Takano N; TAmiya E; Oguri G; Nakayama A; Taya M; Nakajima T; Morita H; Japan.Komuro I;

International Journal Of Cardiology. Heart & Vasculature [Int J Cardiol Heart Vasc] 2019 Jan 08; Vol. 22, pp. 84-91. Date of Electronic Publication: 20190108 (Print Publication: 2019).

To investigate the effect of atrial fibrillation (AF) on the oxygen uptake and exercise tolerance, we evaluated cardiopulmonary exercise test (CPET) data in AF patients and heart rate-matched controls with sinus rhythm (cSR) who received ambulatory cardiac rehabilitation. We compared CPET data between AF (N = 27) and cSR patients (N = 106) who had similar HRs at rest and the peak points. Oxygen uptake (VO2)/kg and relative O2 pulse (ml/bpm/kg) at rest and the anaerobic threshold (AT) level was not different between AF and cSR patients, but these parameters above the AT level were significantly lower in AF than in cSR patients. Concisely the parallel increase of relative O2 pulse during exercise was blunted above the respiratory compensation level (Rc) in the AF group. In addition, the HR change during exercise was inversely correlated with the increase of the O2 pulse above the AT level and this inverse correlation was more prominent in AF patients than in cSR patients. In conclusion, the value of VO2 was significantly lower above the AT level in AF patients. The trend of O2 pulse above the AT level was strongly associated with the detrimental response of HR increase and the response was markedly exaggerated in the AF patients.

Jiang R, Liu H, Pudasaini B, Zhang R, Xu JL, Wang L, Zhao QH, Yuan P, Guo J, He J, Gong SG, Wu C, Wu WH, Luo CJ,Qiu HL, Jing ZC, Liu JM

Clin Respir J. 2019 Jan 22. doi: 10.1111/crj.12996. [Epub ahead of print]

BACKGROUND: Pulmonary hypertension patients with mean pulmonary artery pressure
(mPAP) ≥ 25 mmHg had impaired cardiopulmonary exercise testing (CPET). Borderline
mean pulmonary pressures (boPAP; 21-24 mmHg) represents early pulmonary
vasculopathy. The CPET characteristics of boPAP is a matter of discussion. We
aimed to determine the CPET profile of such borderline hemodynamics.
METHODS: A matched case-control study was conducted on consecutive boPAP patients
at the Shanghai Pulmonary Hospital between Jan 2012 and Jan 2017. Hemodynamics,
echocardiography, the pulmonary function test (PFT) and CPET parameters were
compared between boPAP patients and normal mPAP patients which were matched 1:1
by sex and age. Conditional logistic regression analysis was performed to
determine the efficacy of CPET in detecting boPAP.
RESULTS: A total of 48 patients underwent RHC and CPET (24 Normal, 24 boPAP).
There were no differences in the demographics, echocardiography and PFT. BoPAP
patients had significantly decreased VO2 at the anaerobic threshold and peak VO2
/kg (858.4 ± 246.5 ml/min vs. 727.9 ± 228.0 ml/min, P = 0.037; 21.1 ± 6.4
mL/min/kg vs. 15.5 ± 5.6 mL/min/kg, P = 0.001, respectively). Significant
differences were not observed in ventilation efficiency. A trend of impaired
oxygen pulse and submaximal exercise tolerance were observed in boPAP patients.
Conditional logistical regression analysis revealed the risk of boPAP increased
by 2.493 (95% confident interval: 1.388 to 4.476, P = 0.002) with every 5
mL/min/kg decrease in peak VO2 /kg.
CONCLUSIONS: Patients with boPAP have a greater prevalence of exercise
intolerance, a trend of impaired oxygen pulse and submaximal exercise tolerance.

Armstrong HF; Schulze PC; Bacchetta M; Thirapatarapong W; Bartels MN.

Respirology. 19(5):675-82, 2014 Jul.
VI 1

BACKGROUND AND OBJECTIVE: Pulmonary hypertension (PH) is a known
complication in patients with interstitial lung disease (ILD).
Cardiopulmonary exercise testing (CPET) is an essential tool for the
assessment of patients with cardiac and pulmonary diseases due to its
prognostic and therapeutic implications. Few studies have evaluated the
relationship between CPET response and mean pulmonary artery pressures
(mPAP) in ILD. The purpose of the present study was to determine and
compare the potential correlations between CPET, 6-min walk test (6MWT),
pulmonary function testing (PFT) and PH in patients with ILD being
evaluated for lung transplantation.

METHODS: The present study reviewed patients with ILD who received lung
transplantations and had CPETs within 2 years before transplantation,
right heart catheterizations, PFTs and 6MWTs within 4 months of CPET.

RESULTS: A total of 72 patients with ILD were analysed; 36% had PH. There
were significant correlations between mPAP and CPET parameters in patients
with PH; but mPAP had no impact on percent of predicted diffusion capacity
of the lung for carbon monoxide or 6-min walk distance (6MWD). CPET
parameters were able to detect differences between levels of severity of
PH through the use of the ratio of minute ventilation to rate of carbon
dioxide production (VE/VCO2) and the partial pressure of end-tidal carbon
dioxide.

CONCLUSIONS: This is the first study that analyses 6MWD, PFT and CPET in
patients with ILD awaiting lung transplantation with and without PH. The
present study demonstrates the significant impact of PH on exercise
capacity and performance in patients with ILD awaiting lung
transplantation.

Biccard BM.

British Journal of Anaesthesia. 120(3):419-421, 2018 03.
VI 1

Comment in: Br J Anaesth. 2018 Aug;121(2):496-497; PMID: 30032891

Bhasipol A; Sanjaroensuttikul N; Pornsuriyasak P; Yamwong S; Tangcharoen
T.

Congenital Heart Disease. 13(6):952-958, 2018 Nov.

OBJECTIVE: We aimed to study the efficiency and safety of once-a-week
outpatient rehabilitation followed by home program with tele-monitoring in
patients with complex cyanotic congenital heart disease.

DESIGN: Prospective nonrandomized study.

METHOD: Patients who have been diagnosed either Eisenmenger’s syndrome or
inoperable complex cyanotic heart disease and able to attend 12-week
cardiac rehabilitation program were included. Training with treadmill
walking and bicycling under supervision at cardiac rehabilitation unit
once-a-week in the first 6 weeks followed by home-based exercise program
(bicycle and walking) with a target at 40%-70% of maximum heart rate
(HRmax) at pretraining peak exercise for another 6 weeks was performed in
the intervention group. Video and telephone calls were scheduled for
evaluation of compliance and complication. Data from cardiopulmonary
exercise testing (CPET) on cycle ergometry including peak oxygen
consumption (peakVO2 ), oxygen pulse (O2 pulse), ventilatory equivalent
for carbon dioxide (VE/CO2 at anaerobic threshold), constant work-rate
endurance time (CWRET) at 75% of peak VO2 , and 6-minute walk distance
(6MWD) were compared between baseline and after training by paired t test.

RESULT: Of the 400 patients in our adult congenital heart disease clinic,
60 patients met the inclusion criteria. Eleven patients who could follow
program regularly were assigned home program. There was a statistically
significant improvement of CWRET, O2 pulse, and 6MWD after finishing the
program (P = .003, .039, and .001, respectively). The mean difference of
6MWD change in the home-program group was significantly higher than in the
control group (69.3 +/- 47.9 meters vs. 4.1 +/- 43.4 meters, P = .003). No
serious adverse outcomes were reported during home training.

CONCLUSION: Once-a-week outpatient hospital-based exercise program
followed by supervised home-based exercise program showed a significant
benefit in improvement of exercise capacity in adults with complex
cyanotic congenital heart disease without serious adverse
outcomes.

Shafer KM; Opotowsky AR; Rhodes J.

Congenital Heart Disease. 13(6):903-910, 2018 Nov.

OBJECTIVE: Risk prediction using cardiopulmonary exercise testing (CPET)
in complex congenital heart disease tends to either focus on single
diagnoses or complete cohorts. We aimed to evaluate patients with two
distinct anatomies cared for at a single institution over the same time
period to determine CPET variables associated with mortality.

DESIGN: All Fontan and tetralogy of Fallot (TOF) subjects with CPET
between November 1, 2002 and December 31, 2014 and subsequently died were
identified (cases). Cases were matched 1:3 to controls with similar age,
underlying anatomy and timing of exercise test.

RESULTS: Of the 42 cases, 27 had a Fontan circulation and 15 with TOF.
All Fontan patients had a low peak VO2 but there was no significant
difference between cases and controls (52.5 +/- 14.7 v. 57.4% +/- 13.5%
predicted, P = .11). Spirometry values were significantly lower in Fontan
cases than controls (eg, FVC 67.4 +/- 19.1 v 77.6% +/- 14.9% predicted, P
= .007). Spirometry values were also lower in TOF cases than controls (%
predicted FVC 62.8 +/- 16.7 v 75 +/- 14, P = .006). In contrast to the
Fontan analysis, both %peak predicted VO2 and VE/VCO2 slope were worse in
TOF cases than controls (50.1 +/- 13.5 v. 68.5% +/- 15.0% predicted VO2 ,
P = .0004; 33.9 +/- 12.9 v 26.6 +/- 4.4, P = .002). Multivariable analysis
also identified different predictors of mortality among the anatomic
subgroups. Spirometric data (FVC) correlated most strongly with mortality
in Fontan patients while the VE/VCO2 slope was most associated with
outcome in TOF patients.

CONCLUSIONS: Variables most predictive of mortality in Fontan and TOF
patients diverge but spirometry was abnormal and associated with mortality
in both groups. When compared with age-matched controls, reduced FEV1 and
FVC correlated most strongly with mortality in Fontan patients while
VE/VCO2 slope correlated with mortality for TOF patients. These findings
further support the importance of lung health in patients with complex
congenital heart disease.

Wu FM; Opotowsky AR; Denhoff ER; Gongwer R; Gurvitz MZ; Landzberg MJ;
Shafer KM; Valente AM; Uluer AZ; Rhodes J.

Seminars in Thoracic & Cardiovascular Surgery. 30(4):462-469, 2018 Winter.
VI 1
Comment in: Semin Thorac Cardiovasc Surg. 2018 Winter;30(4):470-471; PMID:
30179673

While the Fontan procedure has improved life expectancy, patients with
single ventricle physiology have impaired exercise capacity due to limited
increase in pulmonary blood flow during activity. Enhancing the “thoracic
pump” using inspiratory muscle training (IMT) may ameliorate this
impairment. Adult nonsmokers with Fontan physiology were recruited through
Boston Children’s Hospital’s outpatient clinic. Participants underwent
cardiopulmonary exercise testing and pulmonary function testing, followed
by 12 weeks of IMT and then repeat testing. The primary endpoint was
change in % predicted peak oxygen consumption (VO2). Secondary endpoints
were changes in other exercise metrics. Eleven patients (6 male) were
enrolled. Median ages at time of enrollment and Fontan completion were
28.8 years (25.7, 45.5) and 7.8 years (3.9, 16.5), respectively. Average
baseline maximal inspiratory pressure (MIP) was normal; only 2 patients
had MIP <70% predicted. Peak work rate improved significantly from
baseline after 12 weeks of IMT (116.5 +/- 45.0 to 126.8 +/- 47.0 W,
P=0.019). Peak VO2 tended to improve (baseline 68.1 +/- 14.3, change + 5.3
+/- 9.6% predicted, P=0.12), as did VE/VCO2 slope (34.1 +/- 6.7 to 31.4
+/- 3.6, P=0.12). There was no change in peak tidal volume or MIP. In a
small cohort of Fontan patients with mostly normal MIP, IMT was associated
with significant improvement in peak work rate and a trend toward higher
peak VO2 and improved ventilatory efficiency. Larger studies are needed to
determine if this reflects true lack of effect or whether this pilot study
was underpowered for effect size, and whether IMT is more narrowly useful
for patients with impaired MIP.

Dougherty RJ; Lindheimer JB; Stegner AJ; Van Riper S; Okonkwo OC; Cook DB.

Journal of Alzheimer’s Disease. 61(2):601-611, 2018.
VI

Cardiorespiratory fitness (CRF) is routinely investigated in older adults;
however, the most appropriate CRF measure to use for this population has
received inadequate attention. This study aimed to 1) evaluate the
reliability and validity of the oxygen uptake efficiency slope (OUES) as a
sub-maximal measurement of CRF; 2) examine demographic, risk-factor, and
exercise testing differences in older adults who satisfied standardized
criteria for a peak oxygen consumption (VO2peak) test compared to those
who did not; and 3) determine the difference between directly measured
VO2peak values and OUES-predicted VO2peak values. One hundred ten
enrollees from the Wisconsin Registry for Alzheimer’s Prevention
participated in this study. Participants performed a graded maximal
exercise test and wore an accelerometer for 7 days. For each participant,
the OUES was calculated at 75%, 90%, and 100% of exercise duration.
VO2peak was recorded at peak effort, and one week of physical activity
behavior was measured. OUES values calculated at separate relative
exercise durations displayed excellent reliability (ICC = 0.995; p <
0.001), and were strongly correlated with VO2peak (rrange = 0.801-0.909; p
< 0.001). As hypothesized, participants who did not satisfy VO2peak
criteria were significantly older than those who satisfied criteria (p =
0.049) and attained a directly measured VO2peak that was 2.31 mL.kg.min-1
less than the value that was predicted by OUES VO2peak (p = 0.003). Older
adults are less likely to satisfy VO2peak criteria, which results in an
underestimation of their CRF. Without adhering to standardized criteria,
VO2peak measurement error may lead to misinterpretation of CRF and
age-related associations. Here, we conclude that OUES is a reliable, valid
measurement of CRF which does not require achievement of standardized
criteria.

Allen S; Brown V; Prabhu P; Scott M; Rockall T; Preston S; Sultan J;

BMJ Open [BMJ Open] 2018 Dec 22; Vol. 8 (12), pp. e023190. Date of Electronic Publication: 2018 Dec 22.

Introduction: Neoadjuvant therapy prior to oesophagogastric resection is the gold standard of care for patients with T2 and/or nodal disease. Despite this, studies have taught us that chemotherapy decreases patients’ functional capacity as assessed by cardiopulmonary exercise (CPX) testing. We aim to show that a multimodal prehabilitation programme, comprising supervised exercise, psychological coaching and nutritional support, will physically, psychologically and metabolically optimise these patients prior to oesophagogastric cancer surgery so they may better withstand the immense physical and metabolic stress placed on them by radical curative major surgery.
Methods and Analysis: This will be a prospective, randomised, controlled, parallel, single-centre superiority trial comparing a multimodal ‘prehabilitation’ intervention with ‘standard care’ in patients with oesophagogastric malignancy who are treated with neoadjuvant therapy prior to surgical resection. The primary aim is to demonstrate an improvement in baseline cardiopulmonary function as assessed by anaerobic threshold during CPX testing in an interventional (prehab) group following a 15-week preoperative exercise programme, throughout and following neoadjuvant treatment, when compared with those that undergo standard care (control group). Secondary objectives include changes in peak oxygen uptake and work rate (total watts achieved) at CPX testing, insulin resistance, quality of life, chemotherapy-related toxicity and completion, nutritional assessment, postoperative complication rate, length of stay and overall mortality.
Ethics and Dissemination: This study has been approved by the London-Bromley Research Ethics Committee and registered on ClinicalTrials.gov. The results will be disseminated in a peer-reviewed journal.

Kaminsky LA; Arena R; Ellingsen Ø; Harber MP; Myers J; Ozemek C; Ross R;

Progress In Cardiovascular Diseases [Prog Cardiovasc Dis] 2019 Jan 09. Date of Electronic Publication: 2019 Jan 09.

The importance of cardiorespiratory fitness (CRF) is now well established and it is increasingly being recognized as an essential variable which should be assessed in health screenings. The key findings that have established the clinical significance of CRF are reviewed in this report, along with an overview of the current relevance of exercise as a form of medicine that can provide a number of positive health outcomes, including increasing CRF. Current assessment options for assessing CRF are also reviewed, including the direct measurement via cardiopulmonary exercise testing which now can be interpreted with age and sex-specific reference values. Future directions for the use of CRF and related measures are presented.