Özdemir Tekeş, Faculty of Medicine, Ankara, Turkey.
Sevgi Esra; Turan, Burak Kamil;Kutlay, Şehim; et al

Physiotherapy theory and practice,2026 Oct 20

• Introduction: Children with cerebral palsy (CP) may exhibit reduced aerobic capacity. While the cardiopulmonary exercise test (CPET) is the gold standard for determining aerobic capacity, motor disorders and accompanying disturbances make its application challenging. The 6-minute walk test (6-MWT) may offer a practical alternative.
• Objective: To evaluate the feasibility of CPET, explore its relationship with the 6-MWT, and investigate the association between aerobic capacity and gross motor function in children with CP.
• Methods: Children aged 6-13 years with unilateral/bilateral spastic CP classified as Gross Motor Function Classification System Level II, who could follow instructions and walk on a treadmill without physical assistance, were included. The Gross Motor Function Measure-88 (GMFM-88), 6-MWT, and treadmill-based CPET were performed. CPET feasibility was evaluated by maximal exertion and termination reasons.
• Results: Eight participants (four males, four females; four spastic unilateral, four spastic bilateral) with a median age of 8.5 years were enrolled. The median (minimum-maximum) peak oxygen consumption (VO_2peak ), respiratory exchange ratio (RER), and maximum heart rate (HR_max ) in CPET were 21 (17.1-30.6) mL/kg/min, 0.87 (0.81-1.00), and 145.5 (97-174) bpm, respectively. One participant achieved near-maximal exertion during CPET, while the others demonstrated submaximal effort. Reasons for CPET termination included lower limb fatigue (n = 5) and poor compliance (n = 3). The 6-minute walk distance (6MWD) was not significantly correlated with VO_2peak (r = 0.000, p > .999). 6MWD was strongly correlated with the GMFM-88 total score (r = 0.790, p = .020). Moderate correlations, which were not statistically significant, were found between 6MWD and the GMFM-88 Dimensions D (r = 0.672, p = .068) and E (r = 0.695, p = .056). No significant correlations were observed between the GMFM-88 scores and VO_2peak, RER, or HR_max.
• Conclusion: Treadmill-based CPET demonstrated limitations in reaching maximal aerobic capacity in this pilot sample of children with CP. The 6-MWT may offer a practical approach for evaluating functional performance, given its association with gross motor function.

Tucker, Sarah;
Wang, Alan;Griffith, Garett;et al

Pediatric cardiology,2026 Dec

Multiparametric cardiac magnetic resonance (CMR) is increasingly used for rejection and coronary artery vasculopathy (CAV) surveillance in pediatric heart transplant recipients (PHTR). There is limited data regarding how graft assessment by multiparametric CMR may reflect functional capacity in PHTR. To explore the relationship between multiparametric CMR and markers of exercise capacity in PHTR. PHTR who underwent CMR within 1 year of cardiopulmonary exercise testing (CPET) were retrospectively reviewed. Those with submaximal effort on CPET (respiratory exchange ratio < 1.10), depressed function (left ventricular ejection fraction (LVEF) < 50% and/or right ventricular ejection fraction (RVEF) < 45%), or significant clinical events (rejection, new or worsening CAV, cardiac hospitalizations) between CMR and CPET were excluded. CMR variables included biventricular volumes, ejection fraction, cardiac index (CI), myocardial T2, T1/extracellular volume fraction (ECV), and myocardial perfusion reserve index (MPRI). CPET variables were VO_2peak, O₂ pulse, percent age-predicted maximum heart rate (APMHR), HR reserve, and exercise duration. Relationships between variables were studied using correlations and regression. Forty-seven PHTR were included. Time between CPET and CMR was 5.5 ± 3.4 months. CI correlated positively with O₂ pulse (R = 0.642, p < 0.001). Global T1 correlated negatively with both APMHR (R = – 0.538, p < 0.001) and HR reserve (R = – 0.598, p < 0.001). Global T2 correlated negatively with APMHR (R = – 0.335, p = 0.049), HR reserve (R = – 0.488, p = 0.003), and VO_2peak (R = – 0.327, p = 0.045). In PHTR with normal LV function, CMR-derived tissue characteristics have correlations with exercise capacity. Larger studies are needed to understand the role of multiparametric CMR in the functional surveillance of PHTR.

Sandberg, Jacob; Division of Respiratory Medicine, Lund University, Sweden.
Mosen, Henrik; Ekström, Magnus;et al

ERJ open research,2026 Oct 19

• Background and Objective: Breathlessness is a leading cause of disability and reduced quality of life in COPD. Inhaled l-menthol may reduce breathlessness but data on its effect on exertional breathlessness is limited. We aimed to evaluate the effect of inhaled l-menthol on exertional breathlessness and exercise capacity in patients with COPD.
• Methods: This was a double-blinded, randomised (ratio 1:1), crossover trial (RCT) of l-menthol inhalation versus placebo. 20 participants with COPD performed two constant-load cycle cardiopulmonary exercise tests (CPET) to exhaustion, with either l-menthol or placebo (strawberry) scented patch in the mask in randomised order. The primary outcome was the difference in breathlessness intensity (Borg 0-10 scale) at isotime. Secondary outcomes were change in breathlessness unpleasantness and leg fatigue at isotime, exercise endurance time (EET), exertional physiological responses and multidimensional breathlessness (MDP).
• Results: Compared with placebo, inhaled l-menthol reduced breathlessness intensity at isotime (mean difference -0.8, 95% CI -1.6-0.0; p=0.042), corresponding to a moderate effect size (Cohen’s d= -0.49). Isotime breathlessness unpleasantness (-0.7, -1.7-0.3) and emotional response score was lower with L-menthol (-2.2, -4.4-0.0). Leg discomfort (-0.5, -1.3-0.2) was numerically lower, EET was longer (0.9 min, -0.7-2.5) and physiological responses were unchanged.
• Conclusion: Inhalation of l-menthol reduced the intensity and emotional response of exertional breathlessness and increased the EET compared with placebo in patients with COPD. The unchanged physiological responses support a central brain effect and l-menthol might be a promising new treatment.

Borghi-Silva,A; Cardiopulmonary Physiotherapy Laboratory, São Carlos, Brazil
Santos-de-Araújo, Aldair D;Montalvo, Sl;

Progress in cardiovascular diseases,2026 Oct 12

• Background: Peak oxygen consumption (pVO2) has been widely recognized to identify potential pathophysiological mechanisms of exercise intolerance and to stratify risk in patients with heart failure (HF).
• Aims: To develop a non-exercise equation to estimate pVO2 (esVO2) and to determine its association with all-cause mortality.
• Methods: A total of 5176 HF patients (age 48 ± 17 years) who underwent a CPET for clinical reasons, and were followed between May 2011, and December 1, 2023. Clinical and historical variables and forced expiratory volume in 1-s (FEV₁ ) were used in a stepwise multivariate regression analysis to predict pVO2 measured from CPET. Kaplan-Meier curves and Cox proportional hazards analyses were used to determine the association between esVO2 and all-cause mortality.
• Results: The first esVO2 model was significantly associated with pVO2 (multiple R = 0.73, P < 0.001). Two other models considered gender separately (male: multiple R = 0.72, P < 0.001 and female (multiple R = 0.70, P < 0.001). A fourth model was proposed when spirometry is not available (age, BMI, resting SBP, HR and gender (multiple R = 0.69, P < 0.001)). The fifth proposed model included history of atrial fibrillation and previous stroke (multiple R = 0.70, P < 0.001). Kaplan-Meier survival curves differentiated patients according to esVO2 and pVO2 ≤ and > 14 mL/kg^-1 per min^-1. Univariate Cox proportional hazard analyses indicated significant prognostic value when esVO2 and pVO2 were ≤ 14 mL/kg^-1 per min^-1 (P = 0.001).
• Conclusions: Multivariable nonexercise models combining spirometry and/or clinical variables commonly obtained during a clinical assessment predict pVO2 reasonably accurately in HF.

Caloian, B; University of Medicine and Pharmacy  Cluj-Napoca, Romania.
Caloian, C S;Tomoaia, R;

Journal of clinical medicine [J Clin Med] 2026 Sep 23; Vol. 15 (19).
Date of Electronic Publication: 2026 Sep 23.

Permanent cardiac pacing abolishes symptomatic bradycardia, yet a substantial proportion of recipients remain limited on exertion. Chronotropic incompetence is present in about half of pacemaker-wearing patients when assessed by the Wilkoff index, and the rate-responsive function intended to correct it is frequently left at the settings applied at implantation. Read across the whole cardiopulmonary exercise test rather than at peak effort, the relationship between heart rate and oxygen consumption distinguishes an inadequate sensor slope, an activity threshold set too high, a reaction time out of step with the onset of exercise, and an upper rate limit reached prematurely, each with a distinct correction. Reprogramming alters the result of the test within 24 h, so the settings should be corrected before rehabilitation begins. The objective is not the highest achievable rate but the individual ceiling above which the ventricle no longer converts frequency into output. Because heart rate is partly device-determined, training intensity should be anchored to the ventilatory threshold, to the corresponding workload and to perceived exertion, with heart rate being monitored for safety rather than used to set intensity. The aim of this review is to describe how cardiopulmonary exercise testing guides device reprogramming and training prescription in the pacemaker-wearing patient.

Ulrich, S;  Department of Pulmonology, University Hospital Zurich, Zurich,
Milger, K;Halank, M;et al

Respiration; international review of thoracic diseases,2026 Oct 17

• Background: Pulmonary hypertension (PH) associated with chronic lung disease (CLD) (PH_lung) is a frequent complication of chronic obstructive pulmonary disease (COPD), interstitial lung disease, and other parenchymal lung disorders, and is associated with impaired exercise capacity, reduced quality of life and poor survival. Despite increasing recognition of its clinical importance, major challenges remain regarding early diagnosis, hemodynamic classification, and optimal treatment.
• Summary: This review summarizes current concepts of the diagnosis and management of PH_lung, with particular emphasis on multimodal screening strategies integrating pulmonary function testing, biomarkers, echocardiography, cardiopulmonary exercise testing, and thoracic imaging to improve patient selection for right heart catheterization. We discuss practical aspects of hemodynamic assessment, overlapping phenotypes, including connective tissue disease, sarcoidosis, and the emerging pulmonary vascular “lung phenotype,” and current evidence supporting targeted therapies with emphasis on patients’ pathways in real-world settings. While inhaled treprostinil has become the first approved treatment for PH associated with interstitial lung disease in some countries, no PH-specific therapy is currently recommended routinely for COPD-associated PH, highlighting the need for careful patient phenotyping and individualized management in expert centers. Earlier recognition, multidisciplinary collaboration, and continued translational and clinical research are essential to improve outcomes in this highly vulnerable patient population.
• Key Messages: Patients with PH_lung may present in pulmonary clinics with worsening CLD or are diagnosed in the work-up of PH. PH_lung is a severe condition that should be managed in expert centers with the possibility of advanced therapies, including transplantation and inclusion in clinical trials.

Chaikijurajai, T  Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN. USA
Reddy, N V;Harada, Ti; et al

Circulation [Circulation] 2026 Oct 11.
Date of Electronic Publication: 2026 Oct 11.

• Background: Left atrial (LA) stiffening augments the LA V wave, pressurizing the pulmonary artery (PA) out of proportion to left ventricular end-diastolic pressure. We characterized the pathophysiologic, diagnostic, and clinical implications of LA stiffening, as defined by prominent V waves, in heart failure with preserved ejection fraction.
• Methods: In this retrospective cohort study, patients with heart failure with preserved ejection fraction and less than moderate mitral regurgitation at rest underwent invasive hemodynamic exercise testing. Patients with heightened operant LA stiffening were defined by the PA wedge pressure (PAWP) V wave exceeding mean PAWP by ≥10 mm Hg. A previously used formula for V wave-corrected PAWP was validated against the PAWP waveform pressure-time-area to explore impact of the V wave on transpulmonary pressure gradients. Clinical, echocardiographic, hemodynamic, and outcome data were compared for patients with and without prominent V waves.
• Results: Compared with patients without prominent V waves (n=844, 79%), those with prominent V waves (n=225, 21%) were older and more likely to be women, with more severe LA myopathy, evidenced by greater LA volume index (42.2±15.0 versus 32.5±13.0 mL/m², P <0.001), lower LA reservoir strain (16.4±7.5% versus 23.2±8.3%, P <0.001), more atrial fibrillation (61.3% versus 22.9%, P <0.001), and increased operant LA reservoir stiffness (0.59±0.25 versus 0.23±0.24 mm Hg/mL, P <0.001). Patients with prominent V waves had markedly higher PA systolic pressure than those without (54±16 versus 38±12 mm Hg, P <0.001) despite no difference in end-diastolic PAWP-PA pressure gradient (3±5 versus 3±4 mm Hg, P =0.950). Incorporating the V wave into PAWP improved correlation between directly measured PAWP pressure-time integral compared with mid-A wave PAWP (R² =0.96 versus R² =0.86, P <0.001 for comparison). In patients with prominent V waves, the prevalence of combined pre- and postcapillary pulmonary hypertension decreased from 60.2% to 29.3% after V wave correction for the transpulmonary pressure gradients. Despite similar corrected pulmonary vascular resistances in patients with and without prominent V waves, apparent PA compliance was much lower in patients with prominent V waves (3.03±1.56 versus 4.90±2.27 mL/mm Hg, P <0.001), augmenting right ventricular afterload, and these changes were coupled with more severe right ventricular dysfunction, tricuspid regurgitation, blunted cardiopulmonary exercise reserve, and increased risk of hospitalization for heart failure or death in patients with versus without prominent V waves (adjusted hazard ratio, 2.09 [95% CI, 1.53-2.86]; P <0.001).
• Conclusions: More than 1 in 5 patients with heart failure with preserved ejection fraction display prominent V waves in excess of end-diastolic PAWP. This augments right ventricular afterload due to backward transmission of the V wave, contributing to right heart failure that is independent of the pulmonary vasculature. Failure to account for the V wave during hemodynamic assessment overestimates the severity of pulmonary vascular disease present.