Category Archives: Publications

Interactive Video Games as a Method to Increase Physical Activity Levels in Children Treated for Leukemia.

Kowaluk A; Woźniewski M;

Healthcare (Basel, Switzerland) [Healthcare (Basel)] 2022 Apr 06; Vol. 10 (4).
Date of Electronic Publication: 2022 Apr 06.

Despite the beneficial effect of exercise, children treated for cancer do not engage in sufficient physical activity. It is necessary to search for attractive forms of physical activity, including interactive video games (IVGs). The aim of this study was to verify the effectiveness of the rehabilitation model developed by the authors based on the use of IVGs in children undergoing leukemia treatment. The study included a group of 21 children aged 7-13 years (12 boys, 9 girls) undergoing treatment for acute lymphoblastic leukemia (ALL) ( n = 13) and acute myeloid leukemia (AML) ( n = 8). The children were randomly assigned to an intervention group and a control group. To assess the level of cardiorespiratory fitness (CRF), each child participated in a Cardiopulmonary Exercise Test. Daily physical activity was assessed using the HBSC questionnaire. The study also used the Children’s Effort Rating Table Scale (CERT) to assess the intensity of physical effort. The children in the intervention group participated in 12 sessions of. The study participants managed to complete all stages of a progressive training program, which confirmed the feasibility of such physical effort by patients with cancer. Pediatric patients reported that the IVG training required a light to moderate physical effort despite high values of energy expenditure (EE).

Sex-Based Differences in Peak Exercise Blood Pressure Indexed to Oxygen Consumption Among Competitive Athletes.

Petek BJ; Gustus SK; Churchill TW; Guseh JS; Loomer G; VanAtta C; BaggishAL; Wasfy MM

Clinical Therapeutics. 44(1):11-22.e3, 2022 01.

PURPOSE: Although exercise testing guidelines define cutoffs for an
exaggerated exercise systolic blood pressure (SBP) response, SBPs above
these cutoffs are not uncommon in athletes given their high exercise
capacity. Alternately, guidelines also specify a normal SBP response that
accounts for metabolic equivalents (METs; mean [SD] of 10 [2] mm Hg per
MET or 3.5 mL/kg/min oxygen consumption [Vo2]). SBP and Vo2 increase less
during exercise in females than males. It is not clear if sex-based
differences in exercise SBP are related to differences in Vo2 or if
current recommendations for normal increase in SBP per MET produce
reasonable estimates using measured METs (ie, Vo2) in athletes. We
therefore examined sex-based differences in exercise SBP indexed to Vo2 in
athletes with the goal of defining normative values for exercise SBP that
account for fitness and sex.

METHODS: Using prospectively collected data from a single sports
cardiology program, normotensive athlete patients were identified who had
no relevant cardiopulmonary disease and had undergone cardiopulmonary
exercise testing with cycle ergometry or treadmill. The relationship
between DELTASBP (peak – rest) and DELTAVo2 (peak – rest) was examined in
the total cohort and compared between sexes.

FINDINGS: A total of 413 athletes (mean [SD] age, 35.5 [14] years; 38%
female; mean [SD] peak Vo2, 46.0 [10.2] mL/kg/min, 127% [27%] predicted)
met the inclusion criteria. The DELTASBP correlated with unadjusted
DELTAVo2 (cycle: R2 = 0.18, treadmill: R2 = 0.12; P < 0.0001). Female
athletes had lower mean (SD) peak SBP (cycle: 161 [15] vs 186 [24] mm Hg;
treadmill: 165 [17] vs 180 [20] mm Hg; P < 0.05) than male athletes.
Despite lower peak SBP, mean (SD) DELTASBP relative to unadjusted DELTAVo2
was higher in female than male athletes (cycle: 25.6 [7.2] vs 21.1 [7.3]
mm Hg/L/min; treadmill: 21.6 [7.2] vs 17.0 [6.2] mm Hg/L/min; P < 0.05).
When Vo2 was adjusted for body size and converted to METs, female and male
athletes had similar mean (SD) DELTASBP /DELTAMET (cycle: 6.0 [2.1] vs 5.8
[2.0] mm Hg/mL/kg/min; treadmill: 4.7 [1.8] vs 4.8 [1.7] mm Hg/mL/kg/min).

IMPLICATIONS: In this cohort of athletes without known cardiopulmonary
disease, observed sex-based differences in peak exercise SBP were in part
related to the differences in DELTAVo2 between male and female athletes.
Despite lower peak SBP, DELTASBP/unadjusted DELTAVo2 was paradoxically
higher in female athletes. Future work should define whether this finding
reflects sex-based differences in the peripheral vascular response to
exercise. In this athletic cohort, DELTASBP/DELTAMET was similar between
sexes and much lower than the ratio that has been proposed by guidelines
to define a normal SBP response. Our observed DELTASBP/DELTAMET, based on
measured rather than estimated METs, provides a clinically useful estimate
for normal peak SBP range in athletes.


Cardiopulmonary exercise test in patients with refractory angina: functional and ischemic evaluation.

de Assumpcao CRA; do Prado DML; Jordao CP; Dourado LOC; Vieira MLC;
Montenegro CGSP; Negrao CE; Gowdak LHW; De Matos LDNJ

Clinics (Sao Paulo, Brazil). 77:100003, 2022.

OBJECTIVE: To evaluate the exercise capacity of children and adolescents
with severe therapy resistant asthma (STRA) aiming to identify its main

METHODS: Cross-sectional study including individuals aged 6-18 years with
a diagnosis of STRA. Clinical (age and gender), anthropometric (weight,
height and body mass index) and disease control data were collected. Lung
function (spirometry), cardiopulmonary exercise testing (CPET) and
exercise-induced bronchoconstriction (EIB) test were performed.

RESULTS: Twenty-four patients aged 11.5 +/- 2.6 years were included. The
mean forced expiratory volume in one second (FEV1) was 91.3 +/- 9.2%. EIB
occurred in 54.2% of patients. In CPET, the peak oxygen uptake (VO2peak)
was 34.1 +/- 7.8 mL kg-1 min-1. A significant correlation between
ventilatory reserve and FEV1 (r = 0.57; p = 0.003) was found. Similarly,
there was a significant correlation between CPET and percent of FEV1 fall
in the EIB test for both VE/VO2 (r = 0.47; p = 0.02) and VE/VCO2 (r =
0.46; p = 0.02). Patients with FEV1<80% had lower ventilatory reserve (p =
0.009). In addition, resting heart rate correlated with VO2peak (r=-0.40;
p = 0.04), VE/VO2 (r = 0.46; p = 0.02) and VE/VCO2 (r = 0.48; p = 0.01).

CONCLUSIONS: Exercise capacity is impaired in approximately 30% of
children and adolescents with STRA. The results indicate that different
aspects of aerobic fitness are influenced by distinct determinants,
including lung function and EIB.

Dissociation Between Minimum Minute Ventilation/Carbon Dioxide Production and Minute Ventilation vs. Carbon Dioxide Production Slope.

Murata M; Kobayashi Y; Adachi H

Circulation Journal. 86(1):79-86, 2021 12 24.

BACKGROUND: Minute ventilation/carbon dioxide production (VE/VCO2) is a
variable of cardiopulmonary exercise testing (CPET), which is evaluated by
arterial CO2pressure and ventilation-perfusion mismatch via invasive
methods. This study evaluated substitute non-invasively obtained variables
for minimum VE/VCO2(Min) and VE vs. VCO2slope (Slope) and the relationship
between Min and Slope.
Methods and Results: This study enrolled 1,052
patients with heart disease who underwent CPET and impedance cardiography
simultaneously. At first, the correlations between the end-tidal
CO2pressure (PETCO2), tidal volume/respiratory rate (TV/RR) ratio, VE and
VCO2Y-intercept (Y-int), and cardiac index (CI) and the Min and Slope were
investigated. Second, the correlation between Min and Slope was
investigated. PETCO2showed the largest correlation value among the 4
variables. These 4 variables could reveal 84.2% and 81.9% of Min and
Slope, respectively. Although Slope correlated with Min (R=0.868) and
predicted 78.9% of Min, considering these 4 variables, Slope+Y-int was
more strongly correlated with Min (R=0.940); the Slope+Y-int revealed
90.6% of the Min relationship in the multiple regression analysis.
CONCLUSIONS: Over 80% of the Min and Slope values were revealed with the
above-mentioned 4 variables collected non-invasively. The formula,
MinSlope+Y-int, can reveal >90% of the Min/Slope relationships, and the
Y-int may be a crucial factor to clarify the relationship between Min and

Exercise cardiac power and the risk of heart failure in men: A population-based follow-up study.

Kurl S; Jae SY; Mäkikallio TH; Voutilainen A; Hagnäs MJ; Kauhanen J; Laukkanen JA;

Journal of sport and health science [J Sport Health Sci] 2022 Mar; Vol. 11 (2), pp. 266-271.
Date of Electronic Publication: 2020 Feb 24.

Background: Little is known about exercise cardiac power (ECP), defined as the ratio of directly measured maximal oxygen uptake with peak systolic blood pressure during exercise, on heart failure (HF) risk. We examined the association of ECP and the risk of HF.
Methods: This was a population-based cohort study of 2351 men from eastern Finland. The average time to follow-up was 25 years. Participants participated at baseline in an exercise stress test. A total of 313 cases of HF occurred.
Results: Men with low ECP (<9.84 mL/mmHg, the lowest quartile) had a 2.37-fold (95% confidence interval (95%CI): 1.68-3.35, p < 0.0001) hazards ratio of HF as compared with men with high ECP (>13.92 mL/mmHg, the highest quartile), after adjusting for age. Low ECP was associated with a 1.96-fold risk (95%CI: 1.38-2.78, p < 0.001) of HF after additional adjustment for conventional risk factors. After further adjustment for left ventricular hypertrophy, the results hardly changed (hazards ratio = 1.87, 95%CI: 1.31-2.66, p < 0.001). One SD increase in ECP (3.16 mL/mmHg) was associated with a decreased risk of HF by 28% (95%CI: 17%-37%).
Conclusion: ECP provides a noninvasive and easily available measure from cardiopulmonary exercise tests in predicting HF. However, ECP did not provide additional value over maximal oxygen uptake .

Cardiorespiratory physiology, exertional symptoms, and psychological burden in post-COVID-19 fatigue.

Schaeffer MR; Cowan J; Milne KM; Puyat JH; Voduc N; Lavoie KL; Mulloy A; Chirinos JA; Abdallah SJ; Guenette JA;

Respiratory physiology & neurobiology [Respir Physiol Neurobiol] 2022 Mar 29; Vol. 302, pp. 103898.
Date of Electronic Publication: 2022 Mar 29.

Fatigue is a common, debilitating, and poorly understood symptom post-COVID-19. We sought to better characterize differences in those with and without post-COVID-19 fatigue using cardiopulmonary exercise testing. Despite elevated dyspnoea intensity ratings, V̇O 2 peak (ml/kg/min) was the only significant difference in the physiological responses to exercise (19.9 ± 7.1 fatigue vs. 24.4 ± 6.7 ml/kg/min non-fatigue, p = 0.04). Consistent with previous findings, we also observed a higher psychological burden in those with fatigue in the context of similar resting cardiopulmonary function. Our findings suggest that lower cardiorespiratory fitness and/or psychological factors may contribute to post-COVID-19 fatigue symptomology. Further research is needed for rehabilitation and symptom management following SARS-CoV-2 infection.

Utility of exercise testing to assess athletes for post COVID-19 myocarditis.

Mitrani RD; Alfadhli J; Lowery MH; Best TM; Hare JM; Fishman J; Dong C; Siegel Y; Scavo V; Basham GJ; Myerburg RJ; Goldberger JJ;

American heart journal plus : cardiology research and practice [Am Heart J Plus] 2022 Mar 31, pp. 100125.
Date of Electronic Publication: 2022 Mar 31.

Purpose: This study assessed a functional protocol to identify myocarditis or myocardial involvement in competitive athletes following SARS-CoV2 infection.
Methods: We prospectively evaluated competitive athletes (n = 174) for myocarditis or myocardial involvement using the Multidisciplinary Inquiry of Athletes in Miami (MIAMI) protocol, a median of 18.5 (IQR 16-25) days following diagnosis of COVID-19 infection. The protocol included biomarker analysis, ECG, cardiopulmonary stress echocardiography testing with global longitudinal strain (GLS), and targeted cardiac MRI for athletes with abnormal findings. Patients were followed for median of 148 days.
Results: We evaluated 52 females and 122 males, with median age 21 (IQR: 19, 22) years. Five (2.9%) had evidence of myocardial involvement, including definite or probable myocarditis (n = 2). Three of the 5 athletes with myocarditis or myocardial involvement had clinically significant abnormalities during stress testing including ventricular ectopy, wall motion abnormalities and/or elevated VE/VCO2, while the other two athletes had resting ECG abnormalities. VO2 max , left ventricular ejection fraction and GLS were similar between those with or without myocardial involvement. No adverse events were reported in the 169 athletes cleared to exercise at a median follow-up of 148 (IQR108,211) days. Patients who were initially restricted from exercise had no adverse sequelae and were cleared to resume training between 3 and 12 months post diagnosis.
Conclusions: Screening protocols that include exercise testing may enhance the sensitivity of detecting COVID-19 related myocardial involvement following recovery from SARS-CoV2 infection.

Cardiopulmonary Outcomes After the Nuss Procedure in Pectus Excavatum.

Jaroszewski DE; Farina JM; Gotway MB; Stearns JD; Peterson MA; Pulivarthi VSKK; Bostoros P; Abdelrazek AS; Gotimukul A; Majdalany DS; Wheatley-Guy CM;Arsanjani R;

Journal of the American Heart Association [J Am Heart Assoc] 2022 Apr 05; Vol. 11 (7), pp. e022149.
Date of Electronic Publication: 2022 Apr 04.

Background Pectus excavatum is the most common chest wall deformity. There is still controversy about cardiopulmonary limitations of this disease and benefits of surgical repair. This study evaluates the impact of pectus excavatum on the cardiopulmonary function of adult patients before and after a modified minimally invasive repair.
Methods and Results In this retrospective cohort study, an electronic database was used to identify consecutive adult (aged ≥18 years) patients who underwent cardiopulmonary exercise testing before and after primary pectus excavatum repair at Mayo Clinic Arizona from 2011 to 2020. In total, 392 patients underwent preoperative cardiopulmonary exercise testing; abnormal oxygen consumption results were present in 68% of patients. Among them, 130 patients (68% men, mean age, 32.4±10.0 years) had post-repair evaluations. Post-repair tests were performed immediately before bar removal with a mean time between repair and post-repair testing of 3.4±0.7 years (range, 2.5-7.0). A significant improvement in cardiopulmonary outcomes ( P <0.001 for all the comparisons) was seen in the post-repair evaluations, including an increase in maximum, and predicted rate of oxygen consumption, oxygen pulse, oxygen consumption at anaerobic threshold, and maximal ventilation. In a subanalysis of 39 patients who also underwent intraoperative transesophageal echocardiography at repair and at bar removal, a significant increase in right ventricle stroke volume was found ( P <0.001).
Conclusions Consistent improvements in cardiopulmonary function were seen for pectus excavatum adult patients undergoing surgery. These results strongly support the existence of adverse cardiopulmonary consequences from this disease as well as the benefits of surgical repair.

Identification of factors impairing exercise capacity after severe COVID-19 pulmonary infection: a 3-month follow-up of prospective COVulnerability cohort.

Ribeiro Baptista B; d’Humieres T; Schlemmer F; Bendib I; Justeau G;
Al-Assaad L; Hachem M; Codiat R; Bardel B; Abou Chakra L; Belmondo T;
Audureau E; Hue S; Mekontso-Dessap A; Derumeaux G; Boyer L

Respiratory Research. 23(1):68, 2022 Mar 22.

BACKGROUND: Patient hospitalized for coronavirus disease 2019 (COVID-19)
pulmonary infection can have sequelae such as impaired exercise capacity.
We aimed to determine the frequency of long-term exercise capacity
limitation in survivors of severe COVID-19 pulmonary infection and the
factors associated with this limitation.

METHODS: Patients with severe COVID-19 pulmonary infection were enrolled
3 months after hospital discharge in COVulnerability, a prospective
cohort. They underwent cardiopulmonary exercise testing, pulmonary
function test, echocardiography, and skeletal muscle mass evaluation.

RESULTS: Among 105 patients included, 35% had a reduced exercise capacity
(VO2peak < 80% of predicted). Compared to patients with a normal exercise
capacity, patients with reduced exercise capacity were more often men
(89.2% vs. 67.6%, p = 0.015), with diabetes (45.9% vs. 17.6%, p = 0.002)
and renal dysfunction (21.6% vs. 17.6%, p = 0.006), but did not differ in
terms of initial acute disease severity. An altered exercise capacity was
associated with an impaired respiratory function as assessed by a decrease
in forced vital capacity (p < 0.0001), FEV1 (p < 0.0001), total lung
capacity (p < 0.0001) and DLCO (p = 0.015). Moreover, we uncovered a
decrease of muscular mass index and grip test in the reduced exercise
capacity group (p = 0.001 and p = 0.047 respectively), whilst 38.9% of
patients with low exercise capacity had a sarcopenia, compared to 10.9% in
those with normal exercise capacity (p = 0.001). Myocardial function was
normal with similar systolic and diastolic parameters between groups
whilst reduced exercise capacity was associated with a slightly shorter
pulmonary acceleration time, despite no pulmonary hypertension.

CONCLUSION: Three months after a severe COVID-19 pulmonary infection,
more than one third of patients had an impairment of exercise capacity
which was associated with a reduced pulmonary function, a reduced skeletal
muscle mass and function but without any significant impairment in cardiac