33243837; PMCID: PMC7850225. REFERENCE #3: Maron BA, Cockrill BA, Waxman AB, Systrom DM. The invasive cardiopulmonary exercise test. Circulation. 2013 Mar 12;127(10):1157-64. doi: 10.1161/CIRCULATIONAHA.112.104463. PMID: 23479667. DISCLOSURES: No relevant relationships by Sami Al Ampnti No relevant relationships by Angel Coz Yataco No relevant relationships by Eduard Krishtopaytis