IMPACT OF MANUAL LYMPHATIC DRAINAGE ON …

13

Lymphology 44 (2011) 13-20

IMPACT OF MANUAL LYMPHATIC DRAINAGE ON HEMODYNAMIC PARAMETERS IN PATIENTS WITH

HEART FAILURE AND LOWER LIMB EDEMA

O. Leduc, V. Crasset, C. Leleu, N. Baptiste, A. Koziel, C. Delahaie, F. Pastouret, F. Wilputte, A. Leduc

Haute Ecole P.H. Spaak (OL,CL,NB,AK,CD,FP,AL) Lympho-Phlebology Unit, Brussels. HôpitalUniversitaire Tivoli (VC), Cardiology, La Louvière, and Cliniques Universitaires de Bruxelles (FW) –ULB Hôpital Erasme, Brussels, Belgium

ABSTRACT

Manual lymphatic drainage (MLD),intermittent sequential pneumatic therapy(ISPT), multilayered bandages (MLB), andcompression garments are main techniques inconservative treatment of peripherallymphedema. Since 1990, it has been thoughtthat ISPT applied to both lower limbssimultaneously should not be used for patientswith heart failure because right atrial,pulmonary arterial, and pulmonary wedgepressures may increase to a critical point. In2005, these same results were observed inpatients with heart failure wearing MLB. Forthese reasons, MLB and ISPT have beencontraindicated during lymphedema treatmentin cardiac patients. The aim of this study wasto determine if we may continue the treatmentof lower limb lymphedema using MLD inpatients with heart failure. We evaluatedhemodynamic parameters using echographyduring MLD in patients with cardiac diseaseand obtained circumferential measurements of the edematous limb before and after treat-ment. MLD treatment significantly decreasedthe limbs as expected. The heart rate alsodecreased following MLD in contrast with allother hemodynamic parameters which werenot affected by MLD. The findings suggestthat there is no contraindication to use MLD

in patients with heart failure and lower limb edema.

Keywords: manual lymphatic drainage, heartfailure, hemodynamic effects

Manual lymphatic drainage (MLD),intermittent sequential pneumatic therapy(ISPT), multilayered bandages (MLB), andcompression garments are main conservativetreatment techniques according to theInternational Society of Lymphology (1).MLD objectives are to improve the lymphaticfunction (2) and also venous circulation.However, the effect on the venous circulationhas not been accurately quantified. We doknow that patients suffering from lowerextremity lymphedema can experienceworsening of their edema when complicatedby congestive heart failure. Therefore, thequestion is: can we still treat those patientswith MLD? We do know the effects of ISPTand MLB on the hemodynamic and cardio-pulmonary parameters and ISPT and MLBare contraindicated in congestive heart failure (3-5). The objective of this study wasto determine the effects of MLD on thehemodynamic and cardiopulmonaryparameters in patients with heart disease and associated limb edema.

Permission granted for single print for individual use. Reproductiom not permitted without permission of Journal LYMPHOLOGY.

14

MATERIAL AND METHODS

Subjects and Protocol

We report studies on 9 patients (3 menand 6 women aged 56 to 82, mean=72)hospitalized in the Cardiology Unit with class III or IV heart failure according to theNew York Heart Association. Thisclassification determines the type of heartfailure based on symptoms occurring duringphysical activity. Class III corresponds todiscomfort during moderate effort and classIV corresponds to discomfort felt during theslightest effort or at rest. Subjects were in astable steady-state on maintenance treatmentand consented to the study. The protocol wasapproved by the Hospital Ethical Committee.Subjects have lower limb edema localized atthe leg and foot. Subjects with unstable heartconditions, psychiatric disorders, or dementiawere excluded.

Patients were placed supine duringexperiments with a cushion at the heel andproximal aspect of the thigh. MLD wasperformed on the lower limb according to“Leduc’s Technique” consisting initially withapplication of the inciting technique at theinguinal region followed by its extensiondown the thigh until the edematous regionwas reached. The resorption technique wasthen applied to the edema, and subsequentlyMLD manipulation was performed in reversedirection with the inciting technique up to thegroin. MLD was applied for a total of 15minutes with the resorption technique beingperformed during the majority of the time.

Hemodynamic parameters weremeasured with duplex on the left and rightside of the heart according to the scheduleoutlined in Table 1 with each patientmeasured at control and experimental timesT1 (after 5 minutes of MLD) and T2 (aftercompletion of MLD). Estimation of left andright ventricular filling pressures usuallyrequires invasive placement of a pulmonaryartery catheter but noninvasive estimation byechocardiography is an accurate and

recognized method of ventricular fillingpressure assessment. In order to estimatehemodynamic effects of MLD, combinedechographic measurements were recordedand compared at the different stages of theMLD. The electrocardiogram was used alsoto monitor heart rate and as a point ofreference for Doppler measurements.

Parameters Measured with Duplex on the Left Side of the Heart at the Level of theMitral Valve

Using E and A wave measurements atthe mitral level, we analyzed the diastolicfunction of the left ventricle. During diastole,the curve of the transmitral blood flow ispositive and biphasic. The E wavecorresponds to the blood flow entering intothe left ventricle at the mitral valve duringdiastole. The A wave corresponds to theblood flow at the mitral valve in the leftventricle after atrial contraction. The E’ waveindicates the velocity of the displacement ofthe left ventricle wall at the level of the mitralvalve. These different parameters estimatethe left ventricle diastolic pressure (6,7). Theratio E/A and E/E’ (7,8) improves theunderstanding of the pressure development inthe left ventricle and confirms the severity ofthe cardiac disease. The ratio dP/dT (dP =systolic gradient pressure between leftventricle and left atrium for dT determined)obtained at the level of the mitral valvecorresponds to the slope of the curveanalyzing the mitral regurgitation during thesystole. This observation estimates thevelocity of the mitral regurgitation and thesystolic pressure in the left ventricle (9,10).

Parameter at the Level of the Aortic Valve

The aortic blood flow providesinformation about the cardiac flow (11).

Parameter at the level of the ventricle

The shortening fraction (11) evaluatesthe global systolic left ventricular function.


15

Parameters Measured with Duplex on theRight Side of the Heart at the Level of theTricuspid Valve

The maximum tricuspid regurgitationvelocity correlates with the systolic arterialpulmonary pressure (12,13). The E and Awaves and the ratio E/A, according to thesame principle were used at the mitral levelto evaluate diastolic right ventricle pressure.The E’ wave indicates velocity of thedisplacement of the right ventricle wall at the level of the tricuspid valve. Thisparameter and the ratio E/E’ estimate theright ventricle diastolic pressure.

Parameters at the Level of the Inferior VenaCava (IVC)

The variation of the diameter of theinferior vena cava (IVC) during therespiratory cycle indicates the level of theright atrial pressure (14). Expiratory andinspiratory IVC diameters and percentcollapse (caval index) was measured within 2 cm of right atrium. A caval index greaterthan or equal to 50% indicates a right atrialpressure less than 10 mm Hg. A caval indexless than 50% indicates a right atrial pressuregreater than or equal to 10 mm Hg (15).

Measurement of the Lower Limbs

Measurements of the limbs at the level of the edema were performed by classicalmanual methods before and after treatment.

For the circumference measurements, thereference was the medial malleolus where ahorizontal line was drawn as a “tattoo.” From this tattoo, three horizontal referencelines were drawn at 10cm, 20cm, and 30cmup the leg and these points were maintainedthroughout the experiment. Measurementswere obtained at these four fixed lines witheach measurement repeated three times bythe same investigator (a physical therapist).The mean value of the four measurementswas calculated for comparisons.

Statistical Analysis

Data were collected at time points T0,T1, and T2. The initial values for the variousmeasures were not homogeneous, andtherefore we expressed T1 and T2 values aspercentage of the baseline with T0 consideredas 100%. Analysis of the variance (ANOVA)was used to evaluate the effect of MLD.When appropriate, Tukey test was used formultiple comparison testing of the meanvalues. Statistical significance was defined as p≤ 0.05.

RESULTS

Baseline echographic parameters wereobtained on the nine subjects and are shownin Table 2. The subjects have left ventriculardysfunction with dP/dT ratio of less than 800mm Hg/sec and mitral E/A ratio greater than2 which is in accordance with high leftventricular diastolic pressure. Their tricuspid

TABLE 1Experimental Outline and Timing


16

TABLE 2Echographic Baseline Parameters

n=9 (mean ± SD)

TABLE 3Experimental Parameters Expressed as Percentage Compared to Baseline

(=100%) at times T1 and T2 (Mean ± SD)


17

E/E’ ratio also reflects high right-sidepressures. Hemodynamic parameters weremeasured and calculated at T1 after 5minutes of MLD and at T2 at conclusion ofMLD. These values were expressed aspercentage compared to baseline (100%) asshown in Table 3. The results demonstratethat all hemodynamic parameters except forheart rate were not significantly changedduring or after MLD with a significantreduction seen in heart rate following MLD(Tables 2-3; Figs. 1-3). Following MLDtreatment, the circumference of the limbsdecreased significantly (p≤0.001, Table 3).

DISCUSSION

In contrast to previously publishedstudies on ISPT (3,4) and MLB (5), which arecontraindicated in this setting, MLD does notappear to have any adverse side effects on thehemodynamics of heart failure patients with

lower limb edema. One could question if thedifference could be related to the differentassessment techniques since during ISPT andMLB research, the Swan Ganz cathetertechnique (invasive technique) was usedduring the measurements. In our study onMLD, we have used the echo-Dopplertechnique (non invasive technique). However,Vanoverschelde et al (16) analyzed therelation between Doppler transmitral flowvelocity indexes and the pulmonary arterialwedge pressure measurements (PAWP) withcatheter and reported a high correlation(0.95) between PAWP and E/A ratio.Moreover, Nagueh et al (6) evaluated therelation of the mitral E/E’ ratio to leftventricle filling pressures and found asignificant correlation with mean pulmonarycapillary wedge pressure with an r value of0.87 (p<0.001). Hadano (17) also confirmedthe same observations. Chen et al (18)demonstrated that mitral regurgitation

Fig. 1. Parameters measured at the level of the mitral valve at time points T1 and T2. Bars depict mean values ± SDnormalized to baseline (T0=100%). (NS= non-significant)


18

Fig. 2. Parameters measured at the level of the tricuspid valve at time points T1 and T2. Bars depict mean values± SD normalized to baseline (T0=100%). (NS= non-significant)

velocity spectrum (dP/dt) is a good method to estimate the left ventricular pressurethroughout the systole and also that thecorrelation between Doppler and cathetermeasurements was similarly good (r = 0.91,p<0.0001). Therefore, according to publishedliterature, the results obtained by echo-Doppler and those obtained by the Swan-Ganztechnique may be compared. We concludethat the two evaluation methods are reliable,irrespective of the treatment applied. Accor-dingly, it is unlikely that the discrepancybetween our results and those reported forISPT and MLB may be attributed to thedifferent treatment techniques.

The pressures applied during MLD arevery soft (30 to 40 mm Hg). These pressuresdo not translocate a large amount of liquid inthe venous system. Therefore, they do notproduce a large pressure increase in the

cardiac cavities. Higher pressures were usedin intermittent sequential pneumatic therapystudy (3) (80 mm Hg on both legs) and inmultilayered bandages study (5) (49.2 mmHg). Moreover, the ISPT and the MLB wereapplied on the entire length of the lower limb.In contrast, MLD is applied exclusively at theinfiltrated area. Thus, the impact on thedisplacement of interstitial and intravascular(venous) liquid to the heart is much greaterwith ISPT and MLB.

Finally, the small number of subjects inthis study is related to the difficulty inrecruiting and studying patients hospitalizedin a coronary unit.

Our results suggest that there is nocontraindication to perform MLD in patientswith heart failure. When a patient undertreatment with MLD for lower limb(lymph)edema develops heart failure, MLD


19

can be continued as hemodynamicparameters do not seem to be influenced by the treatment.

REFERENCES

1. Consensus Document of the InternationalSociety of Lymphology. The Diagnosis andTreatment of Peripheral Lymphedema.Lymphology 42 (2009), 51-60.

2. Leduc, O, P Bourgeois, A Leduc: Manuallymphatic drainage: Scintigraphicdemonstration of its efficacy on colloidalprotein reabsorption. Progress in LymphologyXI. H. Partsh (Ed). Elsevier SciencePublishers (1988), 551-554.

3. Dereppe, H, M Hoylaerts, M Renard:Répercussions hémodynamique de lapressothérapie. J. Mal. Vasc. 15 (1990), 267-269.

4. Leduc, O, H Dereppe, M Hoylaerts, et al:Hemodynamic effects of pressotherapy.Progress in lymphology XII, M. Nbishi, S.

Uchino, S. Yabuki (Eds). Elsevier Sciencepublishers B.V. (1990), 431-434.

5. Wilputte, F, M Renard, J-Ph Venner, et al:Hemodynamic response to multilayeredbandages dressed on a lower limb of patientswith heart failure. Eur. J. Lymphol. 15 (2005),1-4.

6. Nagueh, SF, KJ Middleton, HA Kopelen, et al: Doppler tissue imaging: A noninvasivetechnique for evaluation of left ventricularrelaxation and estimation of filling pressures.J. Am. Coll. Cardio. 30 (1997), 1527-1533.

7. Ommen, SR, RA Nishimura, CP Appleton, et al: Clinical utility of Dopplerechocardiography and tissue Doppler imagingin the estimation of left ventricular fillingpressures: A comparative simultaneousDoppler-Catheterization study. Circulation102 (2000), 1788-1794.

8. Sohn, DW, IH Chai, DJ Lee, et al:Assessment of mitral annulus velocity byDoppler tissue imaging in the evaluation of

Fig. 3. Hemodynamic parameters measured at T1 and T2. Bars depict mean values ± SD normalized to baseline(T0=100%). (NS= non-significant, S= significant, HS= highly significant)


20

left ventricular diastolic function. J. Am. Coll.Cardio. 30 (1997), 474-480.

9. Chen, C, L Rodriguez, JL Guerrero, et al:Noninvasive estimation of the instantaneousfirst derivative of the left ventricular pressureusing continuous-wave Dopplerechocardiography. Circulation 83 (1991),2101-2110.

10. Loutfi, H, RA Nishimura: Quantitativeevaluation of left ventricular systolic functionby Doppler echocardiographic techniques.Echocardiography 11 (1994), 305-314.

11. Klimczak, C, G Drobinski:Echocardiographie, 3ème édition. Masson(1997), 147.

12. Yock, PG, RL Popp: Non invasive estimationof right ventricular systolic pressure byDoppler ultrasound in patients with tricuspidregurgitation. Circulation 70 (1984), 657-662.

13. Masuyama, T, K Kodama, A Kitabatake, et al: Continuous wave Doppler echocardio-graphic detection of pulmonary regurgitationand its application to non invasive estimationof pulmonary artery pressure. Circulation 74(1986), 484-492.

14. Capomolla, S, O Febo, A Caporotondi, et al:Noninvasive estimation of right atrialpressure by combined Doppler echocardio-graphy measurements of the inferior venacava in patients with congestive heart failure.Italian Heart J. 10 (2000), 684-690.

15. Kirsher, BJ, RB Himelman, WB Schiller:Noninvasive estimation of right atrial

pressure from the inspiratory collapse of theinferior vena cava. J. Am. Coll. Cardio. 66(1990), 493-496.

16. Vanoverschelde, JL, AR Robert, A Gerbaux,et al: Noninvasive estimation of pulmonaryarterial wedge pressure with Dopplertransmitral flow velocity pattern in patientswith known heart disease. J. Am. Coll.Cardio. 75 (1995), 383-389.

17. Hadano, Y, K Murata, N Tanaka, et al: Ratioof early transmitral velocity to lateral mitralannular early diastolic velocity has the bestcorrelation with pressure following cardiacsurgery. Circulation 71 (2007), 1274-1278.

18. Chen, C, L Rodriguez, JP Lethor, et al:Continuous wave Doppler echocardiographyfor noninvasive assessment of left ventriculardP/dT and relaxation time constant frommitral regurgitant spectra in patients. J. Am.Coll. Cardio. 23 (1994), 970-976.

Olivier Leduc, PhDUniversity of Brussels26 Avenue Des Di ArpentsBrussels, BELGIUM 1200Telephone #: 32-2-7790054FAX #: 32-2-7792088e-mail: [email protected]


Documents

IMPACT OF MANUAL LYMPHATIC DRAINAGE ON …