Zeineddine RM; Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz.
Farina JM; Shawwaf KA; Botros M; Saleeb A;Lackey JJ; D’Cunha J;Jaroszewski DE;

JTCVS techniques [JTCVS Tech] 2024 Sep 25; Vol. 28, pp. 194-202.
Date of Electronic Publication: 2024 Sep 25 (Print Publication: 2024).

Objective: Pectus arcuatum is a rare variant of pectus deformities that can cause varying degrees of cardiac compression. A review of the evaluation, surgical repair, and outcomes of pectus arcuatum is presented.
Methods: A retrospective review of all patients undergoing surgical treatment of pectus arcuatum at a single institution was conducted between January 1, 2010, and May 31, 2024. Descriptive statistics and surgical techniques are presented.
Results: Twenty patients underwent pectus arcuatum repair (median age, 22.9 years; 55.0% males, median Haller index 2.8 [interquartile range {IQR}, 2.2, 3.6]) during the study period. Preoperatively, all patients were bothered by their chest appearance and symptomatic, with the most common symptoms being exercise intolerance (95.0%), chest pain (90.0%), and shortness of breath (90.0%). Preoperatively, cardiopulmonary exercise testing was performed in almost half the patients with abnormal findings (median maximum oxygen consumption, 67.0% of predicted). A hybrid approach with sternal osteotomy and minimally invasive pectus excavatum repair was utilized in 19 out of 20 cases, with 1 case requiring sternal osteotomy only. Single wedge osteotomy was sufficient in most cases (70.0%). Median intraoperative time was 3.5 hours (IQR, 3.1, 4.2 hours). The adoption of cryoablation in 2018 significantly reduced hospital stays, from 5.0 days (IQR, 4.5, 6.0 days) to 3.0 days (IQR, 2.8, 5.0 days) ( P  < .001). At follow-up, all reported cosmetic satisfaction and most reported symptom improvement.
Conclusions: Pectus arcuatum can be successfully repaired with a hybrid surgical approach involving sternal osteotomy and Nuss bar placement. Symptomatic patients should be considered for surgery, with postoperative improvement expected.
Competing Interests: Dr Jaroszewski has collected consulting and IP/royalties through Mayo Clinic Ventures with Zimmer Biomet Inc, and is a speaker with AtriCure Inc. All other authors reported no conflict of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflict of interest.

Zhu WW; Department of Echocardiography, Beijing Chao Yang Hospital, Capital Medical University, Beijing, China.
Tian RY; Guo DC; Lin MM; Cai QZ; Qin YY; Ding XY; Lv XZ

Frontiers in cardiovascular medicine [Front Cardiovasc Med] 2024 Nov 28; Vol. 11, pp. 1442263.
Date of Electronic Publication: 2024 Nov 28 (Print Publication: 2024).

Aims: This study applied exercise stress echocardiography (ESE) to identify risk factors associated with exercise intolerance in patients with chronic coronary syndrome (CCS).
Methods and Results: 90 CCS patients underwent a cardiopulmonary exercise test and ESE, assessing exercise capacity, left ventricular systolic and diastolic function, and systolic reserve. The patients were divided into two groups according to the percentage of predicted oxygen consumption (VO ₂ ) at peak (≥85%, normal exercise tolerance group; <85%, exercise intolerant group). The left ventricular ejection fraction, average mitral valve S’, and left ventricular global longitudinal strain were lower in the exercise intolerant group than in the normal group, but no significant differences were observed in myocardial work parameters at rest. The average mitral valve E/e’, EDVi/E/e’, and proportion of abnormal diastolic function at the peak were higher in the exercise intolerant group than in the normal group. Moreover, the Δ SVi and flow reserve were lower, but the Δ average mitral valve E/e’ was higher in the exercise-intolerant group. From univariate and multivariate logistic regression analysis, only peak EDVi/E/e’ and Δ SVi correlated independently with exercise intolerance in CCS patients. With cutoff values of 8.64 ml/m ² for peak EDVi/E/e’ and 12.17 ml/m ² for Δ SVi, the combination of these factors had an area under the receiver operating characteristic curve of 0.906 (95% confidence interval, 0.820-0.960) for the prediction of exercise intolerance in CCS patients.
Conclusion: Hemodynamic changes during exercise in CCS patients were effectively evaluated using ESE. An elevated peak EDVi/E/e’ and a decreased Δ SVi are independent risk factors for exercise intolerance in patients with CCS.

Lollert A; Department of Diagnostic and Interventional Radiology, Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany.
Abu-Tair T; Emrich T; Kreitner KF; Sterlin A; Kampmann C; Staatz G;

Diagnostics (Basel, Switzerland) [Diagnostics (Basel)] 2024 Dec 07; Vol. 14 (23).
Date of Electronic Publication: 2024 Dec 07.

Objectives : To evaluate correlations between cardiac magnetic resonance imaging (cMRI) at rest including strain imaging and variables derived from quantitative cardiopulmonary exercise testing using a treadmill in patients with pectus excavatum.
Methods : We retrospectively correlated the results of cMRI and cardiopulmonary exercise testing in 17 patients with pectus excavatum, in whom both examinations were performed during their pre-operative clinical evaluation. In addition to cardiac volumetry, we assessed the strain rates of both ventricles using a feature-tracking algorithm of a piece of commercially available post-processing software.
Results : Right ventricular (RV) ejection fraction correlated negatively with heart rate at anaerobic threshold (rho = -0.543, p = 0.024). A positive correlation between radial strain rate at the RV base and percentage of predicted maximum heart rate (rho = 0.72, p = 0.001) was shown, with equivalent results for circumferential strain rate (rho = -0.64, p = 0.005). Radial strain rate at the RV base correlated in a strongly negative way with maximum oxygen uptake (rho = -0.8, p < 0.001), with a correspondingly positive correlation for circumferential strain rate (rho = 0.73, p = 0.001).
Conclusions : Quantitative parameters derived from cMRI at rest, especially those acquired at the most severely compressed RV base, correlated with cardiopulmonary exercise testing variables. The compression of the RV base by the sternum might be partially compensated by an increased strain rate to induce higher heart frequencies during exercise. However, high strain rates were associated with a higher disease severity and a lower maximum oxygen uptake, indicating a limitation of this compensation mechanism.

Zhang W; The Second Affiliated Hospital of Anhui Medical University, Cardiovascular Department for Gerontism, HeFei, People’s Republic of China.
Xu J;

International journal of general medicine [Int J Gen Med] 2024 Dec 14; Vol. 17, pp. 6145-6152.
Date of Electronic Publication: 2024 Dec 14 (Print Publication: 2024).

Objective: To analyze the relationship between the cardiopulmonary function and prognosis of patients with coronary heart disease after percutaneous coronary intervention (PCI).
Methods: A total of 153 patients with coronary heart disease who underwent PCI from January 2018 to April 2020 were enrolled in this study. Thorough careful assessment, cardiopulmonary exercise test (CPX) was performed 5 to 7 days after PCI. Patients were followed up every 3 months by outpatient examination or telephone visiting for 3 years after discharge. Clinical outcomes were followed up, including cardiac death, rehospitalization, heart failure, atrial fibrillation, stroke and transient ischemic attack. A single clinical event was defined as a poor prognosis and divided into a good prognosis group and a poor prognosis group according to the prognosis. By comparing the cardiorespiratory fitness (CRF) variables and clinical parameters, the variables that may affect the prognosis of patients were determined.
Results: CRF decreased significantly in the poor prognosis group, and peak VO2, VO2/kg AT, PETCO2 and OUES decreased compared with the good prognosis group, and the differences were statistically significant. Heart rate reserve (HRR) increased in the poor prognosis group compared with the good prognosis group, and the difference was statistically significant. Among them, peak VO2 and acute myocardial infarction were independent risk factors for poor prognosis.
Conclusion: Peak VO2 is an independent risk factor for the prognosis of cardiovascular disease after PCI for coronary heart disease.

Wadey CA; Children’s Health & Exercise Research Centre (CHERC) University of Exeter, Exeter, UK & hospitals in Australia
Barker AR; Stuart AG; Dorobantu DM; Pieles GE; Tran DL; Laohachai K; Ayer J; Weintraub RG; Cordina R; Williams CA;

Journal of the American Heart Association [J Am Heart Assoc] 2024 Dec 17; Vol. 13 (24), pp. e034944.
Date of Electronic Publication: 2024 Dec 14.

Background: Peak oxygen consumption (peak VO ₂ ) is traditionally scaled by body mass, but it is most appropriately scaled by fat-free mass. However, it is unknown whether peak VO ₂ scaled by fat-free mass is associated with mortality and morbidity in people with a Fontan circulation. The aim of this study was to assess the associations between different expressions of peak VO ₂ with mortality and morbidity in people with a Fontan circulation.
Methods and Results: Eighty-seven participants (aged 24.1±7.3 years; 53% women) with a Fontan circulation completed a cardiopulmonary exercise test and a dual-energy x-ray absorptiometry scan. Cox proportional hazard regressions models assessed the association (hazard ratio [HR]) between different expressions of peak VO ₂ with a composite outcome of Fontan failure (FF). Participants were followed up for a median of 6.5 years (95% CI, 6.4-6.9). Individuals experiencing FF (n=10/87) had a significantly lower absolute peak VO ₂ . In univariable models, peak VO ₂ ratio scaled to body mass was not significantly associated with FF (HR, 0.91; P =0.111). However, peak VO ₂ scaled by fat-free mass (HR, 0.90; P =0.020) or lean mass (HR, 0.90; P =0.017) was significantly and inversely associated with FF. These associations remained significant after adjusting for age, sex, and peak respiratory exchange ratio.
Conclusions: The association between peak VO ₂ and FF is improved when scaled to measures of body composition. Applied clinically, a 1-unit increase in peak VO ₂ scaled to fat-free mass or lean mass is associated with a ≈10% lower risk of FF.

Usui N; Department of Nephrology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
Nakata J; Uehata A;Kojima S; Ando S; Saitoh M;Inatsu A;Hisadome H; Nishiyama Y; Suzuki Y;

Clinical journal of the American Society of Nephrology : CJASN [Clin J Am Soc Nephrol] 2024 Dec 18.
Date of Electronic Publication: 2024 Dec 18.

Background: Potential impairment of exercise capacity is prevalent even in patients undergoing hemodialysis without frailty. Cardiopulmonary exercise testing (CPET) can detect physiological reserves such as cardiopulmonary, muscle, and autonomic function. We hypothesized that these indices could accurately determine the prognosis of patients on hemodialysis and analyzed them based on their relationship to frailty.
Methods: In this two-center prospective cohort study hemodialysis patients from Japan, participants underwent CPET and physical assessment to evaluate peak oxygen uptake (peak VO2, indicator of exercise capacity), peak work rate (WR, indicator of muscle function), ventilatory equivalent for carbon dioxide (VE/VCO2) slope (indicator of cardiac reserve), heart rate reserve (indicator of chronotropic incompetence), and frailty phenotype. Survival was followed-up for up to 5 years.
Results: Data from 189 patients (median [IQR] age: 71 [62, 77] years) were analyzed. All CPET indicators showed a consistent nonlinear relationship with all-cause mortality after adjustment: for peak VO2, hazard ratio [HR] 0.79 [95% CI: 0.71, 0.88], P <0.001; for peak WR, HR 0.95 [95% CI: 0.93, 0.97], P <0.001; for VE/VCO2 slope, HR 1.09 [95% CI: 1.05, 1.13], P <0.001; for heart rate reserve, HR 0.96 [95% CI: 0.93, 0.99], P=0.02). Frailty phenotype was associated with mortality after adjustment (HR 1.73 [95% CI: 1.06, 2.81], P=0.03); however, this association was not statistically significant in the model after adding peak VO2 (P=0.41). Furthermore, in both subgroups with and without frailty, CPET measures were significantly associated with mortality risk (peak VO2, peak WR, and VE/VCO2 slope: P <0.05). The peak VO2 (Δ area under the curve [AUC] 0.09, 95% CI: 0.02, 0.16) or the peak WR (ΔAUC 0.09, 95% CI: 0.02, 0.15) most significantly improved the prognostic accuracy.
Conclusions: Results showed the fragile aspect of the frailty phenotype in the hemodialysis population and the superior ability of CPET to indicate death risk complementing that aspect.

Ekström M; Department of Clinical Sciences Lund,Faculty of Medicine, Lund University, Lund, Sweden.
Lewthwaite H; Li PZ; Bourbeau J; Tan WC; Jensen D; Montréal, QC,

Chest [Chest] 2024 Oct 28.
Date of Electronic Publication: 2024 Oct 28.

Background: COPD management is guided by the respiratory symptom burden, assessed using the modified Medical Research Council (mMRC) scale, the COPD Assessment Test (CAT), or both.
Research Question: What are the abilities of mMRC and CAT to detect abnormally high exertional breathlessness on incremental cardiopulmonary cycle exercise testing (CPET) in people with COPD?
Study Design and Methods: Analysis of people ≥ 40 years of age with FEV ₁ to FVC ratio of < 0.70 after bronchodilator administration and ≥ 10 pack-years of smoking from the Canadian Cohort Obstructive Lung Disease study. Abnormal exertional breathlessness was defined as a breathlessness (Borg scale 0-10) intensity rating more than the upper limit of normal at the symptom-limited peak of CPET using normative reference equations.
Results: We included 318 people with COPD (40% women) with a mean (SD) age of 66.5 (9.3) years and FEV ₁ of 79.5% predicted (19.0% predicted); 26% showed abnormally low exercise capacity (peak oxygen uptake less than the lower limit of normal). Abnormally high exertional breathlessness was present in 24%, including 9% and 11% of people with mMRC score of 0 and CAT score of < 10, respectively. An mMRC score of ≥ 2 and CAT score of ≥ 10 was most specific (95%) to detect abnormal exertional breathlessness, but showed low sensitivity of only 12%. Accuracy for all scale cutoffs or combinations was < 65%. Compared with people with true-negatives findings, people with abnormal exertional breathlessness but low mMRC score, low CAT scores (false-negatives findings), or both showed worse self-reported and physiologic outcomes during CPET, were more likely to have physician-diagnosed COPD, but were not more likely to be taking any respiratory medication (37% vs 30%; mean difference, 6.1%; 95% CI, -7.2 to 19.4; P= .36).
Interpretation: In COPD, mMRC and CAT show low concordance with CPET and fail to identify many people with abnormally high exertional breathlessness.
Clinical Trial Registry: ClinicalTrials.gov; No.: NCT00920348; URL: www.
Clinicaltrials: gov.
Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: J. B. and W. C. T. report receiving institutional funding for the CanCOLD study from Astra Zeneca Canada, Ltd., Boehringer-Ingelheim Canada, Ltd., GlaxoSmithKline Canada, Ltd., Merck, Novartis Pharma Canada, Inc., as well as Nycomed Canada, Inc. (W. C. T.), Pfizer Canada, Ltd. (W. C. T.), Trudell (J. B.), and Grifolds (J. B.). M. E. declares no conflicts of interest related to this work. Unrelated to this work, M. E. has received a research grant from ResMed and personal fees from AstraZeneca, Boehringer Ingelheim, Novartis, and Roche. None declared (M. E., H. L., P. Z. L., D. J.).

Murakami H; Department of Cardiology and Nephrology, Mie University Graduate School of Medicine Mie Japan.
Fujimoto N; Moriwaki K; Ito H; Takasaki A; .Watanabe K; Kambara A; Kumagai N; Omura T; DKurita T;Momosaki R; Dohi K

Circulation reports [Circ Rep] 2024 Nov 09; Vol. 6 (12), pp. 583-591.
Date of Electronic Publication: 2024 Nov 09 (Print Publication: 2024).

Background: Exercise training based on cardiopulmonary exercise testing (CPET) improves outcomes in patients with acute coronary syndrome (ACS), while nutritional status is also crucial. This study evaluated CPET implementation and the impacts of clinical parameters, including CPET and nutritional status, on 2-year outcomes in ACS patients.
Methods and Results: Data from 2,621 ACS patients enrolled in the Mie ACS registry were analyzed. Of these, 938 were hospitalized in CPET-equipped facilities, while 1,683 were not. Nutritional status was assessed using controlling nutritional status (CONUT) score. Cox regression analysis evaluated the associations between nutritional status, CPET-based exercise education, and 2-year prognosis. Among the 938 patients in CPET facilities, 359 underwent CPET and received exercise education. During the 2-year follow up, 60 all-cause deaths occurred. Univariate Cox regression revealed that CPET implementation was associated with lower all-cause mortality. Other predictors included hemoglobin levels, age, hospitalization length, Killip class ≥2, mechanical support, and malnutrition. In multivariate Cox regression, CPET implementation remained an independent predictor of mortality (hazard ratio 0.47; P=0.04). However, when nutritional status was included, moderate to severe malnutrition emerged as an independent predictor of all-cause mortality (hazard ratio 2.47; P=0.02), diminishing the significance of CPET (P=0.058).
Conclusions: Moderate to severe malnutrition is a powerful independent prognostic factor for mortality in the Mie ACS registry. CPET implementation may enhance survival in ACS patients.
Competing Interests: The authors have no relationships to disclose that are relevant to the contents of this manuscript. K.D. received lecture fees from Otsuka Pharmaceutical Co., Ltd, Daiichi Sankyo Company Limited, Nippon Boehringer Ingelheim Co., Ltd, Novartis Japan, and Takeda Pharmaceutical Company Limited. K.D. received departmental research grant support from Daiichi Sankyo Company Limited, Shionogi Co., Ltd, Takeda Pharmaceutical Company Limited, Abbott Japan LLC, Otsuka Pharmaceutical Co., Ltd, Novartis Japan, Kowa Company, Ltd, Dainippon Sumitomo Pharma Co., Ltd, and Ono Pharmaceutical Co., Ltd. The other authors have no financial conflicts of interest to disclose.

Thompson DC; Department of Vascular Surgery, James Cook University Hospital, Middlesbrough, UK.
Hackett R; Wong PF; Danjoux G; Mofidi R;

European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery [Eur J Vasc Endovasc Surg] 2024 Dec 03.
Date of Electronic Publication: 2024 Dec 03.

Objective: The decision to electively repair an abdominal aortic aneurysm (AAA) involves balancing the risk of rupture, periprocedural mortality, and life expectancy. Random forest classifiers (RFCs) are powerful machine learning algorithms. The aim of this study was to construct and validate a random forest machine learning tool to predict two year survival following elective AAA repair.
Methods: All patients who underwent elective open or endovascular repair of AAA from 1 January 2008 to 31 March 2021 were reviewed. They were assessed using the Vascular Surgery Quality Improvement Program pathway involving cardiopulmonary exercise testing, contrast enhanced computerised tomography scan, and multidisciplinary assessment. Patients were followed up for at least two years. A RFC was developed using 70% of the dataset and validated using 30% to predict survival for at least two years following AAA repair.
Results: A total of 925 patients (n = 836 men; n = 89 women) underwent elective repair of AAA; 126 (13.6%) died during the first two years; 11 (1.2%) died from periprocedural mortality. Variable importance analysis suggested that anaerobic threshold, pre-operative haemoglobin, maximal O ₂ consumption, body mass index, risk category, and forced expiratory volume in 1 second – forced vital capacity ratio were the most important contributors to the model. Sensitivity and specificity of the RFC for prediction of two year survival following surgery was 96.7% (95% CI 94.4 – 99%) and 67.1% (95% CI 61 – 72%); overall accuracy: 92.6% (95% CI 88 – 95%) (positive predictive value: 0.93, negative predictive value: 0.80); 10-fold cross validation revealed area under the receiver operator characteristic curve of 0.88.
Conclusion: RFCs based on readily available clinical data can successfully predict survival in the first two years following elective repair of AAA. Such information can contribute to the risk benefit assessment when deciding to electively repair AAAs.

Egbe AC; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
Ali AE; Miranda WR; Connolly HM;Borlaug BA

Circulation. Heart failure [Circ Heart Fail] 2024 Dec 09, pp. e011981.
Date of Electronic Publication: 2024 Dec 09.

Background: Patients with Fontan palliation have reduced aerobic capacity because of impaired cardiac, pulmonary, and skeletal muscle function. However, the assessment of aerobic capacity in this population still relies on comparisons with people without cardiovascular disease rather than comparison with the expected aerobic capacity of other Fontan patients. The purpose of this study was to determine the expected aerobic capacity of adults with Fontan palliation.
Methods: Adults with Fontan palliation who underwent a cardiopulmonary exercise test at Mayo Clinic (2003-2023) were stratified into quartiles based on the predicted peak oxygen consumption (VO ₂ ). We assessed the correlates of predicted peak VO ₂ and the relationship between predicted peak VO ₂ quartiles and cardiovascular outcomes (death/transplant).
Results: Of 323 patients (age, 29±9 years; 177 [55%] men), the median peak VO ₂ was 19.1 (15.2-23.9) mL/kg per minute, and this corresponds to a predicted peak VO ₂ of 51% (range, 19-88; interquartile range, 41-62). After multivariable adjustments, the correlates of predicted peak VO ₂ were body mass index (β±SE, -2.61±0.95; 2.61% decrease in predicted peak VO ₂ per 5 kg/m ² increase in body mass index; P =0.009), systemic saturation (β±SE, 3.65±0.85; 3.65% increase in predicted peak VO ₂ per 5% increase in oxygen saturation; P <0.001), and Fontan pressure (β±SE, -1.24±0.22; 1.24% decrease in predicted peak VO ₂ per 1 mm Hg increase in Fontan pressures; P <0.001). There was a 47% increase in the risk for death/transplant from a higher predicted peak VO ₂ quartile to the next lower quartile (adjusted hazard ratio, 1.47 [95% CI, 1.09-2.05]; P =0.01).
Conclusions: The results of the current study would help calibrate the interpretation of exercise test data in adults with Fontan palliation and improve risk stratification in this population. It also underscores the need to maintain normal Fontan hemodynamics and body weight, which are important determinants of aerobic capacity.