Category Archives: Publications

Cardiopulmonary Exercise Testing as a Tool for Diagnosing Pulmonary Hypertension in Patients with Dilated Cardiomyopathy

Hirashiki, Akihiro; Kondo, Takahisa; Okumura, Takahiro; Kamimura, Yoshihiro;
Nakano, Yoshihisa; Fukaya, Kenji; Sawamura, Akinori; Morimoto, Ryota;
Adachi, Shiro; Takeshita, Kyosuke; Murohara, Toyoaki.

Annals of Noninvasive Electrocardiology, May 2016, Vol. 21 Issue: Number 3
p263-271, 9p;

Abstract: Recently, it has become increasingly recognized
that pulmonary hypertension (PH) is a particularly threatening result
of left‐sided heart disease. However, there have been few
investigations of the impact of cardiopulmonary exercise testing (CPX)
variables on PH in dilated cardiomyopathy (DCM). We evaluated the
usefulness of crucial CPX variables for detecting elevated pulmonary
arterial pressure (PAP) in patients with DCM. Ninety subjects with DCM
underwent cardiac catheterization and CPX at our hospital. Receiver
operator characteristic (ROC) analysis was performed to assess the
ability of CPX variables to distinguish between the presence and
absence of PH. Overall mean values were: mean PAP (mPAP), 18.0 ± 9.6
mmHg; plasma brain natriuretic peptide, 233 ± 295 pg/mL; and left
ventricular ejection fraction, 30.2 ± 11.0%. Patients were allocated to
one of two groups on the basis of mean PAP, namely DCM without PH [mean
PAP (mPAP) <25 mmHg; n= 75] and DCM with PH (mPAP ≥25 mmHg; n= 15). A
cutoff achieved percentage of predicted peak VO2(%PPeak VO2) of 52.5%
was the best predictor of an mPAP ≥25 mmHg in the ROC analysis (area
under curve: 0.911). In the multivariate analysis, %PPeak VO2was the
only significant independent predictor of PH (Wald 6.52, odds ratio
0.892, 95% CI 0.818–0.974; P = 0.011). %PPeak VO2was strongly
associated with the presence of PH in patients with DCM. Taken
together, these findings indicate that CPX variables could be important
for diagnosing PH in patients with DCM.

Case report: Subjective loss of performance after pulmonary embolism in an athlete- beyond normal values.

Dumitrescu D, Gerhardt F, Viethen T, Schmidt M, Mayer E, Rosenkranz S.

BMC Pulm Med. 2016;16:21.

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease. For patients with operable CTEPH, there is a clear recommendation for surgical removal of persistent thrombi by pulmonary endarterectomy (PEA). However, without the presence of PH, therapeutic management of chronic thromboembolic disease (CTED) is challenging – especially in highly trained subjects exceeding predicted values of maximal exercise capacity.

CASE PRESENTATION: A 43-year-old male athlete reported with progressive exercise limitation since 8 months. Six months earlier, pulmonary embolism had occurred, and was treated since with oral anticoagulation. A pulmonary ventilation/perfusion scan showed severe ventilation/perfusion mismatch: chest CT and pulmonary angiography revealed bilateral wall-adherent thrombotic material, but pulmonary hemodynamics were completely normal. His peak oxygen uptake exceeded predicted values, however exercise ventilatory efficiency was abnormal, compared to a matching athlete. After thoroughly discussing therapeutic options with the patient, he successfully underwent pulmonary endarterectomy at an expert center. Five and twelve months after surgery, his maximal exercise capacity and ventilatory efficiency profoundly improved beyond preoperative values, and his subjective exercise tolerance had returned to normal.
CONCLUSIONS: Significant CTED may be present without relevant pathologic changes in pulmonary hemodynamics at rest. Reaching normal values of maximal exercise capacity does not exclude pulmonary vascular disease in highly trained subjects. More data are needed to evaluate the risk-/benefit ratio of PEA in patients with CTED and normal pulmonary hemodynamics. A thorough discussion with the patient as well as shared decision making regarding therapy are mandatory. Cardiopulmonary exercise testing may add important clinical information in the non-invasive diagnostic evaluation at baseline and during follow-up.

Cardiopulmonary exercise testing in a patient with a permanent tracheostomy

Tran, Steven; Krige, Anton.

Journal of Clinical Anesthesia, November 2016, Vol. 34 Issue: Number 1 p270-271, 2p;
Abstract: The benefits of cardiopulmonary exercise testing have been
well established. Certain patient groups present challenges for
conducting such a test. We were presented with a patient with a
permanent tracheostomy at the preoperative assessment clinic. We
describe our technique in overcoming the problem of connecting him to
the testing machine, as this is normally done with the aid of a
tight-fitting face mask. We used a cuffed tracheostomy tube together
with some widely available tubing from theaters to connect the patient
to the gas analyzer. The test was only stopped because of excessive
secretions from the patient, and we had already established enough data
to tell us that the patient was fit enough to proceed to surgery. As
more patients present with tracheostomies, we feel that this case would
be a useful reference in managing and assessing such patients.

2016 focused update: clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations.

Guazzi M, Arena R, Halle M, Piepoli MF, Myers J, Lavie CJ

Eur Heart J. 2016. May 2

In the past several decades, cardiopulmonary exercise testing (CPX) has seen an exponential increase in its evidence base. The growing volume of evidence in support of CPX has precipitated the release of numerous scientific statements by societies and associations. In 2012, the European Association for Cardiovascular Prevention & Rehabilitation and the American Heart Association developed a joint document with the primary intent of redefining CPX analysis and reporting in a way that would streamline test interpretation and increase clinical application. Specifically, the 2012 joint scientific statement on CPX conceptualized an easy-to-use, clinically meaningful analysis based on evidence-vetted variables in color-coded algorithms; single-page algorithms were successfully developed for each proposed test indication. Because of an abundance of new CPX research in recent years and a reassessment of the current algorithms in light of the body of evidence, a focused update to the 2012 scientific statement is now warranted. The purposes of this update are to confirm algorithms included in the initial scientific statement not requiring revision, to propose revisions to algorithms included in the initial scientific statement, to propose new algorithms based on emerging scientific evidence, to further clarify the application of oxygen consumption at ventilatory threshold, to describe CPX variables with an emerging scientific evidence base, to describe the synergistic value of combining CPX with other assessments, to discuss personnel considerations for CPX laboratories, and to provide recommendations for future CPX research.

Cardiorespiratory fitness and sports activities in children and adolescents with solitary functioning kidney

Tancredi, Giancarlo;  Lambiase, Caterina; Favoriti, Alessandra; Ricupito, Francesca; Paoli,
Sara; Duse, Marzia; De Castro, Giovanna; Zicari, Anna; Vitaliti,  Giovanna; Falsaperla, Raffaele; Lubrano, Riccardo.

Italian Journal of Pediatrics, December 2016, Vol. 42 Issue: Number 1 p1-7, 7p;

An increasing number of children with chronic disease require a
complete medical examination to be able to practice physical activity.
Particularly children with solitary functioning kidney (SFK) need an
accurate functional evaluation to perform sports activities safely. The
aim of our study was to evaluate the influence of regular physical
activity on the cardiorespiratory function of children with solitary
functioning kidney.  Twenty-nine patients with
congenital SFK, mean age 13.9 ± 5.0 years, and 36 controls (C), mean
age 13.8 ± 3.7 years, underwent a cardiorespiratory assessment with
spirometry and maximal cardiopulmonary exercise testing. All subjects
were divided in two groups: sedentary (S) and trained (T) patients, by
means of a standardized questionnaire about their weekly physical
activity.   We found that mean values of maximal oxygen
consumption (VO2max) and exercise time (ET) were higher in T subjects
than in S subjects. Particularly SFK-T presented mean values of VO2max
similar to C-T and significantly higher than C-S (SFK-T: 44.7 ± 6.3 vs
C-S: 37.8 ± 3.7 ml/min/kg; p< 0.0008). We also found significantly
higher mean values of ET (minutes) in minutes in SFK-T than C-S
subjects (SFK-T: 12.9 ± 1.6 vs C-S: 10.8 ± 2.5 min; p<0.02).
Our study showed that regular moderate/high level of physical
activity improve aerobic capacity (VO2max) and exercise tolerance in
congenital SFK patients without increasing the risks for cardiovascular
accidents and accordingly sports activities should be strongly
encouraged in SFK patients to maximize health benefits.

Unexplained exertional dyspnea caused by low ventricular filling pressures: results from clinical invasive cardiopulmonary exercise testing

Pulmonary Circulation, March 2016, Vol. 6 Issue: Number 1
p55-62, 8p;

Abstract: To determine whether low ventricular filling
pressures are a clinically relevant etiology of unexplained dyspnea on
exertion, a database of 619 consecutive, clinically indicated invasive
cardiopulmonary exercise tests (iCPETs) was reviewed to identify
patients with low maximum aerobic capacity (V̇o2max) due to inadequate
peak cardiac output (Qtmax) with normal biventricular ejection
fractions and without pulmonary hypertension (impaired: n= 49, V̇o2max
= 53% predicted [interquartile range (IQR): 47%–64%], Qtmax = 72%
predicted [62%–76%]). These were compared to patients with a normal
exercise response (normal: n= 28, V̇o2max = 86% predicted [84%–97%],
Qtmax = 108% predicted [97%–115%]). Before exercise, all patients
received up to 2 L of intravenous normal saline to target an upright
pulmonary capillary wedge pressure (PCWP) of ≥5 mmHg. Despite this
treatment, biventricular filling pressures at peak exercise were lower
in the impaired group than in the normal group (right atrial pressure
[RAP]: 6 [IQR: 5–8] vs. 9 [7–10] mmHg, P= 0.004; PCWP: 12 [10–16] vs.
17 [14–19] mmHg, P< 0.001), associated with decreased stroke volume
(SV) augmentation with exercise (+13 ± 10 [standard deviation (SD)] vs.
+18 ± 10 mL/m2, P= 0.014). A review of hemodynamic data from 23
patients with low RAP on an initial iCPET who underwent a second iCPET
after saline infusion (2.0 ± 0.5 L) demonstrated that 16 of 23 patients
responded with increases in Qtmax ([+24% predicted [IQR: 14%–34%]),
V̇o2max (+10% predicted [7%–12%]), and maximum SV (+26% ± 17% [SD]).
These data suggest that inadequate ventricular filling related to low
venous pressure is a clinically relevant cause of exercise

Exercise Testing: Who, When, and Why?

Nelson, Nicole; Asplund,
Chad A.. PM&R:

Journal of Injury Function and Rehabilitation, March
2016, Vol. 8 Issue: Number 3, Number 3 Supplement 1 pS16-S23, 8p;

Abstract: There are different modalities of exercise testing that can
provide valuable information to physicians about patient and athlete
fitness and cardiopulmonary status. Cardiopulmonary exercise testing
(CPX) is a form of exercise testing that measures ventilatory and gas
exchange, heart rate, electrocardiogram, and blood pressures to provide
detailed information on the cardiovascular, pulmonary, and muscular
systems. This testing allows an accurate quantification of functional
capacity/measure of exercise tolerance, diagnosis of cardiopulmonary
disease, disease-progression monitoring or response to intervention,
and the prescription of exercise and training. CPX directly measures
inhaled and exhaled ventilator gases to determine the maximal oxygen
uptake, which reflects the body’s maximal use of oxygen and defines the
limits of the cardiopulmonary system.

Randomized clinical trial of prehabilitation before planned liver resection

Dunne, D. F. J.; Jack, S.; Jones, R. P.; Jones, L.;
Lythgoe, D. T.; Malik, H. Z.; Poston, G. J.; Palmer, D. H.; Fenwick, S.

British Journal of Surgery: BJS, April 2016, Vol. 103 Issue: Number
5 p504-512, 9p;

Abstract: Patients with low fitness as assessed by
cardiopulmonary exercise testing (CPET) have higher mortality and
morbidity after surgery. Preoperative exercise intervention, or
prehabilitation, has been suggested as a method to improve CPETvalues
and outcomes. This trial sought to assess the capacity of a 4‐week
supervised exercise programme to improve fitness before liver resection
for colorectal liver metastasis. This was a randomized clinical trial
assessing the effect of a 4‐week (12 sessions) high‐intensity cycle,
interval training programme in patients undergoing elective liver
resection for colorectal liver metastases. The primary endpoint was
oxygen uptake at the anaerobic threshold. Secondary endpoints included
other CPETvalues and preoperative quality of life (QoL) assessed using
the SF‐36®. Thirty‐eight patients were randomized (20 to
prehabilitation, 18 to standard care), and 35 (25 men and 10 women)
completed both preoperative assessments and were analysed. The median
age was 62 (i.q.r. 54–69) years, and there were no differences in
baseline characteristics between the two groups. Prehabilitation led to
improvements in preoperative oxygen uptake at anaerobic threshold (+1·5
(95 per cent c.i. 0·2 to 2·9) ml per kg per min) and peak exercise
(+2·0 (0·0 to 4·0) ml per kg per min). The oxygen pulse (oxygen uptake
per heart beat) at the anaerobic threshold improved (+0·9 (0·0 to 1·8)
ml/beat), and a higher peak work rate (+13 (4 to 22) W) was achieved.
This was associated with improved preoperative QoL, with the overall
SF‐36® score increasing by 11 (95 per cent c.i. 1 to 21) (P= 0·028) and
the overall SF‐36® mental health score by 11 (1 to 22) (P= 0·037). A
4‐week prehabilitation programme can deliver improvements in CPETscores
and QoLbefore liver resection. This may impact on perioperative

Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery

M. A. West R. Asher, M. Browning, G. Minto, M. Swart, K. Richardson,
L. McGarrity, S. Jack and M. P. W. Grocott on behalf of the Perioperative Exercise Testing
and Training Society

British Journal Surgery 2016 (On line)

BACKGROUND: In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery. METHODS: Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity. RESULTS: Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V o2 at theta^L ) and at peak exercise (V o2peak ) gave an area under the ROC curve (AUROC) of 0.79 (95 per cent c.i. 0.76 to 0.83; P < 0.001; cut-off 11.1 ml per kg per min) and 0.77 (0.72 to 0.82; P < 0.001; cut-off 18.2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V o2 at theta^L 11.1 ml per kg per min or less: odds ratio (OR) 7.56, 95 per cent c.i. 4.44 to 12.86, P < 0.001; V o2peak 18.2 ml per kg per min or less: OR 2.15, 1.01 to 4.57, P = 0.047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V E /V co2 at theta^L ) more than 30.9: OR 1.38, 1.00 to 1.89, P = 0.047); BMI exceeding 27 kg/m2 : OR 1.05, 1.03 to 1.08, P < 0.001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0.30, 0.02 to 0.44; P = 0.033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0.83, 95 per cent c.i. 0.79 to 0.87). No adverse clinical events occurred during CPET across the six centres. CONCLUSION: These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.

Preoperative Nutrition and Prehabilitation

Gupta, Ruchir; Gan, Tong J..

Anesthesiology Clinics, March 2016, Vol. 34 Issue: Number 1
p143-153, 11p;

Abstract: Enhanced recovery after surgery is the natural
evolution of what were previously referred to as fast track programs
and seeks to implement a series of interventions to improve and enhance
recovery after major surgical procedures. Two important preoperative
aspects are nutrition and prehabilitation. Identifying nutritionally
deficient patients allows preoperative intervention to optimize their
nutritional status. The contribution of cardiopulmonary exercise
testing to the evaluation of perioperative risk, subsequent development
of a training program, and the use of indices to risk stratify and
measure improvement after a training program allow a personalized
preoperative program to be developed for each patient.