Category Archives: Publications

Influence of impaired right ventricular contractile reserve on exercise capacity in patients with precapillary pulmonary hypertension: A study with exercise stress echocardiography.

Guo DC; Li YD; Yang YH; Zhu WW; Sun LL; Jiang W; Ye XG; Cai QZ; Lu XZ

Echocardiography (Mount Kisco, N.Y.) [Echocardiography] 2019 Feb 22. Date of Electronic Publication: 2019 Feb 22.

Objectives: Right ventricular (RV) contractile reserve reflects the ability of RV to accommodate the increased afterload and may play an essential role in the evaluation of precapillary pulmonary hypertension (PH). This study aimed to assess RV contractile reserve based on exercise stress echocardiography (ESE) and to determine the echocardiographic determinants of exercise capacity in patients with precapillary PH.
Methods: A total of 31 patients with precapillary PH and 15 age- and sex-matched healthy control subjects were prospectively recruited. All subjects underwent ESE to assess RV function at rest and under peak exercise. Changes in these parameters during exercise were calculated to quantify the RV contractile reserve. Patients with precapillary PH also underwent cardiopulmonary exercise test (CPET), and data pertaining to peak oxygen uptake (peak VO2 ) and minute ventilation/carbon dioxide production (VE/VCO2 ) were collected.
Results: Right ventricular contractile reserve including change in tricuspid annular plane systolic excursion (∆TAPSE), change in RV fractional area change (∆RVFAC), and change in Doppler-derived tricuspid lateral annular peak systolic velocity (∆S’) was significantly depressed in precapillary PH patients compared with control subjects (P < 0.05). Parameters of RV function and RV contractile reserve were markedly associated with maximal exercise capacity (P < 0.05). ∆RVFAC was an independent predictor of peak VO2 (r2  = 0.601, P < 0.05).
Conclusions: Assessment of RV contractile reserve facilitates identification of subclinical dysfunction and evaluation of clinical status and severity of precapillary PH. ESE as a noninvasive method may provide a comprehensive clinical assessment and facilitate therapeutic decision-making for these patients.

Endoscopic Lung Volume Reduction: An Expert Panel Recommendation – Update 2019.

Herth FJF Slebos DJ, Criner GJ, Valipour A, Sciurba F, Shah PL.

Respiration. 2019 Mar 5:1-10. doi: 10.1159/000496122. [Epub ahead of print]

Endoscopic lung volume reduction (ELVR) therapies are gaining prominence as a
treatment option with guideline recommendations by COPD GOLD and NICE and the
recent FDA approval for endobronchial valves. The transition from an
experiment-based therapy only to clinical care comes with new challenges. A
significant volume of evidence-based data has been published; all data
demonstrate consistent improvements in several aspects of patient outcomes.
Patients suffering from severe air trapping and thoracic hyperinflation seem to
benefit the most from ELVR. In addition to lung function, baseline assessment
should ideally include cardiopulmonary exercise testing, high-resolution computer
tomography scan, perfusion scintigraphy, and echocardiography. This expert ELVR
statement updates best practice recommendations from 2017 regarding patient
selection and utilization of these various techniques for treating patients with
advanced emphysema.

Effect of Intravenous Iron Sucrose on Exercise Tolerance in Anemic and Nonanemic Patients With Symptomatic Chronic Heart Failure and Iron Deficiency FERRIC-HF: A Randomized, Controlled, Observer-Blinded Trial

Darlington O. Okonko,  Agnieszka Grzeslo,  Tomasz Witkowski,
Amit K. J. Mandal,  Robert M. Slater,  Michael Roughton,
Gabor Foldes, Thomas Thum,  Jacek Majda,
Waldemar Banasiak,  Constantinos G. Missouris,
Philip A. Poole-Wilson, Stefan D. Anker, Piotr Ponikowski,

Journal of the American College of Cardiology Vol. 51: No. 2, 2008

Objectives. We tested the hypothesis that intravenous iron improves exercise tolerance in anemic and nonanemic patients with symptomatic chronic heart failure (CHF) and iron deficiency.
Background. Anemia is common in heart failure. Iron metabolism is disturbed, and administration of iron might improve both symptoms and exercise tolerance.
Methods. We randomized 35 patients with CHF (age 64  13 years, peak oxygen consumption [pVO2] 14.0  2.7 ml/kg/min) to 16 weeks of intravenous iron (200 mg weekly until ferritin 500 ng/ml, 200 mg monthly thereafter) or
no treatment in a 2:1 ratio. Ferritin was required to be 100 ng/ml or ferritin 100 to 300 ng/ml with transferrin
saturation 20%. Patients were stratified according to hemoglobin levels (12.5 g/dl [anemic group] vs. 12.5
to 14.5 g/dl [nonanemic group]). The observer-blinded primary end point was the change in absolute pVO2.
Results. The difference (95% confidence interval [CI]) in the mean changes from baseline to end of study between the iron and control groups was 273 (151 to 396) ng/ml for ferritin (p  0.0001), 0.1 (0.8 to 0.9) g/dl for hemoglobin
(p  0.9), 96 (12 to 205) ml/min for absolute pVO2 (p  0.08), 2.2 (0.5 to 4.0) ml/kg/min for pVO2/kg
(p  0.01), 60 (6 to 126) s for treadmill exercise duration (p  0.08), 0.6 (0.9 to 0.2) for New York
Heart Association (NYHA) functional class (p  0.007), and 1.7 (0.7 to 2.6) for patient global assessment
(p  0.002). In anemic patients (n  18), the difference (95% CI) was 204 (31 to 378) ml/min for absolute
pVO2 (p  0.02), and 3.9 (1.1 to 6.8) ml/kg/min for pVO2/kg (p  0.01). In nonanemic patients, NYHA functional
class improved (p  0.06). Adverse events were similar.
Conclusions Intravenous iron loading improved exercise capacity and symptoms in patients with CHF and evidence of abnormal iron metabolism. Benefits were more evident in anemic patients.

Noninvasive prediction of Blood Lactate through a machine learning-based approach.

Huang SC; Casaburi R; Liao MF; Liu KC; Chen YJ; Fu TC; Su HR;

Scientific Reports [Sci Rep] 2019 Feb 18; Vol. 9 (1), pp. 2180. Date of Electronic Publication: 2019 Feb 18.

We hypothesized that blood lactate concentration([Lac]blood) is a function of cardiopulmonary variables, exercise intensity and some anthropometric elements during aerobic exercise. This investigation aimed to establish a mathematical model to estimate [Lac]blood noninvasively during constant work rate (CWR) exercise of various intensities. 31 healthy participants were recruited and each underwent 4 cardiopulmonary exercise tests: one incremental and three CWR tests (low: 35% of peak work rate for 15 min, moderate: 60% 10 min and high: 90% 4 min). At the end of each CWR test, venous blood was sampled to determine [Lac]blood. 31 trios of CWR tests were employed to construct the mathematical model, which utilized exponential regression combined with Taylor expansion. Good fitting was achieved when the conditions of low and moderate intensity were put in one model; high-intensity in another. Standard deviation of fitting error in the former condition is 0.52; in the latter is 1.82 mmol/liter. Weighting analysis demonstrated that, besides heart rate, respiratory variables are required in the estimation of [Lac]blood in the model of low/moderate intensity. In conclusion, by measuring noninvasive cardio-respiratory parameters, [Lac]blood during CWR exercise can be determined with good accuracy. This should have application in endurance training and future exercise industry.

Exercise prehabilitation may lead to augmented tumor regression following neoadjuvant chemoradiotherapy in locally advanced rectal cancer

Acta Oncologica Published online: 06 Feb 2019

Purpose: We evaluate the effect of an exercised prehabilitation programme on tumour response in rectal cancer patients following neoadjuvant chemoradiotherapy (NACRT).

Patients and Methods: Rectal cancer patients with (MRI-defined) threatened resection margins who completed standardized NACRT were prospectively studied in a post hoc, explorative analysis of two previously reported clinical trials. MRI was performed at Weeks 9 and 14 post-NACRT, with surgery at Week 15. Patients undertook a 6-week preoperative exercise-training programme. Oxygen uptake (VO2) at anaerobic threshold (AT) was measured at baseline (pre-NACRT), after completion of NACRT and at week 6 (post-NACRT). Tumour related outcome variables: MRI tumour regression grading (ymrTRG) at Week 9 and 14; histopathological T-stage (ypT); and tumour regression grading (ypTRG)) were compared.

Results: 35 patients (26 males) were recruited. 26 patients undertook tailored exercise-training with 9 unmatched controls. NACRT resulted in a fall in VO2 at AT −2.0 ml/kg−1/min−1(−1.3,−2.6), p < 0.001. Exercise was shown to reverse this effect. VO2 at AT increased between groups, (post-NACRT vs. week 6) by +1.9 ml/kg−1/min−1(0.6, 3.2), p = 0.007. A significantly greater ypTRG in the exercise group at the time of surgery was found (p = 0.02).

Conclusion: Following completion of NACRT, exercise resulted in significant improvements in fitness and augmented pathological tumour regression

Effects of Congenital Heart Disease Treatment on Quality of Life.

Boukovala M; Müller J; Ewert P; Hager A;

The American Journal Of Cardiology [Am J Cardiol] 2019 Jan 08. Date of Electronic Publication: 2019 Jan 08.

With rising survival rates of patients with congenital heart disease (CHD), functional health variables have become the key aspect in treatment evaluation. The effectiveness of various treatment options on the health-related quality of life (HRQoL) and the objectively measured exercise capacity as peak oxygen uptake (VO2 peak) remains rather unclear and hence, its investigation is the primary aim of this study. Data from 1014 patients (≥14-years-old, various CHD) were retrospectively reviewed. The patients had completed at least twice the SF-36 questionnaire on HRQoL prior to a cardiopulmonary exercise test. Each patient was assigned to 1 of 4 treatment groups (i.e., surgery, catheter intervention, drug therapy, and surveillance) according to the received treatment between the baseline and the follow-up examination. After 4.0 ± 2.2 years of follow-up, patients with surgery and catheter intervention showed an increase in the physical summary score of HRQoL as compared to the other treatment groups (p <0.001). This effect remained also significant in a multivariable model accounting for anthropometric and baseline data. No significant differences in the mental summary score of HRQoL and the VO2 peak were evident between the different treatment groups in the multivariable model. No significant correlation was found between the changes in HRQoL and VO2 peak over time. In conclusion, despite insignificant changes in aerobic capacity, adolescents and adults with CHD report better physical HRQoL following surgery and catheter intervention compared to the other treatment options. HRQoL and exercise capacity need to be considered concurrently in the evaluation of adolescents and adults with CHD.

A Systematic Approach to Interpreting the Cardiopulmonary Exercise Test in Pediatrics.

Van Brussel M; Bongers BC; Hulzebos EHJ; Burghard M; Takken T;

Pediatric Exercise Science [Pediatr Exerc Sci] 2019 Jan 28, pp. 1-10. Date of Electronic Publication: 2019 Jan 28.

The use of cardiopulmonary exercise testing in pediatrics provides critical insights into potential physiological causes of unexplained exercise-related complaints or symptoms, as well as specific pathophysiological patterns based on physiological responses or abnormalities. Clinical interpretation of the results of a cardiopulmonary exercise test in pediatrics requires specific knowledge with regard to pathophysiological responses and interpretative strategies that can be adapted to address concerns specific to the child’s medical condition or disability. In this review, the authors outline the 7-step interpretative approach that they apply in their outpatient clinic for diagnostic, prognostic, and evaluative purposes. This approach allows the pediatric clinician to interpret cardiopulmonary exercise testing results in a systematic order to support their physiological reasoning and clinical decision making.

Cardiac vagal dysfunction and myocardial injury after non-cardiac surgery: a planned secondary analysis of the measurement of Exercise Tolerance before surgery study.

Abbott TEF; Pearse RM; Cuthbertson BH; Wijeysundera DN; Ackland GL;

British Journal Of Anaesthesia [Br J Anaesth] 2019 Feb; Vol. 122 (2), pp. 188-197. Date of Electronic Publication: 2018 Dec 17.

Background: The aetiology of perioperative myocardial injury is poorly understood and not clearly linked to pre-existing cardiovascular disease. We hypothesised that loss of cardioprotective vagal tone [defined by impaired heart rate recovery ≤12 beats min-1 (HRR ≤12) 1 min after cessation of preoperative cardiopulmonary exercise testing] was associated with perioperative myocardial injury.
Methods: We conducted a pre-defined, secondary analysis of a multi-centre prospective cohort study of preoperative cardiopulmonary exercise testing. Participants were aged ≥40 yr undergoing non-cardiac surgery. The exposure was impaired HRR (HRR≤12). The primary outcome was postoperative myocardial injury, defined by serum troponin concentration within 72 h after surgery. The analysis accounted for established markers of cardiac risk [Revised Cardiac Risk Index (RCRI), N-terminal pro-brain natriuretic peptide (NT pro-BNP)].
Results: A total of 1326 participants were included [mean age (standard deviation), 64 (10) yr], of whom 816 (61.5%) were male. HRR≤12 occurred in 548 patients (41.3%). Myocardial injury was more frequent amongst patients with HRR≤12 [85/548 (15.5%) vs HRR>12: 83/778 (10.7%); odds ratio (OR), 1.50 (1.08-2.08); P=0.016, adjusted for RCRI). HRR declined progressively in patients with increasing numbers of RCRI factors. Patients with ≥3 RCRI factors were more likely to have HRR≤12 [26/36 (72.2%) vs 0 factors: 167/419 (39.9%); OR, 3.92 (1.84-8.34); P<0.001]. NT pro-BNP greater than a standard prognostic threshold (>300 pg ml-1) was more frequent in patients with HRR≤12 [96/529 (18.1%) vs HRR>12 59/745 (7.9%); OR, 2.58 (1.82-3.64); P<0.001].
Conclusions: Impaired HRR is associated with an increased risk of perioperative cardiac injury. These data suggest a mechanistic role for cardiac vagal dysfunction in promoting perioperative myocardial injury.