Category Archives: Publications

Cardiopulmonary Rehabilitation Improves Respiratory Muscle Function and Functional Capacity in Children with Congenital Heart Disease. A Prospective Cohort Study.

Ferrer-Sargues FJ; Peiró-Molina E; Salvador-Coloma P; Carrasco Moreno JI; Cano-Sánchez A; Vázquez-Arce MI; Insa Albert B; Sepulveda Sanchis P; Cebrià I Iranzo MÀ;

nternational journal of environmental research and public health [Int J Environ Res Public Health] 2020 Jun 17; Vol. 17 (12). Date of Electronic Publication: 2020 Jun 17.

Critical surgical and medical advances have shifted the focus of congenital heart disease (CHD) patients from survival to achievement of a greater health-related quality of life (HRQoL). HRQoL is influenced, amongst other factors, by aerobic capacity and respiratory muscle strength, both of which are reduced in CHD patients. This study evaluates the influence of a cardiopulmonary rehabilitation program (CPRP) on respiratory muscle strength and functional capacity.
Fifteen CHD patients, ages 12 to 16, with reduced aerobic capacity in cardiopulmonary exercise testing (CPET) were enrolled in a CPRP involving strength and aerobic training for three months. Measurements for comparison were obtained at the start, end, and six months after the CPRP. A significant improvement of inspiratory muscle strength was evidenced (maximum inspiratory pressure 21 cm H 2 O, 23%, p < 0.01). The six-minute walking test showed a statistically and clinically significant rise in walked distance (48 m, p < 0.01) and a reduction in muscle fatigue (1.7 out of 10 points, p = 0.017).
These results suggest CPRP could potentially improve respiratory muscle function and functional capacity, with lasting results, in children with congenital heart disease, but additional clinical trials must be conducted to confirm this finding.

Limited usefulness of resting hemodynamic assessments in predicting exercise capacity in hypertensive patients.

Kurpaska M; Krzesiński P; Gielerak G; Uziębło-Życzkowska B;

Journal of human hypertension [J Hum Hypertens] 2020 Jun 25. Date of Electronic Publication: 2020 Jun 25.

Reliable assessments of reduced exercise capacity based on resting tests are one of the major challenges in clinical practice. The aim of this study was to evaluate the relationship between hemodynamic parameters obtained via resting tests (echocardiography and impedance cardiography (ICG)) and objective parameters of exercise capacity assessed via cardiopulmonary exercise testing and exercise ICG in patients with controlled arterial hypertension (AH). The left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), diastolic function parameters (e’, E/A, E/e’), cardiac output (CO), stroke volume (SV), and systemic vascular resistance index were evaluated for any correlations with selected parameters of exercise capacity, such as peak oxygen uptake (VO 2 ) and peak CO in 93 people with AH (mean age 54 years, 47 women). Statistically relevant correlations occurred between indices of exercise capacity (peak VO 2 ; peak CO) and only the following hemodynamic parameters: diastolic blood pressure (R = 0.23, p = 0.026; R = 0.24, p = 0.021; respectively), e’ (R = 0.32, p = 0.002; R = 0.24, p = 0.027), E/e’ (R = 0.35, p < 0.001; ns), E/A (R = 0.23, p = 0.030; R = 0.21, p = 0.047), SV at rest (ns; R = 0.24, p = 0.019), and CO at rest (ns; R = 0.21, borderline p = 0.052). No significant correlations between the exercise capacity parameters and either LVEF or GLS were observed. No hemodynamic parameter proved to be an independent correlate of either peak VO 2 or peak CO. The association between hemodynamic parameters at rest and parameters of exercise capacity was weak and limited to selected parameters of diastolic function. Exercise capacity assessment in patients with AH based on resting tests alone is insufficiently reliable and should be supplemented with exercise tests.

Cardiopulmonary exercise testing in severe osteoarthritis: a crossover comparison of four exercise modalities.

Roxburgh BH; Campbell HA; Cotter JD; Reymann U; Williams MJA; Gwynne-Jones D; Thomas KN;

Anaesthesia [Anaesthesia] 2020 Jun 27. Date of Electronic Publication: 2020 Jun 27.

Cardiopulmonary exercise testing is performed increasingly for cardiorespiratory fitness assessment and pre-operative risk stratification. Lower limb osteoarthritis is a common comorbidity in surgical patients, meaning traditional cycle ergometry-based cardiopulmonary exercise testing is difficult. The purpose of this study was to compare cardiopulmonary exercise testing variables and subjective responses in four different exercise modalities. In this crossover study, 15 patients with osteoarthritis scheduled for total hip or knee arthroplasty (mean (SD) age 68 (7) years; body mass index 31.4 (4.1) kg.m -2 ) completed cardiopulmonary exercise testing on a treadmill, elliptical cross-trainer, cycle and arm ergometer. Mean (SD) peak oxygen consumption was 20-30% greater on the lower limb modalities (treadmill 21.5 (4.6) (p < 0.001); elliptical cross-trainer (21.2 (4.1) (p < 0.001); and cycle ergometer (19.4 (4.2) ml.min -1 .kg -1 (p = 0.001), respectively) than on the arm ergometer (15.7 (3.7) ml.min -1 .kg -1 ). Anaerobic threshold was 25-50% greater on the lower limb modalities (treadmill 13.5 (3.1) (p < 0.001); elliptical cross-trainer 14.6 (3.0) (p < 0.001); and cycle ergometer 10.7 (2.9) (p = 0.003)) compared with the arm ergometer (8.4 (1.7) ml.min -1 .kg -1 ). The median (95%CI) difference between pre-exercise and peak-exercise pain scores was greater for tests on the treadmill (2.0 (0.0-5.0) (p = 0.001); elliptical cross-trainer (3.0 (2.0-4.0) (p = 0.001); and cycle ergometer (3.0 (1.0-5.0) (p = 0.001)), compared with the arm ergometer (0.0 (0.0-1.0) (p = 0.406)). Despite greater peak exercise pain, cardiopulmonary exercise testing modalities utilising the lower limbs affected by osteoarthritis elicited higher peak oxygen consumption and anaerobic threshold values compared with arm ergometry.

Expiratory Flow Limitation at Different Exercise Intensities in Coronary Artery Disease.

Castello-Simões V; Karsten M;Minatel V; Simões RP; Silva E; Tamburús NY; Arena R; Borghi-Silva A; Catai AM;

Cardiology research and practice [Cardiol Res Pract] 2020 May 21; Vol. 2020, pp. 4629548. Date of Electronic Publication: 2020 May 21 (Print Publication: 2020).

Introduction: Expiratory flow limitation (EFL) during moderate intensity exercise is present in patients with myocardial infarction (MI), whereas in healthy subjects it occurs only at a high intensity. However, it is unclear whether this limitation already manifests in those with stable coronary artery disease (CAD) (without MI).
Materials and Methods: Forty-one men aged 40-65 years were allocated into (1) recent MI (RMI) group ( n  = 8), (2) late MI (LMI) group ( n  = 12), (3) stable CAD group ( n  = 9), and (4) healthy control group (CG) ( n  = 12). All participants underwent two cardiopulmonary exercise tests at a constant workload (moderate and high intensity), and EFL was evaluated at the end of each exercise workload.
Results: During moderate intensity exercise, the RMI and LMI groups presented with a significantly higher number of participants with EFL compared to the CG ( p < 0.05), while no significant difference was observed among groups at high intensity exercise ( p > 0.05). Moreover, EFL was only present in MI groups during moderate intensity exercise, whereas at high intensity all groups presented EFL. Regarding the degree of EFL, the RMI and LMI groups showed significantly higher values at moderate intensity exercise in relation to the CG. At high intensity exercise, significantly higher values for the degree of EFL were observed only in the LMI group.
Conclusion: The ventilatory limitation at moderate intensity exercise may be linked to the pulmonary consequences of the MI, even subjects with preserved cardiac and pulmonary function at rest, and not to CAD per se.

Cardiorespiratory fitness fails to predict short-term postoperative mortality in patients undergoing elective open surgery for abdominal aortic aneurysm.

Bailey DM; Berg R; Davies RG; Appadurai IR; Lewis MH;

Annals of the Royal College of Surgeons of England [Ann R Coll Surg Engl] 2020 Jun 15, pp. 1-4. Date of Electronic Publication: 2020 Jun 15.

Introduction: Preoperative cardiopulmonary exercise testing aids surgical risk stratification and is an established predictor of mid- to long-term survival in patients undergoing elective open abdominal aortic aneurysm repair. Whether cardiopulmonary exercise testing also predicts 30-day mortality in this population remains to be established.
Materials and Methods: Data for 109 patients (mean age 72 years) who underwent cardiopulmonary exercise testing to assess risk for surgical abdominal aortic aneurysm repair was analysed. Patients were classified according to cardiopulmonary fitness as fit (peak oxygen uptake ≥ 15ml O 2 .kg -1 .min -1 ) or unfit (peak oxygen uptake less than 15ml O 2 .kg -1 .min -1 ) and further stratified according to clamp position (infrarenal or suprarenal). Between-group postoperative outcomes were compared for in-hospital 30-day mortality, postoperative morbidity scale scores (day 5) and hospital length of stay.
Results: Seventy-nine patients underwent open surgery and 30 patients were treated conservatively. No deaths were recorded at 30 days post-surgery. Unfit patients with infrarenal clamping exhibited higher postoperative morbidity scale scores (64% vs 26%) and longer length of stay (four days) than fit patients ( p < 0.05). Conversely, with suprarenal clamping, postoperative morbidity scale scores were similar and length of stay longer (three days) in fit compared with unfit patients ( p < 0.05).
Discussion and Conclusion: Preoperative fitness level defined by peak oxygen uptake failed to identify patients at risk of 30-day mortality when undergoing elective abdominal aortic aneurysm repair. Postoperative morbidity and length of stay in patients with suprarenal clamping was high independent of cardiopulmonary fitness. These findings suggest that cardiopulmonary exercise testing may be a useful predictor of complications following infrarenal rather than suprarenal clamping but may not be a good predictor of 30-day mortality.

Prehabilitation in patients awaiting elective coronary artery bypass graft surgery – effects on functional capacity and quality of life: a randomized controlled trial.

Steinmetz C; Bjarnason-Wehrens B; Baumgarten H; Walther T; Mengden T; Walther C;

Clinical rehabilitation [Clin Rehabil] 2020 Jun 16, pp. 269215520933950. Date of Electronic Publication: 2020 Jun 16.

Objective: To determine the impact of an exercise-based prehabilitation (EBPrehab) program on pre- and postoperative exercise capacity, functional capacity (FC) and quality of life (QoL) in patients awaiting elective coronary artery bypass graft surgery (CABG).
Design: A two-group randomized controlled trail.
Setting: Ambulatory prehabilitation.
Subjects: Overall 230 preoperative elective CABG-surgery patients were randomly assigned to an intervention (IG, n  = 88; n  = 27 withdrew after randomization) or control group (CG, n  = 115).
Intervention: IG: two-week EBPrehab including supervised aerobic exercise. CG: usual care.
Main Measures: At baseline (T1), one day before surgery (T2), at the beginning (T3) and at the end of cardiac rehabilitation (T4) the following measurements were performed: cardiopulmonary exercise test, six-minute walk test (6MWT), Timed-Up-and-Go Test (TUG) and QoL (MacNew questionnaire).
Results: A total of 171 patients (IG, n  = 81; CG, n  = 90) completed the study. During EBPrehab no complications occurred. Preoperatively FC (6MWT IG : 443.0 ± 80.1 m to 493.5 ± 75.5 m, P  = 0.003; TUG IG : 6.9 ± 2.0 s to 6.1 ± 1.8 s, P  = 0.018) and QoL (IG: 5.1 ± 0.9 to 5.4 ± 0.9, P  < 0.001) improved significantly more in IG compared to CG. Similar effects were observed postoperatively in FC (6MWD IG : Δ-64.7 m, p T1-T3 =  0.013; Δ+47.2 m, p T1-T4 <  0.001; TUG IG : Δ+1.4 s, p T1-T3 =  0.003).
Conclusions: A short-term EBPrehab is effective to improve perioperative FC and preoperative QoL in patients with stable coronary artery disease awaiting CABG-surgery.

Wearable Patch Based Estimation of Oxygen Uptake and Assessment of Clinical Status during Cardiopulmonary Exercise Testing in Patients with Heart Failure.

Shandhi MMH; Hersek S; Fan J; Sander E; Marco T; Heller JA; Etemadi M; Klein L; Inan OT;

Journal of cardiac failure [J Card Fail] 2020 May 27. Date of Electronic Publication: 2020 May 27.

Objective: To estimate oxygen uptake (VO 2 ) from cardiopulmonary exercise testing (CPX) using simultaneously recorded seismocardiogram (SCG) and electrocardiogram (ECG) signals captured with a small wearable patch.
Background: CPX is an important risk stratification tool for patients with heart failure (HF) due to the prognostic value of the features derived from the gas exchange variables such as VO 2 . However, CPX requires specialized equipment, as well as trained professionals to conduct the study.
Methods: We have conducted a total of 68 CPX tests on 59 subjects with HF with reduced ejection fraction (31% women, mean age 55±13 years, ejection fraction 0.27±0.11, 79% stage C). The subjects were fitted with a wearable sensing patch and underwent treadmill CPX. We divided the dataset into a training-testing (N=44) and a separate validation set (N=24). We developed globalized (population) regression models to estimate VO 2 from the SCG and ECG signals measured continuously with the patch. We further classified the patients as stage D or C using the SCG and ECG features to assess the ability to detect clinical state from the wearable patch measurements alone. We developed the regression and classification model with cross-validation on the training-testing set and validated the models on the validation set.
Results: The regression model to estimate VO 2 from the wearable features yielded a moderate correlation (R 2 of 0.64) with a root-mean-square-error (RMSE) of 2.51±1.12 ml.kg -1 .min -1 on the training-testing set, whereas R 2 and RMSE on the validation set were 0.76 and 2.28±0.93 ml.kg -1 .min -1 respectively. Furthermore, the classification of clinical state yielded accuracy, sensitivity, specificity, and an area under the receiver operating characteristic curve values of 0.84, 0.91, 0.64, and 0.74 respectively for the training-testing set, and 0.83, 0.86, 0.67, and 0.92 respectively for the validation set.
Conclusion: Wearable SCG and ECG can assess CPX oxygen uptake and thereby classify clinical status for patients with HF. These methods may provide value in risk stratification of patients with HF by tracking cardiopulmonary parameters and clinical status outside of specialized settings, potentially allowing for more frequent assessments to be performed during longitudinal monitoring and treatment.

Risk Stratification in Hypertrophic Cardiomyopathy. Insights from Genetic Analysis and Cardiopulmonary Exercise Testing.

Magrì D; Gallo G; Zachara E; Re F; Agostoni P; Giordano D; Rubattu S; Forte M; ICotugno M; Torrisi MR; Petrucci S; Germani A; Savio C; Maruotti A; Volpe M; Autore C; Piane M; Musumeci B;

Journal of clinical medicine [J Clin Med] 2020 May 28; Vol. 9 (6). Date of Electronic Publication: 2020 May 28.

The role of genetic testing over the clinical and functional variables, including data from the cardiopulmonary exercise test (CPET), in the hypertrophic cardiomyopathy (HCM) risk stratification remains unclear. A retrospective genotype-phenotype correlation was performed to analyze possible differences between patients with and without likely pathogenic/pathogenic (LP/P) variants. A total of 371 HCM patients were screened at least for the main sarcomeric genes MYBPC3 (myosin binding protein C), MYH7 (β-myosin heavy chain), TNNI3 (cardiac troponin I) and TNNT2 (cardiac troponin T): 203 patients had at least an LP/P variant, 23 patients had a unique variant of uncertain significance (VUS) and 145 did not show any LP/P variant or VUS. During a median 5.4 years follow-up, 51 and 14 patients developed heart failure (HF) and sudden cardiac death (SCD) or SCD-equivalents events, respectively. The LP/P variant was associated with a more aggressive HCM phenotype. However, left atrial diameter (LAd), circulatory power (peak oxygen uptake*peak systolic blood pressure, CP%) and ventilatory efficiency (C-index = 0.839) were the only independent predictors of HF whereas only LAd and CP% were predictors of the SCD end-point (C-index = 0.738). The present study reaffirms the pivotal role of the clinical variables and, particularly of those CPET-derived, in the HCM risk stratification.

A Frame of Reference for Assessing the Intensity of Exertional Dyspnoea During Incremental Cycle Ergometry.

Neder JA; Berton DC; Nery LE; Tan WC; Bourbeau J; O’Donnell DE;

The European respiratory journal [Eur Respir J] 2020 May 29. Date of Electronic Publication: 2020 May 29.

Assessment of dyspnoea severity during incremental cardiopulmonary exercise testing (CPET) has long been hampered by the lack of reference ranges as a function of work rate (WR) and ventilation (V̇E). This is particularly relevant to cycling, a testing modality which overtaxes the leg muscles leading to a heightened sensation of leg discomfort.Reference ranges based on dyspnoea percentiles (0-10 Borg scale) at standardised WRs and V̇E were established in 275 apparently healthy subjects aged 20-85 (131 men). They were compared with values recorded in a randomly selected “validation” sample (N=451, 224 men). Their usefulness in properly uncovering the severity of exertional dyspnoea were tested in 167 subjects under investigation for chronic dyspnoea (“testing sample”) who terminated CPET due to leg discomfort (86 men).Iso-WR and, to a lesser extent, iso-V̇E reference ranges (5th-25th, 25th-50th, 50-75th and 75th-95th percentiles) increased as a function of age, being systematically higher in women (p<0.01). There was no significant differences in percentiles distribution between “reference” and “validation” samples (p>0.05). Submaximal dyspnoea-WR scores lied within the 75th-95th or >95th percentiles in 108/118 (91.5%) subjects of the “testing” sample who showed physiological abnormalities known to elicit exertional dyspnoea i.e. , ventilatory inefficiency and/or critical inspiratory constraints. In contrast, dyspnoea scores typically lied in the 5th-50th range in subjects without those abnormalities (p<0.001).This frame of reference might prove useful to uncover the severity of exertional dyspnoea in subjects who otherwise would be labeled as “non-dyspneic” while providing mechanistic insights into the genesis of this distressing symptom